1
|
Rojas-Victoria EJ, Hernández-Ruiz SI, García-Perdomo HA. Effectiveness of the pharmacological therapy to prevent post ERCP acute pancreatitis: a network meta-analysis. Expert Rev Gastroenterol Hepatol 2024; 18:203-215. [PMID: 38725175 DOI: 10.1080/17474124.2024.2345640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 04/17/2024] [Indexed: 05/24/2024]
Abstract
OBJECTIVE To determine the effectiveness of the different pharmacological agents in preventing post-ERCP acute pancreatitis. METHODS We included clinical trials of pharmacological interventions for prophylaxis of acute post-ERCP pancreatitis. The event evaluated was acute pancreatitis. We conducted a search strategy in MEDLINE (OVID), EMBASE, and Cochrane Central Register of Controlled Trials from inception to nowadays. We reported the information in terms of relative risks (RR) with a 95% confidence interval. We assessed the heterogeneity using the I2 test. RESULTS We included 84 studies for analysis (30,463 patients). The mean age was 59.3 years (SD ± 7.01). Heterogeneity between studies was low (I2 = 34.4%) with no inconsistencies (p = 0.2567). Post ERCP pancreatitis was less in prophylaxis with NSAIDs (RR 0.65 95% CI [0.52 to 0.80]), aggressive hydration with Lactate Ringer (RR 0.32 95% CI [0.12-0.86]), NSAIDs + isosorbide dinitrate (RR 0.28 95% CI [0.11-0.71]) and somatostatin and analogues (RR 0.54 [0.43 to 0.68]) compared with placebo. CONCLUSIONS NSAIDs, the Combination of NSAIDs + isosorbide dinitrate, somatostatin and analogues, and aggressive hydration with lactate ringer are pharmacological strategies that can prevent post-ERCP pancreatitis when compared to placebo. More clinical trials are required to determine the effectiveness of these drugs.
Collapse
Affiliation(s)
| | | | - Herney Andrés García-Perdomo
- Division of Urology/Urooncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
| |
Collapse
|
2
|
Park SJ, Park SY, Kang SY, Kim JH, Heo JY, Yoo JY. The effect of ulinastatin on acute kidney injury in patients undergoing off-pump cardiac bypass surgery. J Cardiothorac Surg 2024; 19:96. [PMID: 38360763 PMCID: PMC10870510 DOI: 10.1186/s13019-024-02562-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/30/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Ulinastatin, an anti-inflammatory and antioxidant trypsin inhibitor, has shown potential in mitigating acute kidney injury (AKI) and reducing serum creatinine levels after various surgeries. This retrospective study aimed to evaluate the effects of ulinastatin on AKI in patients undergoing off-pump coronary artery bypass (OPCAB) surgery. METHODS We hypothesized that the administration of ulinastatin could prevent AKI in OPCAB. Electrical medical records were reviewed to identify OPCAB patients between January 2015 and June 2020. The utilization of ulinastatin was randomly determined and applied during this period. Acute kidney injury was defined according to the KDIGO guideline, and its incidence was compared between the ulinastatin administration group and the control group. To investigate the effect of ulinastatin on renal function, multivariate logistic regression analysis was used to calculate propensity scores for each group. RESULTS A total 454 OPCAB were performed, and after following inclusion and exclusion process, 100 patients were identified in the ulinastatin group and 303 patients in the control group. Using 1:2 propensity score matching, we analyzed 100 and 200 patients in the ulinastatin and control groups. The incidence of AKI was similar between the groups (2.5% for the control group, 2.0% for the ulinastatin group, p > 0.999). However, the serum creatinine value on the first post-operative day were significantly lower in the ulinastatin group compared to the control group (0.774 ± 0.179 mg/dL vs 0.823 ± 0.216 mg/dL, P = 0.040), while no significant differences were observed for the other time points (P > 0.05). The length of ICU stay day was significantly shorter in the ulinastatin group (2.91 ± 2.81 day vs 5.22 ± 7.45 day, respectively, P < 0.001). CONCLUSIONS Ulinastatin did not have a significant effect on the incidence of AKI; it demonstrated the ability to reduce post-operative serum creatine levels at first post-operative day and shorten the length of ICU stay.
Collapse
Affiliation(s)
- Soo Jung Park
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, Korea
| | - Sung Yong Park
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, Korea
| | - Se Yoon Kang
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, Korea
| | - Ji Ho Kim
- Department of Medical Sciences, Ajou University School of Medicine, Suwon, Korea
| | - Ji Yeong Heo
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, Korea
| | - Ji Young Yoo
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon, Korea.
| |
Collapse
|
3
|
Fukuda R, Hakuta R, Nakai Y, Hamada T, Takaoka S, Tokito Y, Suzuki Y, Oyama H, Kanai S, Noguchi K, Suzuki T, Ishigaki K, Saito K, Saito T, Takahara N, Mizuno S, Ito Y, Kogure H, Fujishiro M. Development and external validation of a nomogram for prediction of post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreatology 2023; 23:789-796. [PMID: 37666733 DOI: 10.1016/j.pan.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 06/04/2023] [Accepted: 08/26/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic retrograde cholangiopancreatography (ERCP) is widely performed for management of pancreatobiliary diseases; however, post-ERCP pancreatitis (PEP) remains as an unsolved problem. Although various risk factors for PEP have been reported, the prediction of PEP remains controversial. This study aimed to develop a predictive model for PEP. METHODS Consecutive patients undergoing ERCP for biliary indications at two centers were retrospectively studied. Using data from a training cohort, we utilized a multivariable model to select five variables to construct a nomogram. The predictive model was internally and externally validated. Based on the nomogram, the patients were categorized into low-, moderate-, and high-risk groups. RESULTS Using the data of 2224 patients in the training cohort, five variables were selected to generate a nomogram: 1) sex, 2) indication for ERCP, 3) difficult cannulation, 4) guidewire insertion into the pancreatic duct, and 5) endoscopic sphincterotomy or sphincteroplasty. The most significant risk factor was endoscopic papillary balloon dilation such as endoscopic sphincterotomy or sphincteroplasty. The bias-corrected concordance index was 0.72 in the training cohort and 0.72 in the validation cohort. Calibration curves for both cohorts demonstrated good agreement between the predicted and observed frequencies of the actual outcome. In the validation cohort, PEP developed in 5.0% and 14% of patients in the moderate- and high-risk groups, respectively. CONCLUSIONS We successfully developed a good predictive model for PEP. The prevention of PEP in high risk patients should be investigated further.
Collapse
Affiliation(s)
- Rintaro Fukuda
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan.
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shinya Takaoka
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yurie Tokito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukari Suzuki
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hiroki Oyama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sachiko Kanai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kensaku Noguchi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsunori Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Chemotherapy, The University of Tokyo Hospital, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
4
|
Akshintala VS, Kanthasamy K, Bhullar FA, Sperna Weiland CJ, Kamal A, Kochar B, Gurakar M, Ngamruengphong S, Kumbhari V, Brewer-Gutierrez OI, Kalloo AN, Khashab MA, van Geenen EJM, Singh VK. Incidence, severity, and mortality of post-ERCP pancreatitis: an updated systematic review and meta-analysis of 145 randomized controlled trials. Gastrointest Endosc 2023; 98:1-6.e12. [PMID: 37004815 DOI: 10.1016/j.gie.2023.03.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 03/01/2023] [Accepted: 03/21/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND AND AIMS The incidence, severity, and mortality of post-ERCP pancreatitis (PEP) largely remain unknown with changing trends in ERCP use, indication, and techniques. We sought to determine the incidence, severity, and mortality of PEP in consecutive and high-risk patients based on a systemic review and meta-analysis of patients in placebo and no-stent arms of randomized control trials (RCTs). METHODS The MEDLINE, Embase, and Cochrane databases were searched from the inception of each database to June 2022 to identify full-text RCTs evaluating PEP prophylaxes. The incidence, severity, and mortality of PEP from the placebo or no-stent arms of RCTs were recorded for consecutive and high-risk patients. A random-effects meta-analysis for a proportions model was used to calculate PEP incidence, severity, and mortality. RESULTS One hundred forty-five RCTs were found with 19,038 patients in the placebo or no-stent arms. The overall cumulative incidence of PEP was 10.2% (95% confidence interval [CI], 9.3-11.3), predominantly among the academic centers conducting such RCTs. The cumulative incidences of severe PEP and mortality were .5% (95% CI, .3-.7) and .2% (95% CI, .08-.3), respectively, across 91 RCTs with 14,441 patients. The cumulative incidences of PEP and severe PEP were 14.1% (95% CI, 11.5-17.2) and .8% (95% CI, .4-1.6), respectively, with a mortality rate of .2% (95% CI, 0-.3) across 35 RCTs with 3733 patients at high risk of PEP. The overall trend for the incidence of PEP among patients randomized to placebo or no-stent arms of RCTs has remained unchanged from 1977 to 2022 (P = .48). CONCLUSIONS The overall incidence of PEP is 10.2% but is 14.1% among high-risk patients based on this systematic review of placebo or no-stent arms of 145 RCTs; this rate has not changed between 1977 and 2022. Severe PEP and mortality from PEP are relatively uncommon.
Collapse
Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Kavin Kanthasamy
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Furqan A Bhullar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Ayesha Kamal
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Merve Gurakar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Anthony N Kalloo
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Erwin-Jan M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| |
Collapse
|
5
|
An Insight on Pharmacological and Mechanical Preventive Measures of Post-ERCP PANCREATITIS (PEP)—A Review. GASTROENTEROLOGY INSIGHTS 2022. [DOI: 10.3390/gastroent13040038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pancreatitis is the most common complication following endoscopic retrograde cholangio-pancreatography (ERCP). With the progress of research in many drugs and technologies, promising efficacy has been achieved in preventing post-ERCP pancreatitis (PEP). Recently, combined prevention has received more attention in order to further reduce the incidence of PEP. However, there is no review about the combined prevention of PEP. This review summarizes the medication and ERCP techniques that are used to prevent PEP and emphasizes that appropriate combination prevention approaches should be based on risk stratification.
Collapse
|
6
|
Post-ERCP Pancreatitis: Prevention, Diagnosis and Management. Medicina (B Aires) 2022; 58:medicina58091261. [PMID: 36143938 PMCID: PMC9502657 DOI: 10.3390/medicina58091261] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/21/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) carries a post-ERCP pancreatitis (PEP) rate of 2–10%, which could be as high as 30–50% in high-risk cases. PEP is severe in up to 5% of cases, with potential for life-threatening complications, including multi-organ failure, peripancreatic fluid collections, and death in up to 1% of cases. The risk of PEP is potentially predictable and may be modified with pharmacological measures and endoscopist technique. This review covers the definition, epidemiology and risk factors for PEP, with a focus on the latest evidence-based medical and endoscopic strategies to prevent and manage PEP.
