1
|
Zhang D, Man X, Li L, Tang J, Liu F. Radiocontrast agent and intraductal pressure promote the progression of post-ERCP pancreatitis by regulating inflammatory response, cellular apoptosis, and tight junction integrity. Pancreatology 2022; 22:74-82. [PMID: 34810073 DOI: 10.1016/j.pan.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/19/2021] [Accepted: 11/03/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common complication following ERCP and the mechanism is not fully understood. This study evaluated the changes in the inflammatory response, cellular apoptosis, and tight junction integrity in a rat model of pancreatitis to explore the underlying mechanism. METHODS PEP was induced in rats by retrograde biliopancreatic ductal infusion of contrast agents or saline. Pancreatic tissues were harvested and evaluated by histopathologic, immunohistochemical, immunofluorescence, and Western blot analyses. In addition, amylase and proinflammatory cytokines in plasma were quantified by ELISA assay. RESULTS PEP rats developed more severe acute pancreatitis than the sham group after injection of the contrast agent or isotonic saline. PEP rats exhibited increased tissue damage, plasma amylase, proinflammatory cytokines, necrosis, inflammatory infiltrates, apoptosis, and tight junction disruption. At the molecular level, contrast agent and isotonic saline-injected PEP rats demonstrated elevated NF-κB p65 and STAT3 pathways activation, altered expression and activation of apoptosis-related proteins, and suppressed expression of tight junction molecules. However, the contrast agent concentration had no effect on these changes. CONCLUSIONS In models of acute pancreatitis induced using contrast agent and hydrostatic pressure, the contrast agent and high hydrostatic pressure easily induced the inflammatory response, apoptosis, and tight junction disruption. It is noteworthy that no significant difference in damaged pancreatic acinar cells was observed with different concentrations of the contrast agent.
Collapse
Affiliation(s)
- Di Zhang
- Anhui University of Science and Technology, Huainan, 232001, China
| | - Xiaohua Man
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, China
| | - Lei Li
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian Tang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, China
| | - Feng Liu
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
| |
Collapse
|
2
|
Role of Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography in the Diagnosis of Pancreatic Cancer. Diagnostics (Basel) 2021; 11:diagnostics11020238. [PMID: 33557084 PMCID: PMC7913831 DOI: 10.3390/diagnostics11020238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 12/14/2022] Open
Abstract
Pancreatic cancer has the poorest prognosis among all cancers, and early diagnosis is essential for improving the prognosis. Along with radiologic modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI), endoscopic modalities play an important role in the diagnosis of pancreatic cancer. This review evaluates the roles of two of those modalities, endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP), in the diagnosis of pancreatic cancer. EUS can detect pancreatic cancer with higher sensitivity and has excellent sensitivity for the diagnosis of small pancreatic cancer that cannot be detected by other imaging modalities. EUS may be useful for the surveillance of pancreatic cancer in high-risk individuals. Contrast-enhanced EUS and EUS elastography are also useful for differentiating solid pancreatic tumors. In addition, EUS-guided fine needle aspiration shows excellent sensitivity and specificity, even for small pancreatic cancer, and is an essential examination method for the definitive pathological diagnosis and treatment decision strategy. On the other hand, ERCP is invasive and performed less frequently for the purpose of diagnosing pancreatic cancer. However, ERCP is essential in cases that require evaluation of pancreatic duct stricture that may be early pancreatic cancer or those that require differentiation from focal autoimmune pancreatitis.
Collapse
|
3
|
Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Watanabe K, Nakamura J, Kikuchi H, Takasumi M, Hashimoto M, Hikichi T, Ohira H. Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis using pancreatic stents: A review of efficacy, diameter and length. World J Meta-Anal 2019; 7:259-268. [DOI: 10.13105/wjma.v7.i6.259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/02/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023] Open
Abstract
Although endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure for the diagnosis and treatment of pancreaticobiliary diseases, post-ERCP pancreatitis (PEP) is the most frequent adverse event that can sometimes be fatal. However, prophylactic pancreatic stent (PS) insertion has been performed to prevent PEP in high-risk patients. In some randomized controlled trials (RCTs) and meta-analyses, the efficacy of prophylactic PS insertion has been shown to prevent PEP. In addition, several types of stents have been used to decrease PEP. In this review, we introduce the details of these RCTs and meta-analyses and reveal the specifications for stent placement, for example, the stent diameter and length and the pancreatic region into which the stent should be inserted.
Collapse
Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Hiroki Irie
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Ko Watanabe
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Jun Nakamura
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Hitomi Kikuchi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Minami Hashimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| |
Collapse
|
4
|
Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Watanabe K, Nakamura J, Kikuchi H, Takasumi M, Hashimoto M, Hikichi T, Ohira H. Pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis. World J Meta-Anal 2019; 7:249-258. [DOI: 10.13105/wjma.v7.i5.249] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/07/2019] [Accepted: 05/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in the investigation and treatment of pancreaticobiliary diseases. However, post-ERCP pancreatitis (PEP) is a severe adverse effect. Prior meta-analyses have shown that prophylactic PS was useful for preventing PEP. However, abstract reports and patients who underwent endoscopic ampullectomy were included in the previous analyses. In addition, two meta-analyses involved non-randomized controlled trials (RCTs). The efficacy of PS for preventing severe PEP was different in each meta-analysis. Therefore, we performed the current meta-analysis, which included only full-text articles, and added new findings.
AIM To reveal the efficacy of prophylactic pancreatic stent (PS) placement for preventing PEP.
METHODS We searched the MEDLINE, Cochrane Library and PubMed databases for related RCTs. Among the reports retrieved, 11 studies were included in this meta-analysis. All full-text articles were published between 1993 and 2016. A total of 1475 patients were enrolled in the included studies; of these patients, 734 had a PS inserted, and 741 did not have a PS inserted. PEP and severe PEP occurrence were evaluated in this meta-analysis.
RESULTS PEP was observed in all studies and occurred in 39 (5.3%) patients who received a PS. On the other hand, PEP occurred in 141 (19%) patients who did not receive a PS. The occurrence of PEP was significantly lower in the patients who underwent PS placement than in the patients who did not receive a PS (OR = 0.32; 95%CI: 0.23-0.45; P < 0.001). In addition, the occurrence of severe PEP was evaluated. Notably, the occurrence of severe PEP was not observed in the stent group; however, the occurrence of severe PEP was observed in 8 (1.3%) patients who did not have a PS inserted. Severe PEP occurred significantly less often in the stent group than in the no stent group (OR = 0.24; 95%CI: 0.06-0.94; P = 0.04).
CONCLUSION In conclusion, prophylactic PS placement is useful for preventing PEP and severe PEP.
Collapse
Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Hiroki Irie
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Ko Watanabe
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Jun Nakamura
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Hitomi Kikuchi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Minami Hashimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| |
Collapse
|
5
|
Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Watanabe K, Nakamura J, Kikuchi H, Waragai Y, Takasumi M, Hikichi T, Ohira H. Pancreatic stents for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis should be inserted up to the pancreatic body or tail. World J Gastroenterol 2018; 24:2392-2399. [PMID: 29904246 PMCID: PMC6000294 DOI: 10.3748/wjg.v24.i22.2392] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 03/29/2018] [Accepted: 05/05/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the location to which a pancreatic stent should be inserted to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).
METHODS Over a ten-year period at our hospital, 296 patients underwent their first ERCP procedure and had a pancreatic stent inserted; this study included 147 patients who had ERCP performed primarily for biliary investigation and had a pancreatic stent inserted to prevent PEP. We divided these patients into two groups: 131 patients with a stent inserted into the pancreatic head (head group) and 16 patients with a stent inserted up to the pancreatic body or tail (body/tail group). Patient characteristics and ERCP factors were compared between the groups.
RESULTS Pancreatic amylase isoenzyme (p-AMY) levels in the head group were significantly higher than those in the body/tail group [138.5 (7.0-2086) vs 78.5 (5.0-1266.5), P = 0.03] [median (range)]. No cases of PEP were detected in the body/tail group [head group, 12 (9.2%)]. Of the risk factors for post-ERCP hyperamylasemia (≥ p-AMY median, 131 IU/L), procedure time ≥ 60 min [odds ratio (OR) 2.65, 95%CI: 1.17-6.02, P = 0.02) and stent insertion into the pancreatic head (OR 3.80, 95%CI: 1.12-12.9, P = 0.03) were identified as independent risk factors by multivariate analysis.
CONCLUSION Stent insertion up to the pancreatic body or tail reduces the risk of post-ERCP hyperamylasemia and may reduce the risk of PEP.
Collapse
Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Rei Suzuki
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Naoki Konno
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Yuki Sato
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Hiroki Irie
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Ko Watanabe
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Jun Nakamura
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Hitomi Kikuchi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Yuichi Waragai
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Mika Takasumi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Prophylactic Efficacy of 3- or 5-cm Pancreatic Stents for Preventing Post-ERCP Pancreatitis: A Prospective, Randomized Trial. J Clin Gastroenterol 2016; 50:e30-4. [PMID: 26280707 DOI: 10.1097/mcg.0000000000000397] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND STUDY AIMS Prophylactic pancreatic stent placement is effective for preventing postendoscopic retrograde cholangiopancreatography pancreatitis (PEP). The most effective type of stent, however, remains unclear. Therefore, we prospectively compared the prophylactic efficacy for PEP prevention between short (3 cm) and long (5 cm) pancreatic stent. PATIENTS AND METHODS Between July 2012 and June 2014, 240 consecutive patients requiring therapeutic endoscopic retrograde cholangiopancreatography to remove a choledocholith or for bile drainage for obstructive jaundice were prospectively enrolled and randomized to undergo prophylactic insertion with unflanged, 5 Fr, 3 or 5-cm pancreatic stent. An efficacy of each stent for preventing PEP was evaluated as a primary endpoint. The period until stent dislodgement and the total adverse event rate were also evaluated as a secondary endpoint. RESULTS Per-protocol analysis revealed that the PEP rate was significantly lower with the short stent than with the long stent (2.0% vs. 8.8%, P=0.035), although they were not significantly different in intention-to-treat analysis. The adverse event rate excluding PEP did not differ significantly between groups (3.0% vs. 0.9%, P=0.293). The median period until dislodgement of the short stent was significantly shorter than that of the long stent (2 vs. 4 d, P<0.001). CONCLUSIONS The present study revealed a superiority of 3-cm stents compared with 5-cm stents for prophylactic pancreatic stent. On the basis of the past reports and the result of the present study, we recommend using a 5 Fr, 3-cm unflanged stent.This study was registered on the UMIN Clinical Trial Registry (UMIN000008290).
