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Feder NM, Hernandez I, Feldman WB, Murali M, Kesselheim AS, Elmunzer BJ, Gellad WF. Price and Variability in Hospital Charges for Generic Indomethacin Suppositories. JAMA Netw Open 2024; 7:e2435528. [PMID: 39325456 PMCID: PMC11428000 DOI: 10.1001/jamanetworkopen.2024.35528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 07/29/2024] [Indexed: 09/27/2024] Open
Abstract
This cross-sectional study examines how list prices for indomethacin have changed since 2019 and characterizes variation in hospital charges for the drug, including gross charges and discounted cash prices.
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Affiliation(s)
- Noah M. Feder
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Inmaculada Hernandez
- UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, California
| | - William B. Feldman
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mathavan Murali
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Aaron S. Kesselheim
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston
| | - Walid F. Gellad
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kolodecik TR, Guo X, Shugrue CA, Guo X, Desir GV, Wen L, Gorelick F. Renalase peptides reduce pancreatitis severity in mice. Am J Physiol Gastrointest Liver Physiol 2024; 327:G466-G480. [PMID: 39010833 PMCID: PMC11427088 DOI: 10.1152/ajpgi.00143.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 07/02/2024] [Accepted: 07/10/2024] [Indexed: 07/17/2024]
Abstract
Acute pancreatitis, an acute inflammatory injury of the pancreas, lacks a specific treatment. The circulatory protein renalase is produced by the kidney and other tissues and has potent anti-inflammatory and prosurvival properties. Recombinant renalase can reduce the severity of mild cerulein pancreatitis; the activity is contained in a conserved 20 aa renalase site (RP220). Here, we investigated the therapeutic effects of renalase on pancreatitis using two clinically relevant models of acute pancreatitis. The ability of peptides containing the RP220 site to reduce injury in a 1-day post-endoscopic retrograde cholangiopancreatography (ERCP) and a 2-day severe cerulein induced in mice was examined. The initial dose of renalase peptides was given either prophylactically (before) or therapeutically (after) the initiation of the disease. Samples were collected to determine early pancreatitis responses (tissue edema, plasma amylase, active zymogens) and later histologic tissue injury and inflammatory changes. In both preclinical models, renalase peptides significantly reduced histologic damage associated with pancreatitis, especially inflammation, necrosis, and overall injury. Quantifying inflammation using specific immunohistochemical markers demonstrated that renalase peptides significantly reduced overall bone marrow-derived inflammation and neutrophils and macrophage populations in both models. In the severe cerulein model, administering a renalase peptide with or without pretreatment significantly reduced injury. Pancreatitis and renalase peptide effects appeared to be the same in female and male mice. These studies suggest renalase peptides that retain the anti-inflammatory and prosurvival properties of recombinant renalase can reduce the severity of acute pancreatitis and might be attractive candidates for therapeutic development.NEW & NOTEWORTHY Renalase is a secretory protein. The prosurvival and anti-inflammatory effects of the whole molecule are contained in a 20 aa renalase site (RP220). Systemic treatment with peptides containing this renalase site reduced the severity of post-endoscopic retrograde cholangiopancreatography (ERCP) and severe cerulein pancreatitis in mouse models.