Collapse
|
7
|
Li J, Li M, Li L, Ma L, Cao A, Wen A, Chen W, Li L, Liang Y, Deng J. Real-world safety of ulinastatin: a post-marketing surveillance of 11,252 patients in China. BMC Pharmacol Toxicol 2022; 23:51. [PMID: 35842685 PMCID: PMC9288682 DOI: 10.1186/s40360-022-00585-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 06/28/2022] [Indexed: 12/04/2022] Open
Abstract
Background The safety assessment of ulinastatin can guide clinical practice. The present study aimed to investigate the real-world safety of ulinastatin in China. Methods This multicenter study retrospectively analyzed the post-marketing surveillance data of consecutive patients treated with ulinastatin between August 2014 and June 2017 in the general wards and the intensive care units (ICU) of nine hospitals in China. Adverse drug reactions/adverse drug events (ADRs/ADEs) were collected and evaluated in a post-marketing database. Results A total of 11,252 consecutive patients were included in the study: 7009 ICU patients and 4243 general ward patients. Eleven patients with ADRs/ADEs were observed, including nine ICU patients and two general ward patients. The clinical manifestations were liver dysfunction (n = 5 ICU cases, n = 1 general case), thrombocytopenia (n = 2 ICU cases, n = 1 general case), leukopenia (n = 1 ICU case), and rash (n = 1 ICU case). During the study period, the drug ADR/ADE rate of ulinastatin injection was 0.98‰ (11/11,252 × 1000‰). Among the 11,252 valid patients, only 327 received ulinastatin in accordance with the drug specifications. After excluding unreasonable drug use, the calculated ADR rate was 3.06‰ (1/327 × 1000‰) (95% confidence interval: 0.0‰-17.1‰). In ICU and general ward patients, the use of other drugs combined with ulinastatin was associated with the occurrence of ADRs/ADEs (100% with ADRs/ADEs vs. 0% in controls, P < 0.001). Conclusions The incidence of ADRs/ADEs of ulinastatin is < 5‰. The ADRs/ADEs involved limited organs, mainly the skin, gastrointestinal tract, and blood. In most cases, the ADRs/ADEs gradually alleviated or recovered after drug withdrawal. The inappropriate/off-label use of ulinastatin should be the focus of surveillance. Supplementary Information The online version contains supplementary material available at 10.1186/s40360-022-00585-3.
Collapse
Affiliation(s)
- Jin Li
- Pharmacy Department, Guangzhou United Family Hospital, Guangzhou, 510335, Guangdong, China.,Guangdong Province Pharmacological Society, No. 753 East Dongfeng Road, Guangzhou, 510080, Guangdong, China
| | - Meijun Li
- Guangdong Province Pharmacological Society, No. 753 East Dongfeng Road, Guangzhou, 510080, Guangdong, China
| | - Liren Li
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Lin Ma
- Managed Service Organization, Guangdong Hospital of Traditional Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Ailin Cao
- Department of Medicines and Devices, The First Affiliated Hospital of Naval Military Medical University (Shanghai Changhai Hospital), Shanghai, 200433, China
| | - Aiping Wen
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Wenge Chen
- Department of Industrial Engineering, College of Mechanical and Electrical Engineering, Guangdong University of Technology, Guangzhou, 518049, Guangdong, China
| | - Lingling Li
- Guangdong Province Pharmacological Society, No. 753 East Dongfeng Road, Guangzhou, 510080, Guangdong, China
| | - Yan Liang
- Guangdong Province Pharmacological Society, No. 753 East Dongfeng Road, Guangzhou, 510080, Guangdong, China
| | - Jianxiong Deng
- Guangdong Province Pharmacological Society, No. 753 East Dongfeng Road, Guangzhou, 510080, Guangdong, China.
| |
Collapse
|
8
|
Effects of Fasting and Administration of Octreotide Acetate and Ulinastatin on Clinical Outcomes of Pancreatic Fistula after Pancreatoduodenectomy. Int Surg 2022. [DOI: 10.9738/intsurg-d-21-00022.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: Postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy is the most serious complication of these surgical procedures; therefore, we examine the effectiveness of fasting, and administration of octreotide acetate and ulinastatin as a method of prevention. Summary of Background Data : Although various drug therapies and surgical techniques have been used for the treatment of POPF, no decisive treatment for POPF exists. Methods: The clinical course of 30 patients who developed POPF was retrospectively evaluated and compared between no dietary intake (n=18), octreotide acetate (n=8), and ulinastatin (n=8) using an overlapping design. Patients were allocated to either the dietary intake or fasting (no dietary intake) group, and those in the no dietary intake group were further divided into the octreotide acetate or ulinastatin group. Results: Length of hospitalization was longer for the no dietary intake group than for the dietary intake group (p=0.002). When considering only grade B or C POPF cases, the no dietary intake group had a longer length of hospitalization and a higher white blood cell count on day 7 after the diagnosis of POPF than the dietary intake group (p<0.05). The white blood cell count was also higher in the octreotide acetate group than in the ulinastatin group (p=0.021). The length of hospitalization was shorter in the ulinastatin group than in the octreotide acetate group (p=0.025). Conclusions: The use of no dietary intake, octreotide acetate, and ulinastatin do not seem to contribute to the clinical course of patients with POPF after pancreatoduodenectomy.
Collapse
|
9
|
Cooling the papilla with ice water in preventing post-ERCP pancreatitis (ice water challenge study). Surg Endosc 2022; 36:6002-6006. [PMID: 34977992 DOI: 10.1007/s00464-021-08924-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 11/21/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The most common adverse event of endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). The aim of this study was to investigate the efficacy of cooling the papilla with iced water to reduce PEP. PATIENTS AND METHODS Between December 2018 and July 2019, 100 consecutive patients with native papilla undergoing ERCP were prospectively enrolled in this study. In all patients, iced water was injected endoscopically toward the papilla via the working channel at the end of ERCP. The results were compared with 100 previous cases with native papilla that underwent ERCP under the same conditions without papilla cooling. RESULTS Although the difference was not significant, the incidence of PEP tended to be lower in the study group (4%) than in the control group (11%) (p = 0.060). In addition, the incidence of PEP was significantly reduced in patients who underwent biliary sphincterotomy (p = 0.033). All cases of PEP were mild. CONCLUSIONS Cooling the papilla with iced water injection, which is safe, easy, and cheap might reduce PEP.
Collapse
|
10
|
Tomishima K, Ishii S, Fujisawa T, Yatagai N, Kabemura D, Sato S, Amano N, Murata A, Tsuzura H, Sato S, Matsumoto K, Shimada Y, Genda T, Nagahara A, Isayama H. Does restricting fluid volume impact post-ERCP pancreatitis in patient with heart disease? Saudi J Gastroenterol 2021; 27:355-360. [PMID: 34213425 PMCID: PMC8656333 DOI: 10.4103/sjg.sjg_693_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
METHODS Two hundred and forty seven of 480 patients with naïve papilla undergoing therapeutic ERCP between April 2013 and March 2018 were enrolled for the study. The following patient characteristics were investigated: age, sex, body mass index, previous diseases (heart disease, renal failure, cerebrovascular disorders, coexisting malignancy and pulmonary disease), history of PEP, common bile duct diameter, diverticula and volume of fluid infused 24 hours after the procedure. All ERCP cases had naïve papilla and had undergone treatment. RESULTS The incidence of PEP was 8.5%. Significant differences were observed in the volume of fluid infused between patients without and with a history of heart disease (1,380 vs. 1,755 mL). The mean volume of the infused fluid was significantly lower in the PEP than non-PEP group (1,483 vs. 1,688 mL, P = 0.02). Moreover, PEP incidence differed according to a fluid infusion cutoff of 1,000 mL (7 vs. 11 cases of PEP in those with ≦1,000 mL and >1,000 mL fluid volume, respectively, P < 0.001). CONCLUSION Restricted fluid volume was a newly identified risk factor for PEP, particularly in patients with heart and renal diseases as comorbidities.
Collapse
Affiliation(s)
- Ko Tomishima
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan,Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Tokyo, Japan
| | - Shigeto Ishii
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Toshio Fujisawa
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Noboru Yatagai
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan,Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Tokyo, Japan
| | - Daishi Kabemura
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan,Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Tokyo, Japan
| | - Sho Sato
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Tokyo, Japan
| | - Nozomi Amano
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Tokyo, Japan
| | - Ayato Murata
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Tokyo, Japan
| | - Hironori Tsuzura
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Tokyo, Japan
| | - Shunsuke Sato
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Tokyo, Japan
| | - Kouhei Matsumoto
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan,Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Tokyo, Japan
| | - Yuji Shimada
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Tokyo, Japan
| | - Takuya Genda
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Tokyo, Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan,Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan,Address for correspondence: Prof. Hiroyuki Isayama, Department of Gastroenterology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo - 113-8421, Japan. E-mail:
| |
Collapse
|
11
|
Sugimoto S, Hattori A, Maegawa Y, Nakamura H, Okuda N, Takeuchi T, Oyamada J, Kamei A, Kawabata H, Aoki M, Naota H. Long-term Outcomes of Therapeutic Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis in Patients ≥90 Years Old: A Multicenter Retrospective Study. Intern Med 2021; 60:1989-1997. [PMID: 33551408 PMCID: PMC8313914 DOI: 10.2169/internalmedicine.6478-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/16/2020] [Indexed: 12/27/2022] Open
Abstract
Objective The safety and prognosis of complete stone removal for the treatment of choledocholithiasis in older patients are unknown. This multicenter retrospective study assessed the outcomes of complete stone removal in elderly patients (≥90 years) with respect to the prognosis. Methods We divided patients who underwent endoscopic cholangiopancreatography for choledocholithiasis into two groups: complete stone removal or incomplete stone removal with plastic stent insertion. The patient characteristics, adverse events, number of endoscopic cholangiopancreatographies, overall survival rates, and disease-specific cumulative death were compared between the groups. Patients Two hundred and twenty-three participants ≥90 years old were included in the study, including 48 (22%) men and 175 (78%) women. The median age was 92 (range, 90-104) years old. There were 160 (72%) and 63 (28%) patients in the complete and incomplete groups, respectively. Results The age, performance status, comorbidities, severe complication rates, and stone diameter were comparable between the groups. The proportion of patients with at least 5 stones was significantly higher in the incomplete group than in the complete group [complete group: 8.1% (13/160) and incomplete group: 21% (13/63), p<0.01]. The overall survival rate was significantly higher in the complete group (p<0.01), while the disease-specific cumulative death rate was higher in the incomplete group (p<0.01). Conclusion Complete stone removal for choledocholithiasis may contribute to a better prognosis in elderly patients ≥90 years old.
Collapse
Affiliation(s)
| | - Aiji Hattori
- Division of Gastroenterology, Saiseikai Matsusaka General Hospital, Japan
| | - Yuri Maegawa
- Division of Gastroenterology, Matsusaka Chuo General Hospital, Japan
| | | | - Naoko Okuda
- Division of Gastroenterology, Ise Red Cross Hospital, Japan
| | | | - Jun Oyamada
- Division of Gastroenterology, Ise Red Cross Hospital, Japan
| | - Akira Kamei
- Division of Gastroenterology, Ise Red Cross Hospital, Japan
| | - Hiroyuki Kawabata
- Division of Gastroenterology, Saiseikai Matsusaka General Hospital, Japan
| | - Masatoshi Aoki
- Division of Gastroenterology, Saiseikai Matsusaka General Hospital, Japan
| | - Hiroaki Naota
- Division of Gastroenterology, Matsusaka Chuo General Hospital, Japan
| |
Collapse
|
12
|
Teshigahara Y, Kakizaki I, Hirao W, Tanaka K, Takahashi R. A Chondroitin Sulfate Chain of Urinary Trypsin Inhibitor Enhances Protease Inhibitory Activity of the Core Protein. J Appl Glycosci (1999) 2021; 67:63-66. [PMID: 34354530 PMCID: PMC8283410 DOI: 10.5458/jag.jag.jag-2019_0021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 02/12/2020] [Indexed: 11/24/2022] Open
Abstract
Human urinary trypsin inhibitor (UTI) is a proteoglycan composed of one core protein covalently linked to one glycosaminoglycan, which is a low sulfated chondroitin 4-sulfate. It is used as an anti-inflammatory medicine based on the protease inhibitory activity of the core protein. However, functions of the chondroitin sulfate have not been clarified. Recently, we succeeded in remodeling the UTI chondroitin sulfate to hyaluronan to create hyaluronan hybrid UTI, without changing the core protein. Here, we investigated the effect of the remodeled chondroitin sulfate on the activities of serine proteases. Native UTI showed stronger protease inhibitory activity than hyaluronan hybrid UTI or hydrolyzed glycosaminoglycan UTI. Chondroitin 4-sulfate chains with a small peptide derived from the native UTI did not show any protease inhibitory activity. These results suggest that the chondroitin sulfate chain linked covalently to core protein enhances protease inhibitor activity of UTI although the chondroitin sulfate chain itself does not.