Collapse
|
8
|
Liverani A, Muroni M, Santi F, Neri T, Anastasio G, Moretti M, Favi F, Solinas L. One-step Laparoscopic and Endoscopic Treatment of Gallbladder and Common Bile Duct Stones: Our Experience of the Last 9 Years in a Retrospective Study. Am Surg 2013. [DOI: 10.1177/000313481307901213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The optimal timing and best method for removal of common bile duct stones (CBDS) associated with gallbladder stones (GBS) is still controversial. The aim of this study is to investigate the outcomes of a single-step procedure combining laparoscopic cholecystectomy (LC), intra-operative cholangiography (IOC), and endoscopic retrograde cholangiopancreatography (ERCP). Between January 2003 and January 2012, 1972 patients underwent cholecystectomy at our hospital. Of those, 162 patients (8.2%; male/female 72/90) presented with GBS and suspected CBDS. We treated 54 cases (Group 1) with ERCP and LC within 48 to 72 hours. In 108 patients (Group 2) we performed LC with IOC and, if positive, was associated with IO-ERCP and sphincterotomy. In Group 1, a preoperative ERCP and LC were completed in 50 patients (30%). In four cases (2%), an ERCP and endobiliary stents were performed without cholecystectomy and then patients were discharged because of the severity of clinical conditions and advanced American Society of Anesthesiologists score (III to IV). Two months later a preoperative ERCP and removal of biliary stents were performed followed by LC 48 to 72 hours later. In Group 2, the IOC was performed in all cases and CBDS were extracted in 94 patients (87%). In two cases, the laparoscopic choledochotomy was necessary to remove large stones. In another two cases, an open choledochotomy was performed to remove safely the stones with T-tube drainage. In three cases, conversion was necessary to safely complete the procedure. The mean operative time was 95 minutes (range, 45 to 150 minutes) in Group 1 and 130 minutes (range, 50 to 300 minutes) in Group 2. The mean hospital stay was 6.5 days (range, 4 to 21 days) in Group 1 and 4.7 days (range, 3 to 14 days) in Group 2. Five cases (two in Group 2 and three in Group 1) presented with CBDS at 12 to 18 months after surgery. They were treated successfully with a second ERCP. There was no perioperative mortality. Our experience suggests that when clinically and technically feasible, a single-stage approach combining LC, IOC, and ERCP to the patients diagnosed with chole-choledocholithiasis is indicated. The IO-ERCP with CBDS extraction is a safe and effective method with low risk of postoperative pancreatitis. One-step treatment is more comfortable for the patient and also reduces the mean hospital stay.
Collapse
Affiliation(s)
- Andrea Liverani
- Department of General Surgery, Regina Apostolorum Hospital, Rome, Italy
| | - Mirko Muroni
- Department of General Surgery, Regina Apostolorum Hospital, Rome, Italy
| | - Francesco Santi
- Department of General Surgery, Regina Apostolorum Hospital, Rome, Italy
| | - Tiziano Neri
- Department of General Surgery, Regina Apostolorum Hospital, Rome, Italy
| | - Gerardo Anastasio
- Department of General Surgery, Regina Apostolorum Hospital, Rome, Italy
| | - Marco Moretti
- Department of General Surgery, Regina Apostolorum Hospital, Rome, Italy
| | - Francesco Favi
- Department of General Surgery, Regina Apostolorum Hospital, Rome, Italy
| | - Luigi Solinas
- Department of General Surgery, Regina Apostolorum Hospital, Rome, Italy
| |
Collapse
|
9
|
Peng C, Nietert PJ, Cotton PB, Lackland DT, Romagnuolo J. Predicting native papilla biliary cannulation success using a multinational Endoscopic Retrograde Cholangiopancreatography (ERCP) Quality Network. BMC Gastroenterol 2013; 13:147. [PMID: 24112846 PMCID: PMC3882886 DOI: 10.1186/1471-230x-13-147] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Accepted: 09/29/2013] [Indexed: 02/08/2023] Open
Abstract
Background Success in deep biliary cannulation via native ampullae of Vater is an accepted measure of competence in ERCP training and practice, yet prior studies focused on predicting adverse events alone, rather than success. Our aim is to determine factors associated with deep biliary cannulation success, with/ without precut sphincterotomy. Methods The ERCP Quality Network is a unique prospective database of over 10,000 procedures by over 80 endoscopists over several countries. After data cleaning, and eliminating previously stented or cut papillae, two multilevel fixed effect multivariate models were used to control for clustering within physicians, to predict biliary cannulation success, with and without allowing “precut” to assist an initially failed cannulation. Results 13018 ERCPs were performed by 85 endoscopists (March 2007 - May 2011). Conventional (without precut) and overall cannulation rates were 89.8% and 95.6%, respectively. Precut was performed in 876 (6.7%). Conventional success was more likely in outpatients (OR 1.21), but less likely in complex contexts (OR 0.59), sicker patients (ASA grade (II, III/V: OR 0.81, 0.77)), teaching cases (OR 0.53), and certain indications (strictures, active pancreatitis). Overall cannulation success (some precut-assisted) was more likely with higher volume endoscopists (> 239/year: OR 2.79), more efficient fluoroscopy practices (OR 1.72), and lower with moderate (versus deeper) sedation (OR 0.67). Conclusion Biliary cannulation success appears influenced by both patient and practitioner factors. Patient- and case-specific factors have greater impact on conventional (precut-free) cannulation success, but volume influences ultimate success; both may be used to select appropriate cases and can help guide credentialing policies.
Collapse
Affiliation(s)
- Chunyan Peng
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, 25 Courtenay Drive, ART 7100A, Charleston, SC 29425, USA.
| | | | | | | | | |
Collapse
|
10
|
Risk Stratification for the Development of Post-ERCP Pancreatitis by Sphincter of Oddi Dysfunction Classification. South Med J 2013; 106:298-302. [DOI: 10.1097/smj.0b013e318290c6be] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
11
|
Testoni PA, Giussani A, Vailati C, Testoni S, Di Leo M, Mariani A. Precut sphincterotomy, repeated cannulation and post-ERCP pancreatitis in patients with bile duct stone disease. Dig Liver Dis 2011; 43:792-6. [PMID: 21733768 DOI: 10.1016/j.dld.2011.05.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 04/30/2011] [Accepted: 05/17/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Repeated attempts at cannulating the papilla of Vater and "needle-knife" precut sphincterotomy are independent risk factors for post-ERCP pancreatitis. Whether precut alone or repeated attempts at cannulation is the culprit factor in the development of post-ERCP pancreatitis remains controversial. AIM To retrospectively assess the role of precutting and multiple cannulation in the occurrence of post-ERCP pancreatitis in a consecutive series of patients with bile stone disease. METHODS 2004 patients who had undergone endoscopic retrograde cholangio-pancreatography over a 9-year period for bile stones were evaluated. Pancreatitis rate was assessed in relation to the number of cannulation attempts (<10 and ≥10) and precutting. RESULTS Procedures were successful in 1878 patients (93.7%). Cannulation was done without precutting in 1717 cases and with in 161. Pancreatitis occurred in 2.7% of patients who had undergone biliary cannulation without precutting and in 6.5% with (p=0.006). It was lower with <10 attempts than with ≥10 (p<0.0001), either without (p<0.0001) or with precutting (p<0.01). Pancreatitis rate did not differ without and with precutting when <10 attempts at cannulation were done, whilst it was lower when precut was done before 10 attempts than when 10 or more attempts were made without precutting (p=0.02). CONCLUSIONS Pancreatitis rate was lower when precut was done with <10 attempts than when ≥10 attempts were made without precutting. In experienced hands precut biliary sphincterotomy does not seem to be an independent risk factor for post-ERCP pancreatitis in patients undergoing endoscopic retrograde cholangio-pancreatography for bile duct stones.
Collapse
Affiliation(s)
- Pier Alberto Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, Via Olgettina 60, 20132 Milan, Italy.
| | | | | | | | | | | |
Collapse
|
12
|
Testoni PA, Mariani A, Giussani A, Vailati C, Masci E, Macarri G, Ghezzo L, Familiari L, Giardullo N, Mutignani M, Lombardi G, Talamini G, Spadaccini A, Briglia R, Piazzi L. Risk factors for post-ERCP pancreatitis in high- and low-volume centers and among expert and non-expert operators: a prospective multicenter study. Am J Gastroenterol 2010; 105:1753-61. [PMID: 20372116 DOI: 10.1038/ajg.2010.136] [Citation(s) in RCA: 180] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Prospective studies have identified a number of patient- and procedure-related independent risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, with different conclusions, so various questions are still open. The endoscopist's expertise, case volume, and case mix can all significantly influence the outcome of ERCP procedures, but have been investigated little to date. METHODS We identified patient- and procedure-related risk factors for post-ERCP pancreatitis and the impact of the endoscopist's experience and the center's case volume, using univariate and multivariate analysis, in a multicenter, prospective study involving low- and high-volume centers, over a 6-month period. RESULTS A total of 3,635 ERCP procedures were included; 2,838 (78%) ERCPs were performed in the 11 high-volume centers (median 257 each) and 797 in the 10 low-volume centers (median 45 each). Overall, 3,331 ERCPs were carried out by expert operators and 304 by less-skilled operators. There were significantly more grade 3 difficulty procedures in high-volume centers than in low-volume ones (P<0.0001). Post-ERCP pancreatitis occurred in 137 patients (3.8%); the rates did not differ between high- and low-volume centers (3.9% vs. 3.1%) and expert and non-expert operators (3.8% vs. 5.5%). However, in high-volume centers, there were 25% more patients with patient- and procedure-related risk factors, and the pancreatitis rate was one-third higher among non-expert operators. Univariate analysis found a significant association with pancreatitis for history of acute pancreatitis, either non-ERCP- or ERCP-related and recurrent, young age, absence of bile duct stones, and biliary pain among patient-related risk factors, and >10 attempts to cannulate the Vater's papilla, pancreatic duct cannulation, contrast injection of the pancreatic ductal system, pre-cut technique, and pancreatic sphincterotomy, among procedure-related risk factors. Multivariate analysis also showed that a history of post-ERCP pancreatitis, biliary pain, >10 attempts to cannulate the Vater's papilla, main pancreatic duct cannulation, and pre-cut technique were significantly associated with the complication. CONCLUSIONS A history of pancreatitis among patient-related factors, and multiple attempts at cannulation among procedure-related factors, were associated with the highest rates of post-ERCP pancreatitis. Pre-cut sphincterotomy, although identified as another significant risk factor, appeared safer when done early (fewer than 10 attempts at cannulating), compared with repeated multiple cannulation. The risk of post-ERCP pancreatitis was not associated with the case volume of either the single endoscopist or the center; however, high-volume centers treated a larger proportion of patients at high risk of pancreatitis and did a significantly greater number of difficult procedures.