Collapse
Affiliation(s)
- Yu Teshigahara
- 1 Department of Glycotechnology, Center for Advanced Medical Research, Hirosaki University School of Medicine
| | - Ikuko Kakizaki
- 2 Department of Glycotechnology, Center for Advanced Medical Research, Hirosaki University Graduate School of Medicine
| | - Wataru Hirao
- 2 Department of Glycotechnology, Center for Advanced Medical Research, Hirosaki University Graduate School of Medicine
| | - Kanji Tanaka
- 3 Department of Obstetrics and Gynecology, Hirosaki University Graduate School of Medicine
| | | |
Collapse
|
13
|
Honselmann KC, Antoine C, Frohneberg L, Deichmann S, Bolm L, Braun R, Lapshyn H, Petrova E, Keck T, Wellner U, Bausch D. A simple nomogram for early postoperative risk prediction of clinically relevant pancreatic fistula after pancreatoduodenectomy. Langenbecks Arch Surg 2021; 406:2343-2355. [PMID: 34009458 PMCID: PMC8578094 DOI: 10.1007/s00423-021-02184-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 04/28/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Postoperative pancreatic fistulae (POPF) present a serious and life-threatening complication after pancreatic head resections (PD). Therefore, reliable risk stratification to identify those at risk is urgently needed. The aim of this study was to identify postoperative laboratory parameters for the prediction of POPF in the early postoperative period. METHODS One hundred eighty-two patients who underwent PD from 2012 until 2017 were retrospectively analyzed. Multivariate logistic regression was performed using the GLM (general linear model) method for model building. Two nomograms were created based on the GLM models of postoperative day one and postoperative day one to five. A cohort of 48 patients operated between 2018 and 2019 served as internal validation. RESULTS Clinically relevant pancreatic fistulae (CR-POPF) were present in 16% (n = 29) of patients. Patients with CR-POPF experienced significantly more insufficiencies of gastroenterostomies, delayed gastric emptying, and more extraluminal bleeding than patients without CR-POPF. Multivariate analysis revealed multiple postoperative predictive models, the best one including ASA, main pancreatic duct diameter, operation time, and serum lipase as well as leucocytes on day one. This model was able to predict CR-POPF with an accuracy of 90% and an AUC of 0.903. Two nomograms were created for easier use. CONCLUSION Clinically relevant fistula can be predicted using simple laboratory and clinical parameters. Not serum amylase, but serum lipase is an independent predictor of CR-POPF. Our simple nomograms may help in the identification of patients for early postoperative interventions.
Collapse
Affiliation(s)
- K C Honselmann
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - C Antoine
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - L Frohneberg
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - S Deichmann
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - L Bolm
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - R Braun
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - H Lapshyn
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - E Petrova
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - T Keck
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - U Wellner
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - D Bausch
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany. .,Department of Surgery, Marien Hospital Herne-University Medical Center of the Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Germany.
| |
Collapse
|
14
|
Maruyama H, Shiba M, Ishikawa-Kakiya Y, Kato K, Ominami M, Fukunaga S, Otani K, Hosomi S, Tanaka F, Kamata N, Taira K, Nagami Y, Yamagami H, Tanigawa T, Watanabe T, Yamamoto A, Kabata D, Shintani A, Fujiwara Y. Positive correlation between pancreatic volume and post-endoscopic retrograde cholangiopancreatography pancreatitis. J Gastroenterol Hepatol 2020; 35:769-776. [PMID: 31618801 DOI: 10.1111/jgh.14878] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 08/16/2019] [Accepted: 09/25/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remains the most common and serious adverse event associated with ERCP. Risk factors for PEP have been described in various reports. However, risk factors have not been quantified to date. The aim of this study was to investigate the risk factors for PEP by quantification of pancreatic volume using pre-ERCP images. METHODS Overall, 800 patients were recruited from April 2012 to February 2015 for this study. There were 168 patients who satisfied the inclusion criteria. Measurement of pancreatic volume was achieved using the volume analyzer SYNAPSE VINCENT in all cases and was used to evaluate the risk factors for PEP. RESULTS According to the criteria established by the consensus guidelines (Cotton classification), 17 patients (10.1%) were classified as having mild disease, 4 (2.4%) as having moderate disease, and 5 (3.0%) as having severe disease. Multivariate model analysis showed that a large pancreatic volume was a significant risk factor for PEP (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.06-1.13; P < 0.001). In addition, the association between the pancreatic volume and the severity of PEP was positively correlated (the effect of volume [per 1 mL]; OR 1.09, 95% CI 1.07-1.12; P < 0.001, the effect of volume [per 10 mL]; OR 2.27, 95% CI 1.72-3.00; P < 0.001). A larger pancreatic volume was significantly associated with a higher incidence of PEP. CONCLUSIONS A large pancreatic volume was identified as a risk factor for PEP. The results of this study suggest that pre-ERCP images might be useful for predicting PEP.
Collapse
Affiliation(s)
- Hirotsugu Maruyama
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Masatsugu Shiba
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Yuki Ishikawa-Kakiya
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Kunihiro Kato
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Shusei Fukunaga
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Koji Otani
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Noriko Kamata
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Koichi Taira
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hirokazu Yamagami
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Tetsuya Tanigawa
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Daijiro Kabata
- Department of Medical Statistics, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| |
Collapse
|
15
|
Meng WT, Qing L, Li CZ, Zhang K, Yi HJ, Zhao XP, Xu WG. Ulinastatin: A Potential Alternative to Glucocorticoid in the Treatment of Severe Decompression Sickness. Front Physiol 2020; 11:273. [PMID: 32273851 PMCID: PMC7113395 DOI: 10.3389/fphys.2020.00273] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 03/10/2020] [Indexed: 01/08/2023] Open
Abstract
Inflammatory reaction is the crux in various clinical critical diseases including decompression sickness (DCS). Ulinastatin (UTI), a potent anti-inflammatory agent, has been used clinically, including as a substitution for steroids. This study aimed to explore the potential effects of UTI upon DCS in a rabbit model. Eighty-eight rabbits were subjected to simulated diving to 6 atmospheres absolute (ATA) for 60 min with 2.5-minute decompression. Three doses of UTI (15/7.5/3.75 × 105 U/kg) or saline were intravenously administered immediately following decompression. Circulating bubbles were monitored for 3 h following decompression and DCS signs were evaluated for 24 h. Blood was sampled 8 times during 72 h after decompression for inflammatory, endothelial, oxidative and routine blood indices. Lung tissues were also sampled for evaluating endothelial function. Another six rabbits were used as Normal controls. In the high dose UTI group the mortality, general morbidity and incidence of severe DCS was decreased from 31.25 to 9.38% (P = 0.030), 84.38 to 62.50% (P = 0.048) and 46.88 to 21.88% (P = 0.035), respectively. The high dose of UTI significantly postponed the occurrence of DCS (P = 0.030) and prolonged survival time (P = 0.009) compared with the Saline group, and significantly ameliorated inflammation responses, endothelial injuries and oxidative damage. The results strongly suggest the benefit of UTI on DCS, especially for severe cases. Large doses are needed to achieve significant effects. UTI may be a potential ideal pharmacological candidate for the treatment of severe DCS.
Collapse
Affiliation(s)
- Wen-Tao Meng
- Department of Diving and Hyperbaric Medicine, Naval Special Medicine Center, Naval Medical University, Shanghai, China
| | - Long Qing
- Naval Diving Medical Discipline, Naval Special Medicine Center, Naval Medical University, Shanghai, China
| | - Chun-Zhen Li
- School of Basic Medicines, Naval Medical University, Shanghai, China
| | - Kun Zhang
- Department of Diving and Hyperbaric Medicine, Naval Special Medicine Center, Naval Medical University, Shanghai, China
| | - Hong-Jie Yi
- Department of Diving and Hyperbaric Medicine, Naval Special Medicine Center, Naval Medical University, Shanghai, China
| | - Xu-Peng Zhao
- Department of Diving and Hyperbaric Medicine, Naval Special Medicine Center, Naval Medical University, Shanghai, China
| | - Wei-Gang Xu
- Department of Diving and Hyperbaric Medicine, Naval Special Medicine Center, Naval Medical University, Shanghai, China
| |
Collapse
|
16
|
Meng F, Du C, Zhang Y, Wang S, Zhou Q, Wu L, Wang Y, Yang X. Protective effect of rhubarb combined with ulinastatin for patients with sepsis. Medicine (Baltimore) 2020; 99:e18895. [PMID: 32049789 PMCID: PMC7035124 DOI: 10.1097/md.0000000000018895] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Sepsis is the leading cause of death in critically ill patients. Ulinastatin (UTI), a protease inhibitor, and rhubarb, used as a traditional Chinese medication, are proved to be effective in treating sepsis, but the effect of the combination therapy of these two drugs on sepsis remains unclear. This study aimed to investigate the effect of the combination treatment of UTI and rhubarb on sepsis patients. METHODS A total of 75 septic patients were randomly divided into control group, UTI group, Rhubarb group, and UTI plus Rhubarb group. Clinical data and score of Acute Physiology and Chronic Health Evaluation II (APACHE II) were collected; lymphocyte subtypes in the peripheral blood were analyzed before and after the 5-day treatment in the Intensive Care Unit. RESULTS All the therapeutic interventions (UTI alone, rhubarb alone, or UTI plus rhubarb) significantly reduced the levels of C-Reactive protein, white blood cell density, lactic acid, and APACH II scores, and elevated the levels of CD4/CD8, but only UTI plus rhubarb treatment obviously decreased the level of procalcitonin. CONCLUSION This study suggested that the combination of UTI and rhubarb may be a promising therapeutic scheme to ameliorate sepsis.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Yanli Wang
- Department of Mental Health, First Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, China
| | | |
Collapse
|
17
|
Okuda N, Sugimoto S, Nakamura H, Hisada H, Temma T, Hashimoto Y, Hayashi S, Ito T, Takami M, Oyamada J, Kamei A. Is complete stone removal for choledocholithiasis always necessary in extremely elderly patients? JGH Open 2020; 4:16-21. [PMID: 32055692 PMCID: PMC7008169 DOI: 10.1002/jgh3.12198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 04/21/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Endoscopic stone removal has some complications. Although the life expectancy of elderly patients has increased dramatically worldwide, little information is available on the necessity of complete endoscopic stone removal in extremely elderly patients. This study aimed to evaluate the safety and efficacy of complete endoscopic stone removal in extremely elderly patients. METHODS All extremely elderly patients (>90 years) who underwent endoscopic stone removal for choledocholithiasis at our hospital between January 2012 and January 2017 were retrospectively evaluated. The included patients were divided into complete stone removal and incomplete stone removal groups. Complication rate, overall survival (OS), and disease-specific survival (DSS) rates were compared between the two groups. RESULTS Overall, 73 patients were included in this study. The median number of stones was one (range, 0-10) and two (range, 1-12) (P = 0.043), while the median diameter of the largest stones was 9 (range, 0-27) and 14 (range, 5-46) mm (P = 0.001) in the complete and incomplete stone removal groups, respectively. During the follow-up period, OS was 60% and 39% and DSS was 95% and 97% in the complete and incomplete stone removal groups, respectively. Kaplan-Meier analysis found no significant difference in OS and DSS between the two groups (P = 0.052 and P = 0.646, respectively). CONCLUSION Complete stone removal might not always be necessary in extremely elderly patients aged ≥90 years.
Collapse
Affiliation(s)
- Naoko Okuda
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| | | | | | | | - Taishi Temma
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| | - Yuki Hashimoto
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| | | | - Tatsuya Ito
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| | - Mayuko Takami
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| | - Jun Oyamada
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| | - Akira Kamei
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| |
Collapse
|
18
|
Ulinastatin treatment for acute respiratory distress syndrome in China: a meta-analysis of randomized controlled trials. BMC Pulm Med 2019; 19:196. [PMID: 31684936 PMCID: PMC6829844 DOI: 10.1186/s12890-019-0968-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 10/18/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Epidemiologic studies have shown inconsistent conclusions about the effect of ulinastain treatment for acute respiratory distress syndrome (ARDS). It is necessary to perform a meta-analysis of ulinastatin's randomized controlled trials (RCTS) to evaluate its efficacy for treating ARDS. METHODS We searched the published RCTs of ulinastatin treatment for ARDS from nine databases (the latest search on April 30th, 2017). Two authors independently screened citations and extracted data. The meta-analysis was performed using Rev. Man 5.3 software. RESULTS A total of 33 RCTs involving 2344 patients satisfied the selection criteria and were included in meta-analysis. The meta-analysis showed that, compared to conventional therapy, ulinastatin has a significant benefit for ARDS patients by reducing mortality (RR = 0.51, 95% CI:0.43~0.61) and ventilator associated pneumonia rate (RR = 0.50, 95% CI: 0.36~0.69), and shortening duration of mechanical ventilation (SMD = -1.29, 95% CI: -1.76~-0.83), length of intensive care unit stay (SMD = -1.38, 95% CI: -1.95~-0.80), and hospital stay (SMD = -1.70, 95% CI:-2.63~-0.77). Meanwhile, ulinastatin significantly increased the patients' oxygenation index (SMD = 2.04, 95% CI: 1.62~2.46) and decreased respiratory rate (SMD = -1.08, 95% CI: -1.29~-0.88) and serum inflammatory factors (tumor necrosis factor-α: SMD = -3.06, 95% CI:-4.34~-1.78; interleukin-1β: SMD = -3.49, 95% CI: -4.64~-2.34; interleukin-6: SMD = -2.39, 95% CI: -3.34~-1.45; interleukin-8: SMD = -2.43, 95% CI: -3.86~-1.00). CONCLUSIONS Ulinastatin seemly showed a beneficial effect for ARDS patients treatment and larger sample sized RCTs are needed to confirm our findings.
Collapse
|
19
|
Lyu Y, Wang B, Cheng Y, Xu Y, Du W. Comparative Efficacy of 9 Major Drugs for Postendoscopic Retrograde Cholangiopancreatography Pancreatitis: A Network Meta-Analysis. Surg Laparosc Endosc Percutan Tech 2019; 29:426-432. [DOI: 10.1097/sle.0000000000000707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
20
|
Liao XL, Danzeng QZ, Zhang W, Hou CS, Xu BB, Yang J, Kang Y. Role of using two-route ulinastatin injection to alleviate intestinal injury in septic rats. Chin J Traumatol 2018; 21:323-328. [PMID: 30591258 PMCID: PMC6354214 DOI: 10.1016/j.cjtee.2018.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 07/08/2018] [Accepted: 08/15/2018] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Early application of protease inhibitors through the intestinal lumen could increase survival following experimental shock by blocking the pancreatic digestive enzymes. Hence, it was hypothesized that two-route injection (intraintestinal + intravenous) of ulinastatin (UTI), a broad-spectrum protease inhibitor, could better alleviate intestinal injury than single-route injection (either intravenous or intraintestinal). METHODS A sepsis model induced by lipopolysaccharide on rats was established. The rats were randomly divided into five groups: sham, sepsis, UTI intravenous injection (Uiv), UTI intraintestinal injection (Uii), and UTI intraintestinal + intravenous injection (Uii + Uiv) groups. The mucosal barrier function, enzyme-blocking effect, levels of systemic inflammatory cytokines, and 5-day survival rate were compared among groups. The small intestinal villus height (VH), crypt depth (CD), and two components of mucosal barrier (E-cadherin and mucin-2) were measured to evaluate the mucosal barrier function. The levels of trypsin and neutrophil elastase (NE) in the intestine, serum, and vital organs were measured to determine the enzyme-blocking effect. RESULTS Compared with the single-route injection group (Uiv or Uii), the two-route injection (Uii + Uiv) group displayed: (1) significantly higher levels of VH, VH/CD, E-cadherin, and mucin-2; (2) decreased trypsin and NE levels in intestine, plasma, and vital organs; (3) reduced systemic inflammatory cytokine levels; and (4) improved survival of septic rats. CONCLUSION Two-route UTI injection was superior to single-route injection in terms of alleviating intestinal injury, which might be explained by extensive blockade of proteases through different ways.
Collapse
Affiliation(s)
- Xue-Lian Liao
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Qu-Zhen Danzeng
- Department of Critical Care Medicine, Tibet Autonomous Region People's Hospital, Lhasa 850000, Tibet, China
| | - Wei Zhang
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical College, Zunyi 563000, Guizhou Province, China
| | - Chen-Shu Hou
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Bin-Bin Xu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jie Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China,Corresponding author.
| |
Collapse
|
21
|
Chen G, Gao Y, Jiang Y, Yang F, Li S, Tan D, Ma Q. Efficacy and Safety of Xuebijing Injection Combined With Ulinastatin as Adjunctive Therapy on Sepsis: A Systematic Review and Meta-Analysis. Front Pharmacol 2018; 9:743. [PMID: 30087610 PMCID: PMC6066690 DOI: 10.3389/fphar.2018.00743] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 06/19/2018] [Indexed: 12/11/2022] Open
Abstract
Background: Xuebijing injection (XBJ), transforming from Xuefuzhuyu decoction, is the only Chinese medicine injection approved for sepsis. XBJ and ulinastatin (UTI) combination therapy is supposed to be beneficial for sepsis patients. To fill the gap between the lack of evidence for the efficacy of combination therapy and its increasing application among patients, an extensive meta-analysis was performed. Methods: Eight databases were searched to identify randomized controlled trials (RCTs) comparing XBJ plus UTI with UTI alone in treating sepsis from inception to February 5, 2018. Data extraction and methodological quality assessment of the included RCTs were implemented by two investigators independently. All data were synthesized and analyzed utilizing Review Manager 5.3. Results: Seventeen RCTs with a total of 1,247 participants corresponded with the inclusion criteria of our study. The findings reflected that in comparison to single UTI, XBJ and UTI combination therapy could significantly lower 28-day mortality (RR = 0.54, 95% CI [0.39, 0.73], P < 0.0001), shorten duration of mechanical ventilation (SMD = −1.13, 95% CI [−1.30, −0.95], P < 0.00001), reduce length of ICU stay (SMD = −0.84, 95% CI [−1.00, −0.67], P < 0.00001), and decrease APACHE II score (SMD = −1.09, 95% CI [−1.49, −0.69], P < 0.00001). Additionally, XBJ plus UTI had superiority over single UTI in lowering PCT levels (SMD = −1.61, 95% CI [−2.23, −0.98], P < 0.00001), and improving inflammatory cytokines—IL-6 and TNF-α levels (SMD = −1.45, 95% CI [−1.71, −1.19], P < 0.00001; SMD = −1.11, 95% CI [−1.42, −0.80], P < 0.00001). Moreover, CRP, hs-CRP, and LPS levels were remarkably reduced by XBJ plus UTI compared with UTI alone (SMD = −1.50, 95% CI [−2.00, −1.00], P < 0.00001; SMD = −1.31, 95% CI [−1.70, −0.93], P < 0.00001; SMD = −1.17, 95% CI [−1.42, −0.92], P < 0.00001). Three studies involving 14 patients reported the occurrences of adverse events. Conclusions: Comparing with UTI alone, XBJ and UTI combination therapy appeared to be more effective for sepsis. However, owing to the limitations of this meta-analysis, additional RCTs with higher-quality and more rigorous design are needed to confirm our findings.
Collapse
Affiliation(s)
- Guochao Chen
- Department of Pharmacy of Chinese Materia Medica, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Yanyan Gao
- Department of Pharmacy of Chinese Materia Medica, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Yue Jiang
- Department of Pharmacy of Chinese Materia Medica, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Fei Yang
- Department of Pharmacy of Chinese Materia Medica, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Shuangshuang Li
- Department of Pharmacy of Chinese Materia Medica, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Di Tan
- Department of Pharmacy of Chinese Materia Medica, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Qun Ma
- Department of Pharmacy of Chinese Materia Medica, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| |
Collapse
|
22
|
Mine T, Morizane T, Kawaguchi Y, Akashi R, Hanada K, Ito T, Kanno A, Kida M, Miyagawa H, Yamaguchi T, Mayumi T, Takeyama Y, Shimosegawa T. Clinical practice guideline for post-ERCP pancreatitis. J Gastroenterol 2017; 52:1013-1022. [PMID: 28653082 DOI: 10.1007/s00535-017-1359-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/04/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERPC) is used for the diagnosis and treatment of pancreatic and biliary diseases. Post-ERCP pancreatitis (PEP) is a complication which needs special care and clinical practice guideline for this morbidity is also needed. METHODS The key clinical issues of diagnosis and treatment of PEP were listed and checked, and then the clinical questions were formulated. PubMed (MEDLINE) and Ichushi-web (Japanese medical literature) were used as databases. For the study of diagnostic test accuracy, items similar to QUADAS-2, i.e., random selection from a population to which the diagnostic test is applied, blinding of index tests and reference tests, completeness of reference standard, completeness of test implementations, the same timing of tests, and missing data were assessed as well as the indirectness of the study subjects, index tests, reference standard, and outcomes. Grading of recommendations was determined as strong or weak. In clinical practice, the judgment of attending doctors should be more important than recommendations described in clinical practice guidelines. Gastroenterologists are the target users of this clinical practice guideline. General practitioners or general citizens are not supposed to use this guideline. The guideline committee has decided to include wide clinical issues such as etiological information, techniques of ERCP, the diagnosis, treatments, and monitoring of PEP in this guideline. RESULTS In this concise report, we described ten clinical questions, recommendations, and explanations pertaining to risk factors, diagnosis, prognostic factors, treatments, and preventive interventions in the medical practice for PEP. CONCLUSIONS We reported here the essence of the clinical practice guideline for PEP.
Collapse
Affiliation(s)
- Tetsuya Mine
- Tokai University, School of Medicine, Isehara, Japan.
| | | | | | - Ryukichi Akashi
- Kumamoto City Medical Association Health Care Center, Kumamoto, Japan
| | | | - Tetsuhide Ito
- Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Atsushi Kanno
- Department of Gastroenterology, Tohoku University, Sendai, Japan
| | - Mitsuhiro Kida
- Kitasato University School of Medicine, Sagamihara, Japan
| | | | | | - Toshihiko Mayumi
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | |
Collapse
|
23
|
Zhu K, Wang JP, Su JG. Prophylactic ulinastatin administration for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis. Exp Ther Med 2017; 14:3036-3056. [PMID: 28966682 PMCID: PMC5613208 DOI: 10.3892/etm.2017.4910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 05/05/2017] [Indexed: 01/23/2023] Open
Abstract
The objective of the present study was to perform a meta-analysis of all available studies on the effect of prophylactic ulinastatin administration on preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The PubMed, Web of Knowledge and Chinese National Knowledge Infrastructure databases were searched to identify all relevant studies published in English or Chinese prior to April 2016. Cochrane Review Manager was used to calculate the pooled risk ratio (RR) and 95% confidence interval (CI) to determine the effect of prophylactic ulinastatin on PEP, post-ERCP hyperamylasemia (PEHA) and post-ERCP abdominal pain. The analysis revealed that prophylactic ulinastatin administration significantly reduced the PEP risk (RR=0.49; 95% CI: 0.33–0.74; P=0.0006; I2=24); however, such significant risk reduction occurred only in patients with low or average risk for PEP and high-dosage ulinastatin (150,000 or 200,000 U) administration, and when the ulinastatin administration began prior to or during ERCP. Pre-ERCP ulinastatin administration alone without additional administration after ERCP was sufficient. Prophylactic ulinastatin also significantly reduced the PEHA risk (RR=0.68; 95% CI: 0.56–0.83; P=0.0001; I2=19) and marginally reduced the incidence of post-ERCP abdominal pain (RR=0.67; 95% CI: 0.45–1.00; P=0.05; I2=67). In conclusion, prophylactic ulinastatin administration significantly reduced the risk of PEP in patients with low or average risk for PEP when administered at a high dosage prior to or during ERCP. High-quality studies, particularly on high-risk patients, are warranted.