Collapse
Affiliation(s)
- Pier Alberto Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, Università Vita-Salute San Raffaele, IRCCS San Raffaele Hospital, Milan, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Pata C, Akyüz U, Erzin Y, Mutlu N, Mercan A, Dirican A. Post-procedure elevated amylase and lipase levels after double-balloon enteroscopy: relations with the double-balloon technique. Dig Dis Sci 2010; 55:1982-8. [PMID: 19731024 DOI: 10.1007/s10620-009-0956-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Accepted: 08/10/2009] [Indexed: 12/28/2022]
Abstract
BACKGROUND Small elevations of pancreatic enzymes are recently recognized complications of double-balloon enteroscopy (DBE). AIMS The aim of this study was to check the post-procedure pancreatic enzyme (p-amylase, lipase) levels and to disclose their relationships with technical features of DBE. METHODS Peroral (48) and peranal (8) DBEs were performed in 56 patients, and the p-amylase and lipase levels were measured just before and after the procedure. Patients were also evaluated for abdominal pain after DBE using a visual analog scale (VAS). The route-total duration of the procedure, the total insertion length of the scope, the insertion length where the overtube balloon was inflated for the first time, and the duration between the first and second inflations were also noted. RESULTS Pancreatitis was observed in 6 of 48 (12.5%) peroral DBE patients. A VAS score above 5 at 4 h had a sensitivity of 100% and specificity of 96% for developing post-DBE pancreatitis. Significant correlations were noted between the levels of pancreatic enzymes after DBE and the total insertion length, duration, and duration between the first and second inflations of the balloon, and an inverse correlation was observed between the levels of these enzymes and insertion length at the first inflation, but an age-sex-adjusted regression analysis only disclosed the duration between the first and second inflations as an independent predictor of post-DBE pancreatitis (P = 0.012). CONCLUSIONS Hyperamylasemia and hyperlipasemia after DBE seems to be a complication of peroral DBE, which might be prevented by reducing the time between the first and second inflations of the overtube balloon.
Collapse
Affiliation(s)
- Cengiz Pata
- Department of Gastroenterology, Yeditepe University Medical Faculty, Istanbul, Turkey
| | | | | | | | | | | |
Collapse
|
14
|
Woods KE, Willingham FF. Endoscopic retrograde cholangiopancreatography associated pancreatitis: A 15-year review. World J Gastrointest Endosc 2010; 2:165-78. [PMID: 21160744 PMCID: PMC2998911 DOI: 10.4253/wjge.v2.i5.165] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 04/29/2010] [Accepted: 05/06/2010] [Indexed: 02/06/2023] Open
Abstract
The aim of this article is to review the literature regarding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. We searched for and evaluated all articles describing the diagnosis, epidemiology, pathophysiology, morbidity, mortality and prevention of post-ERCP pancreatitis (PEP) in adult patients using the PubMed database. Search terms included endoscopic retrograde cholangiopancreatography, pancreatitis, ampulla of vater, endoscopic sphincterotomy, balloon dilatation, cholangiography, adverse events, standards and utilization. We limited our review of articles to those published between January 1, 1994 and August 15, 2009 regarding human adults and written in the English language. Publications from the reference sections were reviewed and included if they were salient and fell into the time period of interest. Between the dates queried, seventeen large (> 500 patients) prospective and four large retrospective trials were conducted. PEP occurred in 1%-15% in the prospective trials and in 1%-4% in the retrospective trials. PEP was also reduced with pancreatic duct stent placement and outcomes were improved with endoscopic sphincterotomy compared to balloon sphincter dilation in the setting of choledocholithiasis. Approximately 34 pharmacologic agents have been evaluated for the prevention of PEP over the last fifteen years in 63 trials. Although 22 of 63 trials published during our period of review suggested a reduction in PEP, no pharmacologic therapy has been widely accepted in clinical use in decreasing the development of PEP. In conclusion, PEP is a well-recognized complication of ERCP. Medical treatment for prevention has been disappointing. Proper patient selection and pancreatic duct stenting have been shown to reduce the complication rate in randomized clinical trials.
Collapse
Affiliation(s)
- Kevin E Woods
- Kevin E Woods, Department of Medicine, Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | | |
Collapse
|
15
|
Post-ERCP pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:70-8. [PMID: 20012323 DOI: 10.1007/s00534-009-0220-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 12/16/2022]
Abstract
Pancreatitis remains the most common severe complication of endoscopic retrograde cholangiopancreatography (ERCP). Detailed information about the findings of previous studies concerning post-ERCP pancreatitis has not been utilized sufficiently. The purpose of the present article was to present guidelines for the diagnostic criteria of post-ERCP pancreatitis, and its incidence, risk factors, and prophylactic procedures that are supported by evidence. To achieve this purpose, a critical examination was made of the articles on post-ERCP pancreatitis, based on the data obtained by research studies published up to 2009. At present, there are no standardized diagnostic criteria for post-ERCP pancreatitis. It is appropriate that post-ERCP pancreatitis is defined as acute pancreatitis that has developed following ERCP, and its diagnosis and severity assessment should be made according to the diagnostic criteria and severity assessment of the Japanese Ministry of Health, Labour and Welfare. The incidence of acute pancreatitis associated with diagnostic and therapeutic ERCP is 0.4-1.5 and 1.6-5.4%, respectively. Endoscopic papillary balloon dilation is associated with a high risk of acute pancreatitis compared with endoscopic sphincterotomy. It was made clear that important risk factors include dysfunction of the Oddi sphincter, being of the female sex, past history of post-ERCP pancreatitis, and performance of pancreaticography. Temporary prophylactic placement of pancreatic stents in the high-risk group is useful for the prevention of post-ERCP pancreatitis [odds ratio (OR) 3.2, 95% confidence interval (CI) 1.6-6.4, number needed to treat (NNT) 10]. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with a reduction in the development of post-ERCP pancreatitis (OR 0.46, 95% CI 0.32-0.65). Single rectal administration of NSAIDs is useful for the prevention of post-ERCP pancreatitis [relative risk (RR) 0.36, 95% CI 0.22-0.60, NNT 15] and decreases the development of pancreatitis in both the low-risk group (RR 0.29, 95% CI 0.12-0.71) and the high-risk group (RR 0.40, 95% CI 0.23-0.72) of post-ERCP pancreatitis. As for somatostatin, a bolus injection may be most useful compared with short- or long-term infusion (OR 0.271, 95% CI 0.138-0.536, risk difference 8.2%, 95% CI 4.4-12.0%). The usefulness of gabexate mesilate was not apparent in any of the following conditions: acute pancreatitis (control 5.7 vs. 4.8% for gabexate mesilate), hyperamylasemia (40.6 vs. 36.9%), and abdominal pain (1.7 vs. 8.9%). Formulation of diagnostic criteria for post-ERCP pancreatitis is needed. Temporary prophylactic placement of pancreatic stents in the high-risk group offers the most promise as a means of preventing post-ERCP pancreatitis. As for pharmacological attempts, there are high expectations concerning NSAIDs because they are excellent in terms of cost-effectiveness, ease of use, and safety. There was no evidence of effective prophylaxis with the use of protease inhibitors, especially gabexate mesilate.
Collapse
|
16
|
Topcu O, Kurt A, Nadir I, Arici S, Koyuncu A, Aydin C. Effects of contrast media on the hepato-pancreato-biliary system. World J Gastroenterol 2009; 15:4788-93. [PMID: 19824112 PMCID: PMC2761556 DOI: 10.3748/wjg.15.4788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the effects of high osmolarity contrast media (HOCM) and iso-osmolar contrast media (CM) application, with or without pressure, on hepato-pancreato-biliary (HPB) system.
METHODS: Sixty rats were divided into six equal groups as follows: Group 1: (0.9% NaCl, control), Group 2: (diatrizoate meglumine Na, ionic HOCM, Urographin®), Group 3: (iodixanol, iso-osmolar non-ionic CM, Visipaque®); each of which was applied without pressure, whereas the animals of the remaining three groups (1p, 2p, 3p) were subjected to the same CM with pressure. We performed a duodenal puncture and introduced a catheter into the ampulla. After the catheterization, 0.2 mL CM or 0.9% NaCl was injected with or without pressure. Blood samples were taken for biochemical evaluations. The histopathological examinations of liver, common bile duct, and pancreas were performed.
RESULTS: There were no significant differences between the six groups for blood amylase, alanine aminotransferases, aspartate aminotransferases, bilirubin levels (P > 0.05). Alkaline phosphatase and γ glutamyl transaminase levels were higher (P < 0.05) in the Urographin® groups (2, 2p) than the Visipaque® groups (3, 3p), or control groups (1, 1p). Hepatocyte necrosis, portal area inflammation, and Kupffer’s cell hyperplasia were higher (P < 0.05) in the study groups than the control group. However, there were no significant differences (P > 0.05) between HOCM (2, 2p) and iso-osmolar CM (3, 3p) groups. Bile duct proliferation and regeneration in the Urographin® groups (2, 2p) were significantly higher (P < 0.05) than the Visipaque® groups (3, 3p) or the control groups (1, 1p). Although CM caused minor damage to the pancreas, there were no statistically significant differences (P > 0.05) between the groups. Application of the CM with pressure did not cause additional damage to the HPB system.
CONCLUSION: Iso-osmolar, non-ionic CM could be more reliable than the ionic HOCM, whereas the application of pressure during the CM application had no effect on the HPB system.