Collapse
Affiliation(s)
- Kun Zhu
- Department of Surgery, Shanghai Jiading Central Hospital, Shanghai 201800, P.R. China
| | - Jian-Ping Wang
- Department of Surgery, Shanghai Jiading Central Hospital, Shanghai 201800, P.R. China
| | - Jin-Gen Su
- Department of Surgery, Shanghai Jiading Central Hospital, Shanghai 201800, P.R. China
| |
Collapse
|
24
|
Intraintestinal administration of ulinastatin protects against sepsis by relieving intestinal damage. J Surg Res 2017; 211:70-78. [DOI: 10.1016/j.jss.2016.11.061] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 11/18/2016] [Accepted: 11/30/2016] [Indexed: 11/22/2022]
|
25
|
Parekh PJ, Majithia R, Sikka SK, Baron TH. The "Scope" of Post-ERCP Pancreatitis. Mayo Clin Proc 2017; 92:434-448. [PMID: 28160947 DOI: 10.1016/j.mayocp.2016.10.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/22/2016] [Accepted: 10/31/2016] [Indexed: 12/14/2022]
Abstract
Pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography, with the potential for clinically significant morbidity and mortality. Several patient and procedural risk factors have been identified that increase the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Considerable research efforts have identified several pharmacologic and procedural interventions that can drastically affect the incidence of PEP. This review article addresses the underlying mechanisms at play for the development of PEP, identifying patient and procedural risk factors and meaningful use of risk-stratification information, and details current interventions aimed at reducing the risk of this complication.
Collapse
Affiliation(s)
- Parth J Parekh
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Tulane University, New Orleans, LA
| | - Raj Majithia
- Division of Gastroenterology and Hepatology, University of North Carolina-Johnston Healthcare, Smithfield
| | - Sanjay K Sikka
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Tulane University, New Orleans, LA
| | - Todd H Baron
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill.
| |
Collapse
|
26
|
Atal SS, Atal S. Ulinastatin - a newer potential therapeutic option for multiple organ dysfunction syndrome. J Basic Clin Physiol Pharmacol 2016; 27:91-9. [PMID: 26565549 DOI: 10.1515/jbcpp-2015-0003] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 08/22/2015] [Indexed: 11/15/2022]
Abstract
Despite significant improvements in medical and surgical management, multiple organ dysfunction syndrome (MODS) or multiple organ failure following conditions such as acute pancreatitis, severe sepsis, and traumatic, hemorrhagic, and endotoxin shocks is still accompanied with a high mortality rate. In light of the crucial role of immunologic derangement recently conceptualized in these conditions, ulinastatin, a urinary trypsin inhibitor, is considered as a potentially beneficial immunomodulator drug for MODS. Mechanisms involving protections against tissue organs and endothelial cell and anti-inflammatory effects by ulinastatin are dependent on the inhibition of polymorphonuclear leukocyte (PMN)-derived elastase, tumor necrosis factor α, and other pro-inflammatory cytokines and interleukins (IL-1, IL-6, and IL-8). Ulinastatin also suppresses the activation of PMN cells, macrophages, and platelets. Derived from these properties, ulinastatin has been investigated as a potential clinical therapy for indications including shock and pancreatitis and approved in Japan and China with ongoing clinical trials around the globe. Off-label potential uses of ulinastatin have been reported in preterm labor and hematological, hepatic, renal, and cardiovascular diseases including vasculitis syndromes such as Kawasaki disease.
Collapse
|
27
|
Ishiwatari H, Urata T, Yasuda I, Matsusaki S, Hisai H, Kawakami H, Ono M, Iwashita T, Doi S, Kawakubo K, Hayashi T, Sonoda T, Sakamoto N, Kato J. No Benefit of Oral Diclofenac on Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Dig Dis Sci 2016; 61:3292-3301. [PMID: 27447477 DOI: 10.1007/s10620-016-4251-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/09/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) is a serious complication. Rectal diclofenac (100 mg) has been shown to reduce the incidence of pancreatitis; however, this dosage form is unavailable in several countries. AIMS We aimed to investigate the preventive effect of oral diclofenac on pancreatitis after ERCP in a multicenter, randomized, prospective, placebo-controlled, double-blind trial. METHODS Patients undergoing a first ERCP in seven high-volume centers between July 2012 and August 2014 were considered eligible. Participants were administered oral diclofenac (50 mg) or placebo before and after ERCP. The primary endpoint was the incidence of pancreatitis. A subgroup analysis was performed for patients at high or low risk of pancreatitis. Secondary endpoints were pancreatic enzyme levels (amylase and lipase). RESULTS We initially enrolled 430 patients (216 in the diclofenac and 214 in the placebo group), and 23 were excluded after randomization. The overall incidence of pancreatitis was 9.8 % (20/205) and 9.4 % (19/202) in the diclofenac and placebo groups, respectively (p = 0.90). The incidence of pancreatitis was 20.3 % (13/64) and 21.3 % (13/61) in patients at high risk of pancreatitis (p = 0.78) and 5.0 % (7/141) and 4.3 % (6/141) in patients at low risk of pancreatitis in the diclofenac and placebo groups (p = 0.94), respectively. There were no significant differences in serum amylase and lipase levels between the two groups before and 24 h after ERCP. CONCLUSIONS Oral administration of diclofenac before and after ERCP showed no benefit in the prevention of pancreatitis. CLINICAL TRIALS REGISTRY NO UMIN000008109.
Collapse
Affiliation(s)
- Hirotoshi Ishiwatari
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Takahiro Urata
- Department of Gastroenterology, Japanese Red Cross Kumamoto Hospital, 1-1-2, Nagamineminami, Higashiku, Kumamoto, 861-8520, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, 3-8-3, Mizonokuchi, Takatsuku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Shimpei Matsusaki
- Department of Gastroenterology, Suzuka General Hospital, 53-1275, Uyamanohana, Yasuzukacho, Suzuka, Mie, 513-8630, Japan
| | - Hiroyuki Hisai
- Department of Gastroenterology, Japanese Red Cross Date Hospital, 81, Suenagacho, Date, Hokkaido, 052-8511, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Center for Digestive Disease, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki City, Miyazaki, 889-1692, Japan
| | - Michihiro Ono
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, 1-1, Yanagito, Gifu, Gifu, 501-1194, Japan
| | - Shinpei Doi
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, 3-8-3, Mizonokuchi, Takatsuku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, West 5, North 14, Kitaku, Sapporo, Hokkaido, 060-8648, Japan
| | - Tsuyoshi Hayashi
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Tomoko Sonoda
- Department of Public Health, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, West 5, North 14, Kitaku, Sapporo, Hokkaido, 060-8648, Japan
| | - Junji Kato
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| |
Collapse
|
28
|
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
|
29
|
A Randomized Comparative Study of 24- and 6-Hour Infusion of Nafamostat Mesilate for the Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Prospective Randomized Comparison Trial. Pancreas 2016; 45:1179-83. [PMID: 27253231 DOI: 10.1097/mpa.0000000000000625] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Although prolonged intravenous infusion (24 hours) of nafamostat mesilate is effective for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, it requires hospitalization and is expensive. The aim of this study was to compare the efficacy of 24- versus 6-hour intravenous infusion of 20 mg nafamostat mesilate for the prevention of post-ERCP pancreatitis (PEP). METHODS A total of 382 patients who underwent ERCP were randomly assigned into 2 groups: 24 hours or 6 hours. In both groups, nafamostat mesilate (20 mg) infusion was initiated up to an hour before ERCP and continued for either 24 or 6 hours. RESULTS The overall incidence of pancreatitis was 2.4% (9/371). The rates of PEP following 24- and 6-hour infusion were 2.8% (5/179) and 2.1% (4/192), respectively (P = 0.744). No significant difference was observed in the severity of pancreatitis between the groups. On multivariate analysis, increasing pancreatic duct cannulations (odds ratio, 1.685; 95% confidence interval, 1.036-2.741; P = 0.036) was identified as a statistically significant risk factor of PEP. CONCLUSIONS No difference was found in the incidence of PEP regardless of the duration of nafamostat mesilate infusion. Therefore, 6-hour infusion of 20 mg nafamostat mesilate may be useful for the prevention of PEP in an outpatient setting.
Collapse
|
30
|
Connor S. Defining post-operative pancreatitis as a new pancreatic specific complication following pancreatic resection. HPB (Oxford) 2016; 18:642-51. [PMID: 27485058 PMCID: PMC4972444 DOI: 10.1016/j.hpb.2016.05.006] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/08/2016] [Accepted: 05/17/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Post-operative pancreatic fistula has been well defined. However the underlying aetiology remains poorly understood. The aim of this review was to investigate whether the underlying aetiology for a proportion of patients suffering from post-operative pancreatic fistula was due to post-operative pancreatitis. METHOD A systematic literature review according to the PRISMA guidelines. The date range was from 2005 to 2016. The search strategy included the terms: post-operative pancreatitis, pathophysiology, post-operative pancreatic fistula, pancreaticoduodenectomy, ischaemic pancreatitis, microcirculation and pancreatitis, serum and drain amylase and lipase. The data was summarised without quantitative or qualitative analysis. RESULTS There exists significant physiological, biochemical, clinical and histological evidence in the literature that a proportion of post-operative pancreatic fistula is due to post-operative pancreatitis. A new definition of post-operative pancreatitis based on the presence of biochemical evidence for pancreatic inflammation (urinary trypsinogen-2 >50 ug/L or serum amylase/lipase > upper limit of normal) between post-operative days 0-2. Predicted severity is based on C-reactive protein with a cut-off of 180 mg/L at post-operative day 2. The proposed grading of severity is in line with previous work by international study group of pancreatic surgery. CONCLUSION Post-operative pancreatitis should be recognised as a separate pancreatic specific complication following pancreatic resection. Improved recognition may allow better understanding of potential methods of prevention, treatment and prediction of severity.
Collapse
Affiliation(s)
- Saxon Connor
- Correspondence Saxon Connor, Department of Surgery, Christchurch Hospital, Christchurch, New Zealand. Tel: +64 3 3640640. Fax: +64 3 3640352.Department of SurgeryChristchurch HospitalChristchurchNew Zealand
| |
Collapse
|
31
|
The Efficacy and Immunomodulatory Effects of Ulinastatin and Thymosin α1 for Sepsis: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9508493. [PMID: 27340674 PMCID: PMC4906180 DOI: 10.1155/2016/9508493] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 03/13/2016] [Accepted: 04/05/2016] [Indexed: 12/18/2022]
Abstract
Objective. To systematically review the efficacy and potential immunomodulatory effect of ulinastatin combined with thymosin α1 (UTI) for sepsis. Design. A systematic review and meta-analysis of randomized controlled trials (RCTs). Data Sources. The following databases: PubMed, Embase, and Cochrane Central were searched to identify related clinical trials. The search terms were "ulinastatin", "thymosin", and "sepsis". Results. Six RCTs, 944 septic patients in total, were included in this meta-analysis. The result shows UTI increased the 28-day survival rate of septic patients, odds ratio (OR) = 2.01, 95% CI [1.53, 2.64]. After the treatment with UTI, the APACHE II score (four studies) dropped 4.72 further, mean = -4.72, 95% CI [-6.54, -2.91] (p < 0.00001). The mean time of ICU stay (four studies) in UTI group decreased 3.03 days further, mean = -3.03 [-6.99, 0.95] (p = 0.14), and mechanical ventilation time (four studies) decreased 2.05 days, mean = -1.81 [-2.96, -0.66] (p = 0.002). With the treatment of UTI, CD4+T cells raised 5.13%, mean = 5.13, 95% CI [2.75, 7.50] (p < 0.0001); there was no significant change in CD8+T cells, mean = -0.74 [-2.93, 1.45] (p = 0.51). Conclusion. According to this meta-analysis, with the treatment of UTI, the short-term survival rate of septic patients was increased and the illness severity was alleviated. ICU stay and mechanical ventilation time were effectively shortened. The beneficial effect of UTI might be due to the potential immunomodulatory effects of these two drugs.