Collapse
|
17
|
Barkay O, Fogel EL, Watkins JL, McHenry L, Lehman GA, Sherman S. Endoscopic retrograde pancreatography. Clin Gastroenterol Hepatol 2009; 7:931-43. [PMID: 19523537 DOI: 10.1016/j.cgh.2009.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Revised: 05/29/2009] [Accepted: 06/02/2009] [Indexed: 02/07/2023]
Affiliation(s)
- Olga Barkay
- Division of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, Indiana 46202, USA.
| | | | | | | | | | | |
Collapse
|
18
|
Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg 2009; 7:338-46. [PMID: 19481184 DOI: 10.1016/j.ijsu.2009.05.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Accepted: 05/06/2009] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The advent of endoscopic techniques changed surgery in many regards. In the management of cholelithiasis; laparoscopic cholecystectomy (LC) is today the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of options exist, including endoscopic sphincterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic common bile duct exploration (LCBDE) by the transcystic approach or laparoscopic choledocotomy, open CBD exploration and postoperative ERCP. A major concern regarding both pre- and postoperative extraction of CBD stones (CBDS) by the ERCP is the risk of development of pancreatitis, also more than 10% of the preoperative ERCP is normal. More recently the alternative technique of combined LC with intraoperative ERCP and ES is emerging in an attempt to manage cholecysto-choledocholithiasis in a single-step procedure. OBJECTIVES The aim of this work was to assess the treatment of common bile duct stones (CBDS) in a one-stage operation by laparoscopic cholecystectomy (LC) and intraoperative endoscopic retrograde cholangiopancreatography (LC+IO-ERCP) and endoscopic sphincterotomy (ES). PATIENTS AND METHODS This study was carried out on 45 patients with gall bladder stones and with suspected or confirmed CBDS at the Gastrointestinal Surgery Unit in the Main Alexandria University Hospital. They were treated by a single-step procedure combining LC and IO-ERCP. Laparoscopic intraoperative cholangiography (IOC) was carried out to confirm the presence of CBDS. A soft-tipped guide-wire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guide-wire. Endoscopic sphincterotomy was performed and the stones were extracted with a retrieval balloon or with a Dormia basket. The surgical operating time, surgical success rate, postoperative complications, retained CBDS, and postoperative length of hospital stay were assessed. RESULTS There were 30 females and 15 males. Their mean age was 45.07+11.3 years (ranging from 27 to 65 years). Twenty-seven patients had confirmed CBDS by preoperative ultrasound (US) and/or MRCP. Eighteen patients were suspected for CBDS on clinical, laboratory and/or US basis. Conversion to open cholecystectomy occurred in one case due to severe adhesions at the Calot's triangle. IOC revealed the presence of CBDS in 36 patients. IO-ERCP with ES was performed successfully in 33 patients and stones were extracted endoscopically. Passage of the guide-wire through the papilla failed in three patients. Cholecystectomy was completed laparoscopically in 44 patients. The mean operative time was 119+14.4 min (ranging from 100 to 150 min). Minor postoperative complications occurred in 15 patients. No postoperative complications related to the procedure, i.e., pancreatitis, bleeding, perforation, were encountered. Patients regained their bowel motion on the next day and were discharged after a mean hospital stay of 2.55+0.89 days. None of the patients presented on the postoperative follow-up with symptoms, signs, laboratory or radiological evidence of retained CBDS. The mean duration of the postoperative follow-up was 9+4.07 months (ranging from 3 to 14 months). CONCLUSION The current study suggests that LC+IO-ERCP for the management of cholecysto-choledocholithiasis is a safe and aneffective technique with a low rate of post-ERCP pancreatitis. It offers another alternative for surgeons especially those who do not practice LCBDE to treat patients in a single setting. However, additional studies with larger patient populations are needed keeping in mind that the limiting characteristic is the proximity and availability of the endoscopic settings.
Collapse
Affiliation(s)
- Abdel Hamid Ghazal
- General Surgery Department, Faculty of Medicine, University of Alexandria, Egypt
| | | | | | | |
Collapse
|
19
|
Evaluation of recombinant platelet-activating factor acetylhydrolase for reducing the incidence and severity of post-ERCP acute pancreatitis. Gastrointest Endosc 2009; 69:462-72. [PMID: 19231487 DOI: 10.1016/j.gie.2008.07.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Accepted: 07/22/2008] [Indexed: 12/11/2022]
Abstract
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.
Collapse
|
20
|
García M, Barbáchano EH, Lorenzo PH, San Román JI, López MA, Coveñas R, Calvo JJ. Saline infusion through the pancreatic duct leads to changes in calcium homeostasis similar to those observed in acute pancreatitis. Dig Dis Sci 2009; 54:300-8. [PMID: 18600455 DOI: 10.1007/s10620-008-0339-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2008] [Accepted: 05/06/2008] [Indexed: 12/26/2022]
Abstract
This work focuses on studying the early events associated with pancreatic damage after retrograde infusion through the pancreatic duct in rats. We have analyzed changes in calcium homeostasis and secretory response in pancreatic acini from rats with taurocholate-induced acute pancreatitis. Moreover, in order to test whether pancreatic duct manipulation can trigger damage inside pancreatic acinar cells, we have studied both parameters in acini from animals infused with saline. Our study demonstrates that taurocholate causes evident damage to acinar cells, impairing both calcium homeostasis and secretory response to CCK. In saline, a significant decrease in calcium cytosolic response to CCK was observed. Calcium disturbances similar to those observed in acute pancreatitis appear before secretion blockade and inflammation processes in saline treated rats. These results could be interesting since pancreatitis is associated to clinical procedures that require duct manipulation such as endoscopic retrograde cholangiopancreatography.
Collapse
Affiliation(s)
- Mónica García
- Department of Physiology and Pharmacology, Edificio Departamental, University of Salamanca, Campus Miguel de Unamuno, 37007, Salamanca, Spain
| | | | | | | | | | | | | |
Collapse
|
21
|
Nishino T, Toki F, Oyama H, Shiratori K. MORE ACCURATE PREDICTION OF POST-ERCP PANCREATITIS BY 4-H SERUM LIPASE LEVELS THAN AMYLASE LEVELS. Dig Endosc 2008. [DOI: 10.1111/j.1443-1661.2008.00802.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
|
22
|
Artifon ELA, Sakai P, Cunha JEM, Halwan B, Ishioka S, Kumar A. Guidewire cannulation reduces risk of post-ERCP pancreatitis and facilitates bile duct cannulation. Am J Gastroenterol 2007; 102:2147-53. [PMID: 17581267 DOI: 10.1111/j.1572-0241.2007.01378.x] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate if using a soft-tipped guidewire to cannulate the common bile duct may ameliorate development of post-ERCP pancreatitis and facilitate cannulation of the CBD. DESIGN AND SETTING A single-center, blinded, randomized trial of conventional cannulation technique using sphinctertome and contrast injection versus guidewire cannulation technique. METHODS We prospectively randomized 300 patients to conventional cannulation (group I) or guidewire cannulation (group II) technique. OUTCOME MEASURES Primary outcome measure was incidence of acute pancreatitis and secondary outcome measures were ease of cannulation of common bile duct (assessed by attempts required for common bile duct cannulation & rates of precut sphincterotomy) and overall complication rates. RESULTS Guidewire cannulation was associated with significantly lower likelihood of post-ERCP pancreatitis (adjusted OR 0.43, 95% CI 0.21-0.89, P= 0.02). Twenty-five patients (16.6%) in group I and thirteen patients (8.6%) in group II developed acute pancreatitis, P= 0.037. All instances of pancreatitis were mild. There were more women in group II; 41 in group I and 59 in group II, P= 0.028. Otherwise the two groups were comparable for age, age under 35 yr, indication for ERCP, diagnosis, and number of patients with SOD. The number of patients requiring 0-3, 4-6, and 7-10 attempts for successful cannulation of the common bile duct were 87, 48, and 15 in group I and 117, 24, and 9 in group II, respectively, P= 0.001. A total of 33 patients in group I and 13 patients in group II required precut sphincterotomy, P= 0.007. Rates of accidental pancreatic duct cannulation were 21 in group I and 27 in group II, P= 0.34. Rates of overall complication were not significantly different in the two groups. CONCLUSIONS Guidewire technique for bile duct cannulation lowers likelihood of post-ERCP pancreatitis by facilitating cannulation and reducing need for precut sphincterotomy.
Collapse
Affiliation(s)
- Everson L A Artifon
- Division of Gastroenterology, University of São Paulo School of Medicine, Sao Paulo, Brazil
| | | | | | | | | | | |
Collapse
|
23
|
Abstract
Pancreatic sphincterotomy serves as the cornerstone of endoscopic therapy of the pancreas. Historically, its indications have been less well-defined than those of endoscopic biliary sphincterotomy, yet it plays a definite and useful role in diseases such as chronic pancreatitis and pancreatic-type sphincter of Oddi dysfunction. In the appropriate setting, it may be used as a single therapeutic maneuver, or in conjunction with other endoscopic techniques such as pancreatic stone extraction or stent placement. The current standard of practice utilizes two different methods of performing pancreatic sphincterotomy: a pull-type sphincterotome technique without prior stent placement, and a needle-knife sphincterotome technique over an existing stent. The complications associated with pancreatic sphincterotomy are many, although acute pancreatitis appears to be the most common and the most serious of the early complications. As such, it continues to be reserved for those endoscopists who perform a relatively high-volume of therapeutic pancreaticobiliary endoscopic retrograde cholangio-pancreatography.
Collapse
Affiliation(s)
- Jonathan M Buscaglia
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1830 E. Monument Street, Room 7100-A, Baltimore, MD 21205, USA.
| | | |
Collapse
|
24
|
Li ZS, Pan X, Zhang WJ, Gong B, Zhi FC, Guo XG, Li PM, Fan ZN, Sun WS, Shen YZ, Ma SR, Xie WF, Chen MH, Li YQ. Effect of octreotide administration in the prophylaxis of post-ERCP pancreatitis and hyperamylasemia: A multicenter, placebo-controlled, randomized clinical trial. Am J Gastroenterol 2007; 102:46-51. [PMID: 17266687 DOI: 10.1111/j.1572-0241.2006.00959.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Since the introduction of endoscopic retrograde cholangiopancreatology (ERCP) in clinical use, pancreatitis has become a common complication of ERCP. Octreotide is an inhibitor of pancreatic enzyme secretions. Several studies have evaluated the effect of octreotide on the incidence of clinical pancreatitis after ERCP, but with different results. The aim was to determine the efficacy of prophylactic administration of octreotide for the prevention of post-ERCP pancreatitis (PEP) and hyperamylasemia. METHODS In this study, patients with scheduled ERCP were randomized to receive either octreotide (0.3 mg) via intramuscular injection or a placebo. The study was conducted in 12 digestive endoscopic units in China. Patients were randomized into two groups: an octreotide group (N = 414) and a control group (N = 418). In the octreotide group, octreotide (0.3 mg) was dissolved in 500 mL of 0.9% saline solution and administered by continuous intravenous infusion, beginning 1 h before endoscopic examination and continued for 6 h thereafter; 0.1 mg of octreotide was injected subcutaneously at 6 and 12 h after the intravenous injection was stopped. The control group was given a placebo intravenously. The end point was the development of acute pancreatitis. RESULTS The overall incidence of acute pancreatitis was 3.85%; this included 2.42% (10/414) in the octreotide group and 5.26% (22/418) in the control group (P = 0.046). The overall incidence of hyperamylasemia was 14.9%; 12.32% (51/414) in the octreotide group and 17.46% (73/418) in the control group (P = 0.041). No side effects were found. CONCLUSION The results indicate that octreotide can prevent PEP and hyperamylasemia.