Collapse
|
32
|
Zhang C, Wang Y, Fu W, Zhang W, Wang T, Qin H. A Meta-analysis on the Effect of Ulinastatin on Serum Levels of C-Reactive Protein, Interleukin 6, and Tumor Necrosis Factor Alpha in Asian Patients with Acute Pancreatitis. Genet Test Mol Biomarkers 2016; 20:118-24. [PMID: 26780230 DOI: 10.1089/gtmb.2015.0192] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES We aimed to investigate the influence of ulinastatin (UTI) on the serum levels of C-reactive protein (CRP), interleukin 6 (IL-6), and tumor necrosis factor alpha (TNF-α) in Asian patients with acute pancreatitis (AP) by performance of a meta-analysis. METHODS Two investigators independently searched 11 databases, including PUBMED, EBSCO, Ovid, SpringerLink, Wiley, Web of Science, Cochrane Library, Wanfang database, China National Knowledge Infrastructure (CNKI), Chinese Journal Full-text Database, and China Biomedicine Database. The full-text articles were screened and the data were extracted using a standardized data extraction form. All statistical analyses were conducted with Stata software, version 12.0 (Stata Corporation, College Station, TX). RESULTS A total of 94 studies were initially retrieved, and 10 studies containing 424 Asian patients with AP were ultimately enrolled in this meta-analysis. The results revealed that the serum levels of CRP, IL-6, and TNF-α in Asian AP patients significantly decreased after UTI therapy (CRP: standardized mean difference [SMD] = 3.26, 95% confidence interval [CI] = 1.69-4.83, p < 0.001; IL-6: SMD = 5.92, 95% CI = 2.09-9.75, p = 0.002; TNF-α: SMD = 4.07, 95% CI = 0.79-7.35, p = 0.015). CONCLUSION The results of this meta-analysis suggest that UTI can effectively depress the serum levels of CRP, IL-6, and TNF-α in Asian patients with AP, and thereby inhibit inflammation.
Collapse
Affiliation(s)
- Chunze Zhang
- 1 Department of Colorectal Surgery, Tianjin Union Medicine Centre , Tianjin, P.R. China
| | - Yijia Wang
- 2 Department of Pathology, Tianjin Union Medicine Centre , Tianjin, P.R. China
| | - Wenzheng Fu
- 1 Department of Colorectal Surgery, Tianjin Union Medicine Centre , Tianjin, P.R. China
| | - Weihua Zhang
- 1 Department of Colorectal Surgery, Tianjin Union Medicine Centre , Tianjin, P.R. China
| | - Tao Wang
- 1 Department of Colorectal Surgery, Tianjin Union Medicine Centre , Tianjin, P.R. China
| | - Hai Qin
- 1 Department of Colorectal Surgery, Tianjin Union Medicine Centre , Tianjin, P.R. China
| |
Collapse
|
33
|
Fujinami H, Kajiura S, Ando T, Mihara H, Hosokawa A, Sugiyama T. Direct spraying of shakuyakukanzoto onto the duodenal papilla: a novel method for preventing pancreatitis following endoscopic retrograde cholangiopancreatography. Digestion 2015; 91:42-5. [PMID: 25632916 DOI: 10.1159/000368812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Topical epinephrine application to the duodenal papilla reduces spasm of the sphincter of Oddi and prevents acute pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). Shakuyakukanzoto (TJ-68) has an inhibitory effect on muscle contraction. Therefore, TJ-68 potentially allows the relaxation of the sphincter of Oddi, which can aid in the prevention of post-ERCP pancreatitis. METHODS Thirty-six patients planned for ERCP were divided into TJ-68 (n = 17) and control groups (n = 19). In the TJ-68 group, the TJ-68 solution was endoscopically sprayed directly onto the duodenal papilla of patients. To assess the effects of TJ-68, serum amylase levels were measured at 1 h and 1 day after ERCP and symptoms were evaluated. RESULTS The serum amylase levels at 1 h after ERCP were 273.6 ± 212.0 IU/l in the TJ-68 group and 428.7 ± 281.6 IU/l in the control group, showing a statistically significant difference (p = 0.036). The serum amylase levels at 24 h after ERCP were 230.0 ± 182.7 IU/l in the TJ-68 group and 497.4 ± 514.0 IU/l in the control group (p = 0.011). Post-ERCP pancreatitis was observed in 0 and 4 patients (21.1%) in the TJ-68 and control groups, respectively, which was not statistically significant (p = 0.11). CONCLUSION Direct TJ-68 solution application to the duodenal papilla significantly inhibited the elevation of serum amylase levels. However, the preventive effect regarding post-ERCP pancreatitis was not confirmed in this study.
Collapse
Affiliation(s)
- Haruka Fujinami
- Department of Endoscopy, Toyama University Hospital, Toyama City, Japan
| | | | | | | | | | | |
Collapse
|
34
|
|
35
|
Tsuchida K, Iwasaki M, Tsubouchi M, Suzuki T, Tsuchida C, Yoshitake N, Sasai T, Hiraishi H. Comparison of the usefulness of endoscopic papillary large-balloon dilation with endoscopic sphincterotomy for large and multiple common bile duct stones. BMC Gastroenterol 2015; 15:59. [PMID: 25980964 PMCID: PMC4446805 DOI: 10.1186/s12876-015-0290-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/11/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Endoscopic sphincterotomy (EST) is currently recognized as the primary endoscopic treatment for common bile duct stones. However, it is difficult to remove multiple (≥ 3) or large (≥ 15 mm) common bile duct stones with EST alone. Recently, EST plus endoscopic papillary large-balloon dilation (EPLBD) was reported to be an effective treatment for such bile duct stones. We compared the results of EST and EST + EPLBD for multiple (≥ 3) or large (≥ 15 mm) stones that were difficult to treat using EST alone. We also compared the complication rates between the techniques. METHODS Seventy patients with large (largest diameter, ≥ 15 mm) or ≥ 3 common bile duct stones treated in our department between April 2010 and March 2013 underwent EST + EPLBD (n = 34) or EST alone (n = 36). We compared final successful stone removal rates, rates of successful stone removal in the first session, procedure times, status of concurrent mechanical lithotripsy (ML), and complications between the EST + EPLBD and EST groups. RESULTS The rates of final successful stone removal were similar between the two groups (EST + EPLBD: 100 % vs. EST: 89 %; p = 0.115). The rate of successful stone removal in the first session was significantly higher in the EST + EPLBD group (EST + EPLBD: 88 % vs. EST: 56 %; p = 0.03). Moreover, the procedure time was significantly shorter (EST + EPLBD: 42 min vs. EST: 67 min; p = 0.011) and the rate of ML use was significantly lower in the EST + EPLBD group (EST + EPLBD: 50 % vs. EST: 94 %; p < 0.001). Complications like pancreatitis and bleeding occurred in three patients in the EST + EPLBD group and in 10 patients in the EST group, but the differences were not statistically significant (EST + EPLBD: 9 % vs. EST: 25 %; p = 0.112). CONCLUSIONS Our results suggest that EST + EPLBD is an effective therapy for patients with difficult-to-treat multiple or large common bile duct stones, because it requires fewer sessions and shorter operative times than EST alone.
Collapse
Affiliation(s)
- Kouhei Tsuchida
- Department of Gastroenterology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan.
| | - Mari Iwasaki
- Department of Gastroenterology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan.
| | - Misako Tsubouchi
- Department of Gastroenterology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan.
| | - Tsunehiro Suzuki
- Department of Gastroenterology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan.
| | - Chieko Tsuchida
- Department of Gastroenterology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan.
| | - Naoto Yoshitake
- Department of Gastroenterology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan.
| | - Takako Sasai
- Department of Gastroenterology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan.
| | - Hideyuki Hiraishi
- Department of Gastroenterology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan.
| |
Collapse
|
36
|
Yu G, Li S, Wan R, Wang X, Hu G. Nafamostat mesilate for prevention of post-ERCP pancreatitis: a meta-analysis of prospective, randomized, controlled trials. Pancreas 2015; 44:561-9. [PMID: 25822153 DOI: 10.1097/mpa.0000000000000310] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We aimed to evaluate the efficacy of nafamostat on the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). METHODS Medline, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were searched until April 18, 2014. RESULTS Seven randomized controlled trials and 2956 patients met the search criteria. When compared with nonnafamostat, the incidence of PEP was reduced to 53% in the patients who received nafamostat (risk ratio [RR], 0.47; 95% confidence interval [CI], 0.34-0.63). Further analyses were conducted based on the different risk classifications (n = 641 in patients with high risks: RR, 0.54; 95% CI, 0.30-0.96 and n = 944 with low risks: RR, 0.31; 95% CI, 0.17-0.56), PEP severities (n = 1654: RR, 0.38; 95% CI, 0.25-0.59 for mild; RR, 0.37; 95% CI, 0.15-0.96 for moderate; RR, 0.92; 95% CI, 0.13-6.38 for severe), and nafamostat doses (n = 1902: RR, 0.42; 95% CI, 0.28-0.63 for 20 mg; n = 1150: RR, 0.40; 95% CI, 0.25-0.63 for 50 mg). However, there was no reduction of the incidence of post-ERCP hyperamylasemia (n = 1585; 95% CI, 0.68-1.45) or cannulation difficulty (n = 1585; 95% CI, 0.91-1.23). CONCLUSIONS Pooled analyses from current randomized controlled trials support the effectiveness of nafamostat for prophylaxis of PEP.
Collapse
Affiliation(s)
- Ge Yu
- From the *Department of Gastroenterology, Shanghai First People's Hospital, Shanghai Jiaotong University School of Medicine; and †Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | | | | | | | | |
Collapse
|
37
|
Randomized controlled trial for efficacy of nafamostat mesilate in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreas 2015; 44:415-21. [PMID: 25479585 DOI: 10.1097/mpa.0000000000000278] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The objective of this study was to investigate whether prophylactic administration of nafamostat mesilate reduces the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), its efficacy, and risk factors for PEP. METHODS Potential subjects comprised 876 patients who underwent ERCP between September 2008 and February 2011. Of these, 58 patients were excluded after meeting exclusion criteria, and 818 patients were randomized. Patients in the nafamostat mesilate group were administered 20 mg of nafamostat mesilate dissolved in 500 mL of 5% glucose solution, whereas the control group received 500 mL of 5% glucose solution alone, over 2 hours from the start of ERCP. RESULTS Post-ERCP pancreatitis occurred in 5.1% (41 patients) overall, with a significantly lower frequency in the nafamostat mesilate group (3.5%) than in the control group (6.7%; P = 0.0349). Analysis of the 322 patients who had undergone ERCP for the first time (n = 158 in the nafamostat mesilate group; n = 164 in the control group) found that PEP again significantly less frequently occurred in the nafamostat mesilate group (5.7%) than in the control group (13.4%; P = 0.0172). CONCLUSIONS Our randomized controlled study suggested that short-term administration of nafamostat mesilate 20 mg may reduce the incidence of PEP.