Collapse
Affiliation(s)
- Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, SMMU, Shanghai, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Rochester JS, Jaffe DL. Minimizing complications in endoscopic retrograde cholangiopancreatography and sphincterotomy. Gastrointest Endosc Clin N Am 2007; 17:105-27, vii. [PMID: 17397779 DOI: 10.1016/j.giec.2006.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a major tool in the diagnosis and management of numerous biliary and pancreatic conditions, including choledocholithiasis as well as benign and malignant pancreatic diseases, especially those causing biliary obstruction. Since the procedure's inception, the techniques and indications have evolved along with advances in technology and an improved understanding of risks associated with ERCP. The trend has been away from purely diagnostic procedures; most ERCPs are now therapeutic in intent. ERCP remains among the more invasive of endoscopic procedures, with significant rates of complications that can be major. As advances are made in less invasive technology, it is important to understand the complications of ERCP and how best to avoid them.
Collapse
Affiliation(s)
- Jeremy S Rochester
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467-2490, USA
| | | |
Collapse
|
26
|
Frank CD, Adler DG. Post-ERCP pancreatitis and its prevention. ACTA ACUST UNITED AC 2006; 3:680-8. [PMID: 17130878 DOI: 10.1038/ncpgasthep0654] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Accepted: 09/01/2006] [Indexed: 12/14/2022]
Abstract
Pancreatitis remains the most common severe complication of endoscopic retrograde cholangiopancreatography (ERCP), and typically develops in 5-7% of patients. Although most post-ERCP pancreatitis (PEP) is mild, severe pancreatitis and its complications (including a systemic inflammatory response or the development of pseudocysts or pancreatic necrosis) can occur, and in rare cases death can result. A means of preventing PEP in all patients who undergo the procedure remains elusive. Proper patient selection for ERCP is critical to avoid unnecessary risk. Pharmacologic attempts to prevent PEP have been largely unsuccessful; encouraging results have been difficult to validate. Prophylactic stenting of the pancreatic duct and minimally traumatic cannulation techniques offer the most promise as a means of preventing PEP. This manuscript reviews risk factors for PEP as well as pharmacologic and procedural means that can be used to reduce its incidence.
Collapse
Affiliation(s)
- Carl D Frank
- University of Texas-Houston Medical School, Houston, Texas, USA
| | | |
Collapse
|
27
|
Muralidharan V, Jamidar P. Pharmacologic prevention of post-ERCP pancreatitis: is nitroglycerin a sangreal? Gastrointest Endosc 2006; 64:358-60. [PMID: 16923482 DOI: 10.1016/j.gie.2005.12.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Accepted: 12/29/2005] [Indexed: 12/30/2022]
|
28
|
Sekimoto M, Takada T, Kawarada Y, Hirata K, Mayumi T, Yoshida M, Hirota M, Kimura Y, Takeda K, Isaji S, Koizumi M, Otsuki M, Matsuno S. JPN Guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis. ACTA ACUST UNITED AC 2006; 13:10-24. [PMID: 16463207 PMCID: PMC2779368 DOI: 10.1007/s00534-005-1047-3] [Citation(s) in RCA: 149] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis is a common disease with an annual incidence of between 5 and 80 people per 100 000 of the population. The two major etiological factors responsible for acute pancreatitis are alcohol and cholelithiasis (gallstones). The proportion of patients with pancreatitis caused by alcohol or gallstones varies markedly in different countries and regions. The incidence of acute alcoholic pancreatitis is considered to be associated with high alcohol consumption. Although the incidence of alcoholic pancreatitis is much higher in men than in women, there is no difference in sexes in the risk involved after adjusting for alcohol intake. Other risk factors include endoscopic retrograde cholangiopancreatography, surgery, therapeutic drugs, HIV infection, hyperlipidemia, and biliary tract anomalies. Idiopathic acute pancreatitis is defined as acute pancreatitis in which the etiological factor cannot be specified. However, several studies have suggested that this entity includes cases caused by other specific disorders such as microlithiasis. Acute pancreatitis is a potentially fatal disease with an overall mortality of 2.1%–7.8%. The outcome of acute pancreatitis is determined by two factors that reflect the severity of the illness: organ failure and pancreatic necrosis. About half of the deaths in patients with acute pancreatitis occur within the first 1–2 weeks and are mainly attributable to multiple organ dysfunction syndrome (MODS). Depending on patient selection, necrotizing pancreatitis develops in approximately 10%–20% of patients and the mortality is high, ranging from 14% to 25% of these patients. Infected pancreatic necrosis develops in 30%–40% of patients with necrotizing pancreatitis and the incidence of MODS in such patients is high. The recurrence rate of acute pancreatitis is relatively high: almost half the patients with acute alcoholic pancreatitis experience a recurrence. When the gallstones are not treated, the risk of recurrence in gallstone pancreatitis ranges from 32% to 61%. After recovering from acute pancreatitis, about one-third to one-half of acute pancreatitis patients develop functional disorders, such as diabetes mellitus and fatty stool; the incidence of chronic pancreatitis after acute pancreatitis ranges from 3% to 13%. Nevertheless, many reports have shown that most patients who recover from acute pancreatitis regain good general health and return to their usual daily routine. Some authors have emphasized that endocrine function disorders are a common complication after severe acute pancreatitis has been treated by pancreatic resection.
Collapse
Affiliation(s)
- Miho Sekimoto
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Sakyo-ku, Kyoto 606-8501, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Abstract
Acute pancreatitis is a disease of increasing prevalence, unchanged mortality over many decades, and limited treatment strategies. Progress has been made in developing therapies that reduce the rate of endoscopic retrograde cholangiopancreatography (ERCP)-associated pancreatitis and in preventing infected pancreatic necrosis with intravenous carbapenems. Attempts at reducing pancreatic enzyme output or inhibiting the activity of digestive enzyme proteases have not yielded encouraging results - nor have anti-inflammatory strategies for the treatment of acute pancreatitis been found to be effective so far. Future therapeutic options that are presently being developed or under investigation attempt to restore pancreatic secretory function, interfere with inflammatory pathways in a more effective manner, or inhibit digestive enzyme proteases more selectively.
Collapse
Affiliation(s)
- Paul Georg Lankisch
- Clinic for General Internal Medicine, Centre of Medicine, Municipal Clinic of Luneburg, Luneburg, Germany.
| | | |
Collapse
|
30
|
Katsinelos P, Kountouras J, Chatzis J, Christodoulou K, Paroutoglou G, Mimidis K, Beltsis A, Zavos C. High-dose allopurinol for prevention of post-ERCP pancreatitis: a prospective randomized double-blind controlled trial. Gastrointest Endosc 2005; 61:407-15. [PMID: 15758912 DOI: 10.1016/s0016-5107(04)02647-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pancreatitis is the most common major complication of diagnostic and therapeutic ERCP. Allopurinol, a xanthine oxidase inhibitor that blocks generation of oxygen-derived free radicals, potentially may prevent post-ERCP pancreatitis. This study assessed the efficacy of high-dose oral allopurinol for prevention of post-ERCP pancreatitis. METHODS A prospective, double-blind, placebo-controlled trial was conducted in 250 patients undergoing ERCP. Patients were randomized to receive allopurinol (600 mg) or placebo orally at 15 and 3 hours before the procedure. Patients were clinically evaluated, and serum amylase levels were determined before ERCP and at 6 and 24 hours thereafter. Standardized criteria were used to diagnose and to grade the severity of post-ERCP pancreatitis. RESULTS A total of 243 patients were included in the analysis. The two groups were similar with regard to age; gender; underlying disease; indication for treatment; ERCP findings; and type of treatment, except for biliary sphincterotomy. Only 43 patients in the allopurinol group underwent biliary sphincterotomy vs. 87 in the placebo group ( p < 0.001). The frequency of acute pancreatitis was significantly lower in the allopurinol vs. the placebo group in the final multinomial regression analysis: allopurinol group, 4/125 (3.2%), with all 4 cases graded as mild, vs. placebo group, 21/118 (17.8%), of which 8/118 (6.8%) were graded as mild, 11/118 (9.3%) as moderate, and 2/118 (1.6%) as severe with fatal outcome ( p < 0.001). The protective effect of allopurinol was also apparent in the diagnostic ERCP and the biliary sphincterotomy subgroups when the frequency of post-ERCP pancreatitis was analyzed after stratification by procedure. The mean duration of hospitalization for pancreatitis was significantly shorter in the allopurinol compared with the placebo group (2.5 vs. 5.67 days; p < 0.001). CONCLUSIONS Pretreatment with high-dose, orally administered allopurinol decreases the frequency of post-ERCP pancreatitis. Despite the promising results of this prospective, randomized trial, further studies are needed to verify these observations before allopurinol can be recommended for routine clinical use.
Collapse
|
31
|
Abstract
BACKGROUND Pancreatitis occurs in up to 30% of patients who undergo ERCP. This study tested the hypothesis that post-ERCP pancreatitis can be avoided by initially accessing the bile duct with a soft-tipped Teflon tracer 0.035-inch guidewire. METHODS A single endoscopist performed ERCP in 400 consecutive patients with pancreatobiliary disease who were randomized to two groups. In Group A (200 patients), the bile duct was first accessed by insertion of a soft-tipped Teflon tracer (diameter 0.035 inch) guidewire through a 6F, double channel sphincterotome, followed by cannulation, injection of contrast, and sphincterotomy. In Group B (200 patients), the bile duct was opacified by using traditional methods of cannulation. RESULTS No case of acute pancreatitis was detected in Group A, whereas, 8 cases were observed in Group B (6 mild, one moderate, one severe) (p < 0.01). In 9 patients in Group A vs. 39 in Group B (p < 0.001), the serum amylase rose to more than 5 times the upper normal limit during the 24 hours after the procedure. There was no procedure-related mortality. CONCLUSIONS Accessing the bile duct with a soft-tipped tracer guidewire prevents post-ERCP pancreatitis.
Collapse
Affiliation(s)
- Fausto Lella
- Department of Gastroenterology and Gastrointestinal Endoscopy Unit, Policlinico San Marco, Zingonia, Italy
| | | | | | | |
Collapse
|
32
|
Affiliation(s)
- Martin L Freeman
- Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota, MN 55415, USA
| | | |
Collapse
|
33
|
Rashdan A, Fogel EL, McHenry L, Sherman S, Temkit M, Lehman GA. Improved stent characteristics for prophylaxis of post-ERCP pancreatitis. Clin Gastroenterol Hepatol 2004; 2:322-9. [PMID: 15067627 DOI: 10.1016/s1542-3565(04)00062-x] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pancreatic stenting is an effective method to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients. This retrospective study evaluated the impact of modified stent characteristics on the rate of post-ERCP pancreatitis, spontaneous stent dislodgment, and stent-related sequelae. METHODS A total of 2283 patients underwent 2447 ERCPs over a 6-year period with placement of 3-4F diameter, unflanged pancreatic stents. The indication for stenting was pancreatitis prophylaxis predominantly in suspected sphincter of Oddi dysfunction (SOD), pancreas divisum therapy, and precut sphincterotomy. An abdominal radiograph was obtained 10-14 days later to assess spontaneous stent passage. Post-ERCP pancreatitis was defined according to established criteria. A total of 479 patients underwent repeat ERCPs after an initial ERCP with pancreatic stent placement. The prestenting pancreatogram was then compared with follow-up studies. RESULTS The pancreatitis rate with 3F, 4F, 5F, and 6F stents was 7.5%, 10.6%, 9.8%, and 14.6%, respectively (3F vs. 4F, 5F, 6F: P = 0.047). Spontaneous stent dislodgment was 86%, 73%, 67%, and 65%, respectively (3F vs. 4F, 5F, 6F: P < 0.0001). The frequency of ductal changes was 24% in patients with 3-4F stents compared with 80% with 5-6F stents. Ductal perforation from the stents occurred in 3 patients (0.1%). CONCLUSIONS Small diameter (3-4F), unflanged pancreatic stents are more effective than the traditionally used stents (5-6F) in preventing post-ERCP pancreatitis. Stent-induced ductal changes and the need for endoscopic removal are also significantly less with 3-4F stents. The 3F stent appears to be superior in all aspects studied. Additional studies are needed to define the ideal method to eliminate post-ERCP pancreatitis.
Collapse
Affiliation(s)
- Abdullah Rashdan
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, 46202, USA
| | | | | | | | | | | |
Collapse
|
34
|
Singh P, Gurudu SR, Davidoff S, Sivak MV, Indaram A, Kasmin FE, Nozdak V, Wong RCK, Isenberg G, Stark B, Bank S, Chak A. Sphincter of Oddi manometry does not predispose to post-ERCP acute pancreatitis. Gastrointest Endosc 2004; 59:499-505. [PMID: 15044885 DOI: 10.1016/s0016-5107(03)02876-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sphincter of Oddi manometry is helpful in selecting patients with sphincter of Oddi dysfunction who will respond to sphincterotomy. However, studies have shown that sphincter of Oddi manometry is associated with a high risk of post-procedure pancreatitis. The primary objective of this study was to evaluate the safety of sphincter of Oddi manometry in patients with sphincter of 2Oddi dysfunction. The secondary objective was to determine the risk factors for post-ERCP pancreatitis in patients with sphincter of Oddi dysfunction. METHODS Data were collected retrospectively for 268 patients who had elective ERCP performed at 3 tertiary care medical centers between 1996 and 2000. Consecutive patients with suspected sphincter of Oddi dysfunction formed the case group; the control group consisted of patients with bile duct stone. The case group was further subclassified into group A, patients who underwent sphincter of Oddi manometry followed by immediate ERCP, and group B, patients who had ERCP without manometry. The rate of post-ERCP acute pancreatitis was compared between case and control groups. RESULTS Twenty-seven percent of patients in the case group with suspected sphincter of Oddi dysfunction developed acute pancreatitis compared with 3.2% of patients in the control group with bile duct stone (p<0.001). There was no significant difference in the rate of acute pancreatitis in patients with sphincter of Oddi dysfunction who underwent sphincter of Oddi manometry and ERCP compared with patients with sphincter of Oddi dysfunction who had ERCP without sphincter of Oddi manometry (odds ratio 0.72: 95% CI[0.08, 9.2]). Multivariable logistic regression analysis showed that biliary sphincterotomy (p=0.006) and pancreatography (p=0.03) were independent predictors of acute pancreatitis. CONCLUSIONS Patients with suspected sphincter of Oddi dysfunction are at higher risk of post-ERCP acute pancreatitis. Sphincter of Oddi manometry by itself does not appear to predispose to this complication.
Collapse
Affiliation(s)
- Pankaj Singh
- Current affiliations: Division of Gastroenterology, University Hospitals of Cleveland, Cleveland, Ohio, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
George S, Kulkarni AA, Stevens G, Forsmark CE, Draganov P. Role of osmolality of contrast media in the development of post-ERCP pancreatitis: a metanalysis. Dig Dis Sci 2004; 49:503-8. [PMID: 15139506 DOI: 10.1023/b:ddas.0000020511.98230.20] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The role of osmolality of contrast media (CM) in the development of post-ERCP pancreatitis (PEP) is debated. We therefore performed a metanalysis to determine whether osmolality affects the incidence of PEP. A literature search of English-language studies was performed using computerized databases and manual searching of abstracts and article bibliographies. Randomized controlled trials comparing the incidence of PEP associated with high- and low-osmolality contrast media (HOCM, LOCM) were considered. The outcome assessed was clinical pancreatitis as evidenced by both elevation of pancreatic enzymes and pain. Data were analyzed using logistic regression with terms for study and osmolality. Fisher's exact test was done to compare PEP rates. Homogeneity between studies was indicated by the nonsignificance of the study effect in the logistic regression model. Logistic regression also indicated no difference in PEP rates between LOCM and HOCM (P = 0.399). Comparison of PEP rates in both groups using Fisher's exact test did not indicate a difference in any individual study (all P values > 0.05). Due to the large variation of study sample sizes, we repeated the analysis by creating three study groups. The effect of osmolality was invariant to how the data were combined. The results of this metanalysis indicate that there is no significant difference between HOCM and LOCM with respect to clinical PEP.
Collapse
Affiliation(s)
- Suku George
- Division of Gastroenterology, University of Florida, Gainesville, Florida 32610, USA
| | | | | | | | | |
Collapse
|
36
|
Enochsson L, Lindberg B, Swahn F, Arnelo U. Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) to remove common bile duct stones during routine laparoscopic cholecystectomy does not prolong hospitalization: a 2-year experience. Surg Endosc 2004; 18:367-71. [PMID: 14752630 DOI: 10.1007/s00464-003-9021-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2003] [Accepted: 08/20/2003] [Indexed: 01/09/2023]
Abstract
BACKGROUND There is still some controversy regarding the optimal timing and best method for the removal of common bile duct stones (CBDS). Intraoperative endoscopic retrograde cholangiopancreaticography (IO-ERCP) is an alternative method that should be considered for this procedure. The aim of our study was to investigate the clinical outcome of a single-step procedure (IO-ERCP) to remove CBDS, thereby combining two existing high-volume clinical modalities-i.e., laparoscopic cholecystectomy (LC) and ERCP. METHODS Between January 2000 and December 2001, 674 patients, 192 male and 482 female, underwent cholecystectomy at our hospital. There were 612 LC (90.8%), 37 converted procedures (5.5%), and 25 open operations (3.7%). In 592 of the patients, (87.8%) intraoperative cholangiography (IOC) was performed. In 34 (5.7%) of those who had and IOC, an IO-ERCP was performed. While the surgeon waited for the endoscopist, care was taken to introduce a thin guidewire through the lOC catheter and pass it through the sphincter of Oddi, out into the duodenum. This complementary procedure greatly facilitated the subsequent cannulation of the bile ducts. RESULTS The cannulation frequency of the CBD was 100%. Common bile duct stones were successfully extracted in 93.5%. Endoscopic sphincterotomy (EST), followed by the insertion of a plastic endoprosthesis, was performed in two patients with remaining stones. The CBD of these two patients was cleared by postoperative ERCP. None of the patients developed postoperative pancreatitis. The operating time was prolonged as compared with the time for LC (192 vs 110 mins; p < 0.05). The length of hospitalization for IO-ERCP patients did not differ from that for patients undergoing cholecystectomy alone (2.6 vs 2.1. days; NS). CONCLUSIONS The study suggests that elective IO-ERCP is a safe and efficient method for removing CBDS that has a low risk of inducing postoperative pancreatitis and does not prolong postoperative hospitalization. This technique enables perioperative extraction of CBDS without open or laparoscopic surgical exploration of the CBD and can be used safely in a routine clinical setting.
Collapse
Affiliation(s)
- L Enochsson
- Department of Surgery, Karolinskat Institute at Huddinge University Hospital, S-141 86 Stockholm, Sweden
| | | | | | | |
Collapse
|
37
|
Schwartz JJ, Lew RJ, Ahmad NA, Shah JN, Ginsberg GG, Kochman ML, Brensinger CM, Long WB. The effect of lidocaine sprayed on the major duodenal papilla on the frequency of post-ERCP pancreatitis. Gastrointest Endosc 2004; 59:179-84. [PMID: 14745389 DOI: 10.1016/s0016-5107(03)02540-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute pancreatitis remains a serious cause of ERCP-related morbidity. Topical application of lidocaine reportedly blunts cholecystokinin release from intestinal mucosa and reduces sphincter of Oddi spasm. A randomized trial was conducted to evaluate the effect of lidocaine sprayed on the major duodenal papilla on the frequency of post-ERCP pancreatitis. Secondary outcomes evaluated were ease of cannulation and severity of post-ERCP pancreatitis. METHODS Patients undergoing ERCP were randomized in blocks of 6 to have 10 mL of either 1% lidocaine or normal saline solution sprayed on the major papilla before cannulation. Patients were observed for the development of post-ERCP pancreatitis. Patient history- and procedure-related variables were recorded. RESULTS A total of 326 patients were enrolled, of whom 32 were excluded after randomization but before analysis. Of patients analyzed, 145 were randomized to treatment with lidocaine and 149 to placebo. No patient was lost to follow-up. There was no significant difference noted in patient history- or procedure-related variables. Seven patients in the lidocaine group and 5 in the placebo group developed post-ERCP pancreatitis (p=0.73). Ease of cannulation did not differ between the two groups. CONCLUSIONS Lidocaine sprayed on the major papilla does not decrease the frequency of post-ERCP pancreatitis.