Collapse
|
38
|
Akiyama D, Hamada T, Isayama H, Nakai Y, Tsujino T, Umefune G, Takahara N, Mohri D, Kogure H, Matsubara S, Ito Y, Yamamoto N, Sasahira N, Tada M, Koike K. Superiority of 10-mm-wide balloon over 8-mm-wide balloon in papillary dilation for bile duct stones: A matched cohort study. Saudi J Gastroenterol 2015; 21:213-9. [PMID: 26228364 PMCID: PMC4542419 DOI: 10.4103/1319-3767.161634] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic papillary balloon dilation (EPBD) is a possible alternative to endoscopic sphincterotomy (EST) for common bile duct (CBD) stones. To date, 10- and 8-mm EPBD have not been fully compared. PATIENTS AND METHODS Patients who underwent EPBD for CBD stones at two Japanese tertiary care centers between May 1994 and January 2014 were identified. Matched pairs with 10- and 8-mm EPBD were generated. Short- and long-term outcomes were compared between the two groups. RESULTS A total of 869 patients were identified (61 and 808 patients for 10- and 8-mm EPBD, respectively), and 61 well-balanced pairs were generated. The rate of complete stone removal within a single session was higher in the 10-mm EPBD group than in the 8-mm EPBD group (69% vs. 44%, P < 0.001), and use of lithotripsy was less frequent in the 10-mm EPBD group (23% vs. 56%, P < 0.001). The rates of post-ERCP pancreatitis were similar between the 10- and 8-mm EPBD groups (11% vs. 8%). Cumulative biliary complication-free rates were not statistically different between the two groups: 88% [95% confidence interval (CI): 79-97%] and 94% (95% CI: 88-100%) at 1 year and 69% (95% CI: 56-85%) and 80% (95% CI: 69-93%) at 2 years in the 10- and 8-mm EPBD groups, respectively. In the 10-mm EPBD group, ascending cholangitis was not observed, and pneumobilia was found in 5% of cases during the follow-up period. CONCLUSIONS EPBD using a 10-mm balloon for CBD stones is safe and more effective than 8-mm EPBD. The sphincter function is highly preserved after 10-mm EPBD.
Collapse
Affiliation(s)
- Dai Akiyama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Address for correspondence: Dr. Hiroyuki Isayama, Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655, Japan. E-mail:
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeshi Tsujino
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Gyotane Umefune
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Dai Mohri
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naoki Sasahira
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
39
|
Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials. Gastrointest Endosc 2015; 81:143-149.e9. [PMID: 25088919 DOI: 10.1016/j.gie.2014.06.045] [Citation(s) in RCA: 280] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 06/26/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data regarding the incidence and severity of post-ERCP pancreatitis (PEP) are primarily from nonrandomized studies. OBJECTIVE To determine the incidence, severity, and mortality of PEP from a systematic review of the placebo or no-stent arms of randomized, controlled trials (RCTs). DESIGN MEDLINE, EMBASE, and Cochrane databases were searched to identify RCTs evaluating the efficacy of drugs and/or pancreatic stents to prevent PEP. SETTING Systematic review of patients enrolled in RCTs evaluating agents for PEP prophylaxis. PATIENTS Patients in the placebo or no-stent arms of the RCTs INTERVENTION ERCP. MAIN OUTCOME MEASUREMENTS Incidence, severity, and mortality of PEP. RESULTS There were 108 RCTs with 13,296 patients in the placebo or no-stent arms. Overall, the PEP incidence was 9.7% and the mortality rate was 0.7%. Severity of PEP was reported for 8857 patients: 5.7%, 2.6%, and 0.5% of cases were mild, moderate, and severe, respectively. The incidence of PEP in 2345 high-risk patients was 14.7% and the severity of PEP was mild, moderate, and severe in 8.6%, 3.9%, and 0.8%, respectively, with a 0.2% mortality rate. The incidence of PEP was 13% in North American RCTs compared with 8.4% in European and 9.9% in Asian RCTs. ERCPs conducted before and after 2000 had a PEP incidence of 7.7% and 10%, respectively. LIMITATIONS Difference in PEP risk among patients in the included RCTs. CONCLUSION The incidence of PEP and severe PEP is similar in high-risk patients and the overall cohort. Discrepancies in the incidence of PEP across geographic regions require further study.
Collapse
|
40
|
Elmunzer BJ. Pharmacologic prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: Present and future. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
41
|
Detection and localization of bile duct leaks after cholecystectomy using Gd-EOB-DTPA-enhanced MR cholangiography: retrospective study of 16 patients. J Comput Assist Tomogr 2014; 38:518-25. [PMID: 24651750 DOI: 10.1097/rct.0000000000000083] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine if gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance (MR) cholangiography can detect and localize bile duct leaks in postcholecystectomy patients. MATERIAL AND METHODS Four blinded independent radiologists performed a retrospective review of 16 consecutive patients who underwent MR cholangiography with intravenous Gd-EOB-DTPA for the evaluation of possible biliary leak. Image quality, ductal opacification, and presence and location of any bile leak were evaluated. An independent observer determined the criterion standard using a consensus of all chart, clinical, and imaging findings. RESULTS All 6 bile leaks confirmed at endoscopic retrograde cholangiopancreatography were diagnosed by all reviewers (sensitivity, 100%). Of the 10 patients with no leak, only one reader incorrectly diagnosed a bile leak in a single case (specificity, 98%). The accuracy for detection of the site of leak with Gd-EOB-DTPA-enhanced MR cholangiography was 80%. CONCLUSION Gadolinium-EOB-DTPA-enhanced MR can detect bile leaks with a high sensitivity and specificity.
Collapse
|
42
|
Nishikawa T, Tsuyuguchi T, Sakai Y, Sugiyama H, Sakamoto D, Nakamura M, Yokosuka O. Old age is associated with increased severity of complications in endoscopic biliary stone removal. Dig Endosc 2014; 26:569-76. [PMID: 25180322 DOI: 10.1111/den.12213] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIM Various techniques are required in endoscopic biliary stone removal. Because the presence of biliary stones is a benign disease, it is essential to minimize procedure-related complications. Having a sound knowledge of the risk factors can help reduce the number and severity of complications. We determined the risk factors for complications in patients undergoing endoscopic biliary stone removal. METHODS This was a retrospective observational cohort study. We analyzed 743 consecutive patients with biliary stones who were treated with endoscopic retrograde cholangiopancreatography and identified the independent risk factors for complications. RESULTS Complications occurred in 66 patients (8.9%). Pancreatitis occurred in 26 patients (3.5%), cholangitis in 16 (2.2%), bleeding in 12 (1.6%) and other in 12 (1.6%). Independent risk factors for overall complications were multiple biliary stones (P = 0.0480) and anti-thrombotic drugs (P = 0.0186).Independent risk factors for moderate or severe complications were old age (P = 0.0201), multiple biliary stones (P = 0.0300), anti-thrombotic drugs (P = 0.0131), and cirrhosis of the liver (P = 0.0013). The respective risk factors for pancreatitis, cholangitis, and bleeding were precut technique (P = 0.0005), endoscopic mechanical lithotripsy (P = 0.0421), and both anti-thrombotic drugs (P = 0.0228) and cirrhosis of the liver (P = 0.0115). CONCLUSIONS Old age was associated with a similar complication rate to younger age but increased the severity of complications following endoscopic biliary stone removal. Improved awareness of the severity of complications may be of benefit during periprocedural management. Further studies are warranted.
Collapse
Affiliation(s)
- Takao Nishikawa
- Department of Gastroenterology and Nephrology; Graduate School of Medicine; Chiba University; Chiba Japan
| | - Toshio Tsuyuguchi
- Department of Gastroenterology and Nephrology; Graduate School of Medicine; Chiba University; Chiba Japan
| | - Yuji Sakai
- Department of Gastroenterology and Nephrology; Graduate School of Medicine; Chiba University; Chiba Japan
| | - Harutoshi Sugiyama
- Department of Gastroenterology and Nephrology; Graduate School of Medicine; Chiba University; Chiba Japan
| | - Dai Sakamoto
- Department of Gastroenterology and Nephrology; Graduate School of Medicine; Chiba University; Chiba Japan
| | - Masato Nakamura
- Department of Gastroenterology and Nephrology; Graduate School of Medicine; Chiba University; Chiba Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology; Graduate School of Medicine; Chiba University; Chiba Japan
| |
Collapse
|
43
|
Chen JJ, Wang XM, Liu XQ, Li W, Dong M, Suo ZW, Ding P, Li Y. Risk factors for post-ERCP pancreatitis: a systematic review of clinical trials with a large sample size in the past 10 years. Eur J Med Res 2014; 19:26. [PMID: 24886445 PMCID: PMC4035895 DOI: 10.1186/2047-783x-19-26] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 04/11/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Post- endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common and most severe complication associated with diagnostic and therapeutic ERCP. A multivariate analysis of risk factors for PEP is essential for identifying patients at high risk and subsequently choosing other suitable diagnoses. METHODS Pertinent publications were identified through systematic searches of MEDLINE, Elsevier, and Springer; we performed a systematic review of 12 clinical studies published in the past ten years, selected out of 451 reviewed articles, in which risk factors for pancreatitis were identified. Seven probable risk factors were evaluated, and outcomes expressed in the case of dichotomous variables, as an odds ratio (OR) (with a 95% confidence interval, 95% CI). RESULTS When the risk factors were analyzed, the OR for female gender was 1.40 (95% CI 1.24 to 1.58); the OR for previous PEP was 3.23 (95% CI 2.48 to 4.22); the OR for previous pancreatitis was 2.00 (95% CI 1.72 to 2.33); the OR for endoscopic sphincterotomy was 1.42 (95% CI 1.14 to 1.78); the OR for precut sphincterotomy was 2.11 (95% CI 1.72 to 2.59); the OR for Sphincter of Oddi dysfunction was 4.37 (95% CI 3.75 to 5.09); and the OR for non-prophylactic pancreatic duct stent was 2.10 (95% CI 1.63 to 2.69). CONCLUSIONS It appears that female gender, previous PEP, previous pancreatitis, endoscopic sphincterotomy, precut sphincterotomy, Sphincter of Oddi dysfunction, and non-prophylactic pancreatic duct stent are the risk factors for post-ERCP pancreatitis.
Collapse
Affiliation(s)
| | - Xi-Mo Wang
- Department of Gastroenterology, Tianjin Nankai Hospital, No,6 Changjiang Road Nankai District, Tianjin 300100, China.
| | | | | | | | | | | | | |
Collapse
|
44
|
Park JY, Jeon TJ, Hwang MW, Sinn DH, Oh TH, Shin WC, Choi WC. Comparison between ulinastatin and nafamostat for prevention of post-endoscopic retrograde cholangiopancreatography complications: a prospective, randomized trial. Pancreatology 2014; 14:263-7. [PMID: 25062874 DOI: 10.1016/j.pan.2014.03.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 02/21/2014] [Accepted: 03/31/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this prospective trial was to compare the effect of ulinastatin and nafamostat on the prophylaxis of post-ERCP complications. METHODS A total of 159 patients who underwent ERCP were divided into ulinastatin (n = 53), nafamostat (n = 53) and control (n = 53) groups. Each patient received ulinastatin (150,000 units), nafamostat (20 mg), or placebo from 2-4 h before ERCP to 6-8 h after ERCP. The primary endpoint was the incidence of PEP, and the secondary endpoints were the incidence of post-ERCP hyperamylasemia, hyperlipasemia and abdominal pain. RESULTS The overall incidence of PEP was 6.3% (10/159) and no significant differences were observed between ulinastatin and nafamostat groups in terms of the incidences of PEP (1.9% and 3.8%, P = 0.560), hyperamylasemia, hyperlipasemia, and abdominal pain, although these were significantly lower than those of the control group (P < 0.001). CONCLUSIONS There was no significant difference for preventing PEP between ulinastatin and nafamostat and both drugs were efficacious for preventing post-ERCP complications.