Collapse
Affiliation(s)
- Jeremy J Schwartz
- Gastroenterology Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
| | | | | | | | | | | | | | | |
Collapse
|
38
|
Perney P, Berthier E, Pageaux GP, Hillaire-Buys D, Roques V, Fabbro-Peray P, Melki M, Hanslik B, Bauret P, Larrey D, Blayac JP, Blanc F. Are drugs a risk factor of post-ERCP pancreatitis? Gastrointest Endosc 2003; 58:696-700. [PMID: 14595303 DOI: 10.1016/s0016-5107(03)02019-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatitis is the most severe complication of ERCP. The aim of this study was to assess whether the use of potentially pancreatotoxic drugs is a risk factor for post-ERCP pancreatitis. METHODS Risk factors for post-ERCP pancreatitis and all drugs taken during the month before ERCP were recorded retrospectively in a database. Patients with other causes of acute pancreatitis or chronic pancreatitis were excluded from the analysis. Post-ERCP pancreatitis was defined as abdominal pain and/or vomiting associated with amylase/lipase plasma levels equal to or greater than twice the upper normal value. RESULTS A total of 173 patients (95 men, 78 women; mean age, 68 [16] years) were included. Post-ERCP pancreatitis occurred in 31 patients (18%). Several risk factors were identified in a multivariate analysis: difficulty in cannulation (p<0.001), endoscopic sphincterotomy (p<0.005), and female gender (p=0.02). Having taken potent pancreatotoxic drugs increased the occurrence of post-ERCP pancreatitis: odds ratio 3.7: 95% confidence intervals [1.1,12.4], p=0.04. CONCLUSIONS Use of pancreatotoxic drugs before or during ERCP significantly increased the risk of post-ERCP pancreatitis. Thus, discontinuation of the use of such drugs before ERCP seems justified whenever possible.
Collapse
Affiliation(s)
- Pascal Perney
- Service de Médecine Interne E, Service d'Hépato-Gastroentérologie, Hôpital Saint Eloi, Montpellier Cedex 5, Montpellier, France
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Abstract
Acute pancreatitis is caused by acute or chronic alcohol intake or choledocholithiasis in approximately 80% of cases. In the absence of alcohol abuse or gallstones, a variety of established and putative factors must be considered, any of which can cause a single or recurrent attacks of acute pancreatitis. When the underlying cause eludes detection following an initial thorough search and leads to a second attack, the term idiopathic acute recurrent pancreatitis (IARP) is applied. This article discusses IARP and its work-up.
Collapse
Affiliation(s)
- Asif Khalid
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, PA 15213, USA
| | | |
Collapse
|
40
|
He ZJ, Winston JH, Yusuf TE, Micci MA, Elfert A, Xiao SY, Pasricha PJ. Intraductal administration of an NK1 receptor antagonist attenuates the inflammatory response to retrograde infusion of radiological contrast in rats: implications for the pathogenesis and prevention of ERCP-induced pancreatitis. Pancreas 2003; 27:e13-7. [PMID: 12826913 DOI: 10.1097/00006676-200307000-00018] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The neurogenic inflammatory mediator, substance P (SP), has been implicated in the pathogenesis of acute secretagogue-induced pancreatitis. We hypothesized that it may also play an important role in the development of acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). AIMS Our aim was to evaluate the effectiveness of CP-96345, a NK1 receptor antagonist, in diminishing post-ERCP pancreatitis in a rat model. METHODS The effects of CP-96345, when mixed with the contrast agent, were studied in a rat model of pancreatitis caused by retrograde contrast infusion. After 24 hours, histology, edema, and myeloperoxidase activity (MPO) of pancreas, plasma amylase, and NK1 receptor endocytosis in pancreatic acinar cells were evaluated. RESULTS Intraductal contrast infusion caused increases in plasma amylase, edema, histologic grade, and MPO of pancreas, and NK1 receptor internalization in pancreatic acinar cells. The addition of CP-96345 to the infusate significantly reduced pancreatic edema, MPO activity, and the histologic grade of pancreatitis accompanied by a decrease in NK1 receptor internalization. CONCLUSIONS When an NK1 receptor antagonist is delivered along with the contrast media there is significant reduction in the pancreatic inflammation caused by intraductal contrast infusion. These results provide some insight into the pathogenesis of ERCP induced pancreatitis as well as present novel pharmacological targets for its prevention.
Collapse
Affiliation(s)
- Zhi-Jun He
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Enteric Neuromuscular Disorders and Pain Laboratory, University of Texas Medical Branch, Galveston, Texas 77555, USA
| | | | | | | | | | | | | |
Collapse
|
41
|
Mallery JS, Baron TH, Dominitz JA, Goldstein JL, Hirota WK, Jacobson BC, Leighton JA, Raddawi HM, Varg JJ, Waring JP, Fanelli RD, Wheeler-Harbough J, Eisen GM, Faigel DO. Complications of ERCP. Gastrointest Endosc 2003; 57:633-8. [PMID: 12709688 DOI: 10.1053/ge.2003.v57.amge030576633] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
42
|
Abstract
BACKGROUND Acute pancreatitis can develop after either ERCP or endoscopic sphincterotomy (ES). The pathogenesis of this complication remains poorly understood. METHODS The frequency and severity of acute pancreatitis were retrospectively evaluated after 17,602 ERCP procedures and 3003 ES procedures. Pancreatitis was diagnosed and evaluated according to the scoring system of Ranson and criteria developed in Japan. RESULTS Pancreatitis developed after 15 (0.09%) of 17,602 ERCP procedures and 13 (0.43%) of 3003 ES procedures (p = 0.0001, chi-square). The severity of pancreatitis (Ranson score) was less than 3 in 10 cases of ERCP-induced pancreatitis and from 3 to 5 in 5 cases. One (7%) of the 15 patients with ERCP-related pancreatitis died. All 13 patients with ES-induced pancreatitis had a Ranson score of less than 3; none died (p = 0.04, Fisher exact test). The ERCP pancreatitis score (Japanese criteria) beyond 48 hours after the onset of pancreatitis increased in 5 (33%) of the 15 patients with ERCP-induced pancreatitis; the score did not increase in any of the 13 patients with ES-induced pancreatitis (p = 0.04, Fisher exact test). CONCLUSIONS Although the frequency of ES-induced pancreatitis is significantly higher than that of post-ERCP pancreatitis, the frequency of severe pancreatitis within 48 hours and worsening of pancreatitis after 48 hours is significantly lower with ES-induced pancreatitis. Our hypothesis is that the lowering of pancreatic intraductal pressure after ES mitigates the severity of postprocedure pancreatitis.
Collapse
|
43
|
Sudhindran S, Bromwich E, Edwards PR. Prospective randomized double-blind placebo-controlled trial of glyceryl trinitrate in endoscopic retrograde cholangiopancreatography-induced pancreatitis. Br J Surg 2001; 88:1178-82. [PMID: 11531863 DOI: 10.1046/j.0007-1323.2001.01842.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND One possible aetiology of pancreatitis following endoscopic retrograde cholangio pancreatography (ERCP) is cannulation-induced spasm of the sphincter of Oddi and consequent pancreatic duct obstruction. Sublingual glyceryl trinitrate (GTN) has been shown to produce periampullary sphincter relaxation. The aim of this study was to determine whether prophylactic long-acting GTN could reduce the incidence of ERCP-induced pancreatitis. METHODS In a randomized double-blind study, prophylactic treatment with GTN (2 mg given sublingually 5 min before endoscopy) was compared with placebo in 186 patients who presented for elective ERCP. The primary endpoint was the occurrence of pancreatitis within 24 h, defined as a serum amylase concentration greater than 1000 units/ml in association with a visual analogue pain score of more than 5. RESULTS The incidence of pancreatitis was lower in the GTN group compared with placebo (seven of 90 versus 17 of 96; P < 0.05). Mean serum amylase values were similar in the two groups. The protective effect of GTN appears to be highest in the diagnostic ERCP group (one of 54 versus ten of 66; P = 0.012) and in the group in which cholangiography alone was performed (one of 54 versus eight of 57; P = 0.032). CONCLUSION Prophylactic treatment with GTN reduces the incidence of pancreatitis following ERCP but does not seem to reduce the extent of hyperamylasaemia or the severity of pancreatitis.
Collapse
Affiliation(s)
- S Sudhindran
- Countess of Chester Health Park, Liverpool Road, Chester, UK.
| | | | | |
Collapse
|
44
|
Testoni PA, Bagnolo F, Andriulli A, Bernasconi G, Crotta S, Lella F, Lomazzi A, Minoli G, Natale C, Prada A, Toti GL, Zambelli A. Octreotide 24-h prophylaxis in patients at high risk for post-ERCP pancreatitis: results of a multicenter, randomized, controlled trial. Aliment Pharmacol Ther 2001; 15:965-72. [PMID: 11421871 DOI: 10.1046/j.1365-2036.2001.01015.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pharmacological prophylaxis of post-ERCP pancreatitis is costly and not useful in most non-selected patients, in whom the incidence of pancreatitis is 5% or less. However, it could be useful and probably cost-effective, in patients at high risk for this complication, where the post-procedure pancreatitis rate is 10% and more. AIM To assess the efficacy of octreotide in reducing the incidence and severity of post-ERCP pancreatitis and procedure-related hospital stay, in subjects with known patient-related risk factors. METHODS A total of 120 patients were randomly allocated to receive octreotide or not, in a multicentre, randomized, controlled trial. The drug was given subcutaneously, 200 microg t.d.s., starting 24 h before the ERCP procedure, in patients with either sphincter of Oddi dysfunction, or a history of relapsing pancreatitis or post-ERCP pancreatitis, or who were aged under 35 years, or who had a small common bile duct diameter (< 8 mm). RESULTS A total of 114 patients (58 in the octreotide group and 56 in the control group) completed the trial. Post-procedure pancreatitis occurred in seven octreotide-treated patients (12.0%) and eight controls (14.3%). The two groups showed no significant differences in the incidence or severity of pancreatitis. Twenty-four hours after the procedure, severe hyperamylasemia (more than five times the upper normal limit) without pancreatic-like pain was recorded in three octreotide-treated patients (5.2%) and six controls (10.7%), the difference being not significant. CONCLUSION Twenty-four-hour prophylaxis with octreotide proved ineffective in preventing post-ERCP pancreatitis and in avoiding 24-h severe hyperamylasemia in high-risk patients.