Collapse
Affiliation(s)
- Ji Young Park
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Tae Joo Jeon
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea.
| | - Mi Won Hwang
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Tae-Hoon Oh
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Won Chang Shin
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Won-Choong Choi
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| |
Collapse
|
45
|
Yuhara H, Ogawa M, Kawaguchi Y, Igarashi M, Shimosegawa T, Mine T. Pharmacologic prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis: protease inhibitors and NSAIDs in a meta-analysis. J Gastroenterol 2014; 49:388-99. [PMID: 23720090 DOI: 10.1007/s00535-013-0834-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 05/09/2013] [Indexed: 02/04/2023]
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is the most frequent complication of ERCP. Several meta-analyses have examined the effects of protease inhibitors (gabexate mesilate, ulinastatin, and nafamostat mesilate) and non-steroidal anti-inflammatory drugs (NSAIDs) on post-ERCP pancreatitis, but the results have been confusing. Since the previous meta-analysis, several new studies have been published on this topic. To provide an updated quantitative assessment of the effectiveness of protease inhibitors and NSAIDs in preventing post-ERCP pancreatitis, we conducted a meta-analysis of randomized trials for patients at risk of post-ERCP pancreatitis. Twenty-six articles were included in this meta-analysis. Nafamostat mesilate (summary RR = 0.41; 95 %CI 0.28-0.59; n = 4 studies) and NSAIDs (summary RR = 0.58; 95 %CI = 0.44-0.76; n = 7 studies) were associated with decreased risk of post-ERCP pancreatitis in the high-quality studies. However, gabexate mesilate (summary RR = 0.64; 95 %CI = 0.36-1.13; n = 6 studies) and ulinastatin (summary RR = 0.65; 95 %CI = 0.33-1.30; n = 2 studies) were not associated with decreased risk of post-ERCP pancreatitis in the high-quality studies. This is the first meta-analysis to compare the effects of three protease inhibitors. Solid evidence supports the use of nafamostat mesilate and NSAIDs for preventing post-ERCP pancreatitis.
Collapse
Affiliation(s)
- Hiroki Yuhara
- Department of Gastroenterology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Japan
| | | | | | | | | | | |
Collapse
|
46
|
Results of the Tokyo trial of prevention of post-ERCP pancreatitis with risperidone-2: a multicenter, randomized, placebo-controlled, double-blind clinical trial. Gastrointest Endosc 2013; 78:842-850. [PMID: 23910063 DOI: 10.1016/j.gie.2013.06.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 06/19/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND Our previous study suggested that a combination of ulinastatin and risperidone reduced post-ERCP pancreatitis (PEP) compared with ulinastatin alone. OBJECTIVE The aim of this study was to evaluate the efficacy of risperidone alone for prevention of PEP. DESIGN A multicenter, randomized, placebo-controlled, double-blind clinical trial. SETTING Two academic hospitals and 5 referral hospitals in Tokyo and Saitama, Japan. PATIENTS Patients undergoing therapeutic or interventional-diagnostic ERCP. INTERVENTION The patients were randomized to receive 2 mg of oral risperidone or oral placebo at 0.5 to 2 hours before ERCP. MAIN OUTCOME MEASUREMENTS The primary endpoint was the incidence of PEP. Secondary endpoints were the incidence of hyperenzymemia and enzyme levels (amylase, pancreatic amylase, lipase). Risk factors for PEP were evaluated. RESULTS We initially enrolled 500 patients in the study (250 in the risperidone group and 250 in the placebo group), but 17 (11 in the risperidone and 6 in the placebo group) were excluded after randomization. PEP developed in 24 patients (10.0%) in the risperidone group and 21 patients (8.6%) in the placebo group (P = .587). Serum amylase levels at 3 hours after ERCP were lower in the risperidone group (P = .007 in a single test of hypothesis, significance removed by Bonferroni correction for multiple testing). In multivariate analysis, a small papilla of Vater, total procedure time ≥40 minutes, and stenosis of the intrahepatic duct were significantly associated with PEP. LIMITATIONS Multiplicity of study centers and a relatively wide time range of drug administration time. CONCLUSION Risperidone did not show a benefit in prevention of PEP in this trial. ( CLINICAL TRIAL REGISTRATION NUMBER NCT000004592.).
Collapse
|
47
|
Ulinastatin is a novel candidate drug for sepsis and secondary acute lung injury, evidence from an optimized CLP rat model. Int Immunopharmacol 2013; 17:799-807. [PMID: 24075864 DOI: 10.1016/j.intimp.2013.09.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 08/30/2013] [Accepted: 09/04/2013] [Indexed: 11/24/2022]
Abstract
Ulinastatin is a potent multivalent serine protease inhibitor, which was recently found with therapeutic potentials in treating sepsis, and the most life-threatening complication of critically ill population. However, the pharmacological features and possible mechanisms need to be further elucidated in reliable and clinical relevant sepsis models. As known, sepsis induced by surgery of cecal ligation and puncture (CLP) is widely accepted as the gold standard animal model, but the inconsistency of outcomes is the most obvious problem. In the present experiments, we reported an improved rat CLP model with much more consistent outcomes using self-made three edged puncture needles in our lab. Results from this optimized model revealed that ulinastatin improved survivals of CLP rats, attenuated proinflammatory response and prevented systemic disorder and organ dysfunction. Ulinastatin was also found to be effective in ameliorating sepsis-related ALI, a syndrome most frequent and fatal in sepsis. The molecular mechanism investigation showed that ulinastatin's protection against ALI was probably related to the down-regulation of NF-κB activity and inhibition of TNF-α, IL-6 and elastase expressions in the lung tissue. In conclusion, based on a successful establishment of optimized rat CLP model ulinastatin is proved to be an effective candidate for sepsis treatment, due to its anti-inflammation and anti-protease activities that ameliorate systemic disorders, prevent organ injuries and thus improve the survival outcomes of sepsis in animals.
Collapse
|
48
|
Tsujino T, Isayama H, Nakai Y, Ito Y, Togawa O, Toda N, Arizumi T, Kogure H, Yamamoto K, Mizuno S, Yashima Y, Yagioka H, Sasaki T, Matsubara S, Yamamoto N, Hirano K, Sasahira N, Tada M, Koike K. The results of the Tokyo trial of prevention of post-ERCP pancreatitis with risperidone (Tokyo P3R): a multicenter, randomized, phase II, non-placebo-controlled trial. J Gastroenterol 2013; 48:982-8. [PMID: 23090004 DOI: 10.1007/s00535-012-0698-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 09/25/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND A previous study suggested that ulinastatin effectively prevented post-ERCP pancreatitis (PEP) and hyperenzymemia (PEH) in patients at average risk. In experimental models, risperidone, a selective serotonin 2A antagonist, ameliorated acute pancreatitis. We assessed the effect of risperidone combined with ulinastatin for the prevention of PEP in high-risk patients. METHODS In a multicenter, randomized, controlled, phase II trial, patients undergoing therapeutic ERCP were randomly assigned to receive ulinastatin (150000 U) with or without risperidone (1 mg). A risperidone tablet was taken orally 30-60 min before ERCP and ulinastatin was administered intravenously for 10 min immediately prior to ERCP. The primary end point was the incidence of PEP; secondary end points were PEH severity and enzyme levels (amylase, pancreatic amylase, lipase). RESULTS A total of 226 patients (113 per group) were included in the study. Six patients in the risperidone + ulinastatin group and ten patients in the ulinastatin group developed pancreatitis (5.3 vs. 8.8 %, p = 0.438). The incidence of moderate/severe PEP was lower in the risperidone + ulinastatin group (1.8 %) than in the ulinastatin group (4.4 %), but this difference was not significant. Although the incidence of PEH did not differ significantly, post-ERCP levels of all pancreatic enzymes were significantly lower in the risperidone + ulinastatin group. CONCLUSIONS Prophylactic oral risperidone administration in combination with ulinastatin did not reduce the incidence and severity of PEP in high-risk patients as compared with ulinastatin alone. However, risperidone showed an additive effect with ulinastatin, reducing serum pancreatic enzyme levels.
Collapse
Affiliation(s)
- Takeshi Tsujino
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Itaba S, Nakamura K, Aso A, Tokunaga S, Akiho H, Ihara E, Iboshi Y, Iwasa T, Akahoshi K, Ito T, Takayanagi R. Prospective, randomized, double-blind, placebo-controlled trial of ulinastatin for prevention of hyperenzymemia after double balloon endoscopy via the antegrade approach. Dig Endosc 2013; 25:421-7. [PMID: 23368820 DOI: 10.1111/den.12014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 10/30/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Double balloon endoscopy (DBE) allows the entire small intestine to be viewed using a combination of antegrade and retrograde approaches. Acute pancreatitis is a serious complication of antegrade DBE with no effective prophylactic treatment currently available. Ulinastatin has been shown to be effective for the prevention of pancreatitis following endoscopic retrograde cholangiopancreatography. We therefore assessed the efficacy of ulinastatin for hyperenzymemia after antegrade DBE. PATIENTS AND METHODS Forty-four patients were enrolled in this prospective, randomized, double-blind, placebo-controlled trial. Patients in the ulinastatin group received 150 000 U ulinastatin by i.v. drip infusion for 2 h from the start of the procedure. Serum concentrations of pancreatic amylase and lipase were measured before and 3 and 18 h after antegrade DBE. RESULTS The study was terminated after interim analysis. Of the 44 patients, 23 were randomized to ulinastatin and 21 to placebo.The groups were similar with regard to sex ratio, age, type of endoscope, insertion time, total procedure time, number of endoscope pull-back procedures, and baseline pancreaticamylase and lipase concentrations. Post-DBE hyperenzymemia was observed in 35.0% and 47.8% of patients in the placebo and ulinastatin groups, respectively. The higher frequency of hyperenzymemia in the ulinastatin group was unexpected, but the difference was not statistically significant. One patient in the placebo group (5.0%) and none in the ulinastatin group experienced acute pancreatitis, but the difference was not statistically significant. CONCLUSION The results of this trial suggest that ulinastatin does not prevent hyperenzymemia following antegrade DBE.
Collapse
Affiliation(s)
- Soichi Itaba
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, Fukuoka, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Ulinastatin reduces cancer recurrence after resection of hepatic metastases from colon cancer by inhibiting MMP-9 activation via the antifibrinolytic pathway. BIOMED RESEARCH INTERNATIONAL 2013; 2013:437950. [PMID: 23710449 PMCID: PMC3655446 DOI: 10.1155/2013/437950] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/26/2013] [Accepted: 04/02/2013] [Indexed: 12/13/2022]
Abstract
High recurrence of colon cancer liver metastasis is observed in patients after hepatic surgery, and the cause is believed to be mostly due to the growth of residual microscopic metastatic lesions within the residual liver. Therefore, triggering the progression of occult metastatic foci may be a novel strategy for improving survival from colon cancer liver metastases. In the present study, we identified an anti-recurrence effect of ulinastatin on colon cancer liver metastasis in mice after hepatectomy. Transwell cell invasion assays demonstrated that ulinastatin significantly inhibited the in vitro invasive ability of colon cancer HCT116 cells. Moreover, gelatin zymography and ELISA analysis showed that MMP-9 activity and plasmin activity of colon cancer HCT116 cells were inhibited by ulinastatin, respectively. Furthermore, in vivo BALB/C nu/nu mice model indicated that ulinastatin effectively reduced recurrence after resection of hepatic metastases from colon cancer. The optimum timing for ulinastatin administration was one week after hepatectomy. Taken together, our findings point to the potential of ulinastatin as an effective approach in controlling recurrence of hepatic metastases from colon cancer after hepatectomy via its anti-plasmin activity.
Collapse
|