Collapse
Affiliation(s)
- P A Testoni
- University Vita-Salute San Raffaele, San Raffaele, Milan, Italy.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Testoni PA, Bagnolo F. Pain at 24 hours associated with amylase levels greater than 5 times the upper normal limit as the most reliable indicator of post-ERCP pancreatitis. Gastrointest Endosc 2001; 53:33-9. [PMID: 11154486 DOI: 10.1067/mge.2001.111390] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The frequency of post-ERCP/sphincterotomy pancreatitis is between 1.3% and 7.6% in prospective studies. This range likely reflects differences in definitions of pancreatitis and methods of data collection. METHODS To identify clinical findings and enzymatic values consistent for clinical pancreatitis at 24 hours, the post-ERCP/sphincterotomy course of 1185 procedures was prospectively recorded. Patients were evaluated for pancreatic-type pain, white blood cell count, and serum amylase before and 24 hours after the procedure; pain and amylase levels were also recorded 6 to 8 hours after the procedure. CT was performed in all patients with pain associated with amylase levels greater than 3 times normal. All patients were evaluated clinically at 48 hours. RESULTS Pancreatic-type pain never occurred in cases with amylase levels lower than 3 times normal; it was significantly (p < 0.001) associated with amylase levels greater than 5 times normal, either 6 to 8 hours or 24 hours after the procedure. Leukocytosis and CT findings consistent with pancreatitis were observed only in patients (41.7% and 29.5%, respectively) with 24-hour amylase levels greater than 5 times normal. None of the 18 patients with pain at 24 hours and serum amylase lower than 5 times normal had symptoms that persisted at 48 hours. Twenty-five (41.7%) of the 60 patients with pain at 24 hours and amylase higher than 5 times normal had 48-hour pain at 48 hours and hyperamylasemia. CONCLUSIONS Features consistent with clinical pancreatitis were present only among patients with pancreatic-type pain at 24 hours and amylase levels higher than 5 times normal. Additional follow-up is required for these patients.
Collapse
Affiliation(s)
- P A Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, University Vita-Salute San Raffaele, IRCCS San Raffaele Hospital, Milan, Italy
| | | |
Collapse
|
46
|
Reed DN, Vitale GC. Interventional endoscopic retrograde cholangiopancreatography and endoscopic surgery. Surg Clin North Am 2000; 80:1171-201. [PMID: 10987030 DOI: 10.1016/s0039-6109(05)70219-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Interventional endoscopic techniques have been indespensible in almost every area of modern surgery. As surgeons, we need to continue to advance our skills in these areas if we expect to continue to be involved in these aspects of patient care.
Collapse
Affiliation(s)
- D N Reed
- Department of Surgery, University of Louisville School of Medicine, Kentucky, USA
| | | |
Collapse
|
47
|
Rabenstein T, Schneider HT, Nicklas M, Ruppert T, Katalinic A, Hahn EG, Ell C. Impact of skill and experience of the endoscopist on the outcome of endoscopic sphincterotomy techniques. Gastrointest Endosc 1999; 50:628-36. [PMID: 10536317 DOI: 10.1016/s0016-5107(99)80010-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Our aim was to assess the influence of the skill and experience of the endoscopist on the success and risk of endoscopic sphincterotomy techniques. METHODS The outcome of all endoscopic sphincterotomies (n = 1335) carried out between 1988 and 1995 were retrospectively analyzed with respect to the endoscopist performing the procedure. Endoscopists were differentiated according to whether they had previous experience with endoscopic sphincterotomy techniques (n > 100) and the frequency of endoscopic sphincterotomy during the study period (>40, 26 to 40, 10 to 25, <10 per year). RESULTS Indications for endoscopic sphincterotomy techniques and technical execution had only a minor influence on the results of endoscopic sphincterotomy and were comparable for the individual endoscopists. The overall success rate of endoscopic sphincterotomy was 94.4% and did not significantly differ among the endoscopists. The overall complication rate of endoscopic sphincterotomy was 7.3%. Endoscopists learning endoscopic sphincterotomy techniques with a case frequency of less than 10 procedures per year had a consistently high complication rate (10.5%). Those learning endoscopic sphincterotomy techniques with a case frequency of more than 25 procedures per year had an above-average complication rate for their first 40 endoscopic sphincterotomy procedures and a significant decrease in complication rate as the number of procedures increased. The complication rate for experienced endoscopists was 7.7%. There were distinct and, in one case, significant differences in complication rates between individual endoscopists (11.5% vs. 4.8%, p = 0.01). However, when corrected for multiple testing, there were no significant differences at the p < 0. 05 level. The endoscopic sphincterotomy frequency of the endoscopist was the only significant risk factor for complications. Endoscopists with a frequency of more than 40 procedures per year had a significantly lower complication rate (5.6%) than endoscopists with a lower case frequency (9.3%, p < 0.05). CONCLUSIONS A low endoscopic sphincterotomy frequency is, even for endoscopists with previous experience with the procedure, a risk factor for complications after endoscopic sphincterotomy. The learning of endoscopic sphincterotomy techniques requires a minimum of 40 procedures, but also after 100 procedures a further decrease of the complication rate can be expected.
Collapse
Affiliation(s)
- T Rabenstein
- Department of Medicine I, Institute for Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany.
| | | | | | | | | | | | | |
Collapse
|
48
|
Freeman ML, Nelson DB, Sherman S, Haber GB, Fennerty MB, DiSario JA, Ryan ME, Kortan PP, Dorsher PJ, Shaw MJ, Herman ME, Cunningham JT, Moore JP, Silverman WB, Imperial JC, Mackie RD, Jamidar PA, Yakshe PN, Logan GM, Pheley AM. Same-day discharge after endoscopic biliary sphincterotomy: observations from a prospective multicenter complication study. The Multicenter Endoscopic Sphincterotomy (MESH) Study Group. Gastrointest Endosc 1999; 49:580-6. [PMID: 10228255 DOI: 10.1016/s0016-5107(99)70385-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Same-day discharge after endoscopic biliary sphincterotomy (ES) is a common clinical practice, but there have been few data to guide appropriate selection of patients. Using a prospective, multicenter database of complications, we examined outcomes after same-day discharge as it was practiced by a variety of endoscopists and evaluated the ability of a multivariate risk factor analysis to predict which patients would require readmission for complications. METHODS A 150-variable database was prospectively collected at time of ES, before discharge and again at 30 days in consecutive patients undergoing ES at 17 centers. Complications were defined by consensus criteria and included all specific adverse events directly or indirectly related to ES requiring more than 1 night of hospitalization. RESULTS Six hundred fourteen (26%) of 2347 patients undergoing ES were discharged on the same day as the procedure, ranging from none at 6 centers to about 50% at 2 centers. After initial observation and release, readmission to the hospital for complications occurred in 35 (5.7%) of 614 same-day discharge patients (20 pancreatitis and 15 other complications, 3 severe). Of the same-day discharge patients, readmission was required for 14 (12.2%) of 115 who had at least one independently significant multivariate risk factor for overall complications (suspected sphincter of Oddi dysfunction, cirrhosis, difficult bile duct cannulation, precut sphincterotomy, or combined percutaneous-endoscopic procedure) versus 21 (4.2%) of 499 without a risk factor (odds ratio 3.1: 95% confidence interval [1.6, 6.3], p < 0.001). Of complications presenting within 24 hours after ES, only 44% presented within the first 2 hours, but 79% presented within 6 hours. CONCLUSIONS Same-day discharge is widely utilized and relatively safe but results in a significant number of readmissions for complications. For patients at higher risk of complications, as indicated by the presence of at least one of five independent predictors, observation for 6 hours or overnight may reduce the need for readmission.
Collapse
Affiliation(s)
- M L Freeman
- Hennepin County Medical Center and Minneapolis Veterans Administration Medical Center, MN 55415, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Poon RT, Yeung C, Lo CM, Yuen WK, Liu CL, Fan ST. Prophylactic effect of somatostatin on post-ERCP pancreatitis: a randomized controlled trial. Gastrointest Endosc 1999; 49:593-8. [PMID: 10228257 DOI: 10.1016/s0016-5107(99)70387-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Somatostatin is a potent inhibitor of pancreatic secretion and has been studied for its prophylactic effect on post-ERCP pancreatitis. However, results of previous trials have been inconclusive. METHODS A prospective double-blind controlled study was performed to evaluate the effectiveness of somatostatin in preventing post-ERCP pancreatitis. Post-ERCP enzyme elevation, abdominal pain and pancreatitis were evaluated and compared between 109 patients randomized to receive somatostatin infusion and 111 patients randomized to receive normal saline infusion (placebo); both started 30 minutes before ERCP and continued for 12 hours. RESULTS Post-ERCP elevation of serum amylase and lipase levels at 6 and 24 hours after ERCP was less frequent in the group given somatostatin but not statistically significant. There was a tendency toward lower mean serum amylase and lipase levels at 24 hours in patients given somatostatin, although the difference was not statistically significant either. Eight patients given somatostatin (7%) and 18 patients given placebo (16%) had significant abdominal pain after ERCP requiring analgesia (p = 0.04). The frequency of clinical pancreatitis was significantly lower in patients given somatostatin (3%) than in those given placebo (10%) (p = 0.03). CONCLUSIONS Prophylactic treatment with somatostatin reduced the frequency of post-ERCP pancreatitis.
Collapse
Affiliation(s)
- R T Poon
- Endoscopy Unit, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China
| | | | | | | | | | | |
Collapse
|
50
|
|