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Affiliation(s)
- Thomas R Kolodecik
- Veterans Affairs Health Care System, Yale University, New Haven, Connecticut, United States
- Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Xiaoyu Guo
- State Key Laboratory of Complex, Severe, and Rare Diseases, Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, People's Republic of China
- Center for Biomarker Discovery and Validation, Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, People's Republic of China
| | - Christine A Shugrue
- Veterans Affairs Health Care System, Yale University, New Haven, Connecticut, United States
- Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Xiaojia Guo
- Veterans Affairs Health Care System, Yale University, New Haven, Connecticut, United States
- Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Gary V Desir
- Veterans Affairs Health Care System, Yale University, New Haven, Connecticut, United States
- Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Li Wen
- State Key Laboratory of Complex, Severe, and Rare Diseases, Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, People's Republic of China
- Center for Biomarker Discovery and Validation, Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, People's Republic of China
| | - Fred Gorelick
- Veterans Affairs Health Care System, Yale University, New Haven, Connecticut, United States
- Yale School of Medicine, Yale University, New Haven, Connecticut, United States
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Zuo J, Li H, Zhang S, Li P. Nonsteroidal Anti-inflammatory Drugs for the Prevention of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis. Dig Dis Sci 2024; 69:3134-3146. [PMID: 39102041 DOI: 10.1007/s10620-024-08565-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/11/2024] [Indexed: 08/06/2024]
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remains the most frequent and severe complication following ERCP, elevating both patient suffering and healthcare costs, and posing challenges to the advancement of ERCP techniques. Empirical evidence supports the prophylactic use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the prevention of PEP, especially in high-risk populations, as endorsed by both the American Society for Gastrointestinal Endoscopy (ASGE) and the European Society for Gastrointestinal Endoscopy (ESGE). However, the prophylactic efficacy of NSAIDs in average-risk individuals, alongside the ideal drug selection, dosing, and timing of NSAID administration, remains to be elucidated. Furthermore, the synergistic preventive potential of NSAIDs when integrated with other interventions, such as hydration, pancreatic stenting, somatostatin administration, sublingual nitrate application, and epinephrine, warrants further clarification. In this paper, we conduct an exhaustive review of the prophylactic effect and clinical administration of NSAIDs for PEP. We comprehensively synthesize findings from clinical trials investigating NSAIDs, both in monotherapy and combination regimens, for PEP prevention. Additionally, we scrutinize the current landscape of NSAID usage in clinical practice and evaluate their cost-effectiveness. Future research should concentrate on refining NSAID prophylaxis strategies for PEP in patients at different risk levels, while also enhancing adherence to clinical guidelines and alleviating the issue of NSAID cost inflation.
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Affiliation(s)
- Jiaxuan Zuo
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, 95, Yongan Road, Xicheng District, Beijing, 100050, China
| | - Hengcun Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, 95, Yongan Road, Xicheng District, Beijing, 100050, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, 95, Yongan Road, Xicheng District, Beijing, 100050, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, 95, Yongan Road, Xicheng District, Beijing, 100050, China.
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Bai B, Wang S, Du Y, Li M, Huang Q, Liu S, Zhang C, Fang Y, Chen X, Hong J, Li Y, Xu Z, Liu X, Hong R, Bao J, Mei Q. Indomethacin Does Not Reduce Post-ERCP Pancreatitis in High-Risk Patients Receiving Pancreatic Stenting. Dig Dis Sci 2024; 69:3442-3449. [PMID: 39009916 DOI: 10.1007/s10620-024-08542-2] [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: 04/30/2024] [Accepted: 06/20/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Rectal indomethacin reduces pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). However, there is insufficient evidence regarding its added benefits in patients already receiving prophylactic pancreatic stenting. Our goal was to evaluate the impact of indomethacin in high-risk patients undergoing pancreatic stenting. METHODS A cohort study was conducted on all patients who underwent the rescue cannulation technique for challenging bile duct cannulation (selected high-risk patients). Patients were split into two groups based on the prophylaxis method for post-ERCP pancreatitis (PEP): one receiving a combination of indomethacin and pancreatic stenting, while the other received pancreatic stenting alone. Comparative analyses were carried out on PEP, hyperamylasemia, gastrointestinal bleeding, and postoperative hospital stay among post-ERCP pancreatitis patients. RESULTS Between November 2017 and May 2023, a total of 607 patients with native papillae were enrolled, with 140 grouped into the indomethacin plus stent group and 467 into the stent alone group. The overall PEP rate was 4.4% in the entire cohort, with no statistical differences observed between the groups in terms of PEP rates (P = 0.407), mild PEP (P = 0.340), moderate to severe PEP (P = 1.000), hyperamylasemia (P = 0.543), gastrointestinal bleeding (P = 0.392), and postoperative hospital stay (P = 0.521). Furthermore, sensitivity analysis using multivariable analysis also validated these findings. CONCLUSIONS Indomethacin did not reduce the incidence or severity of PEP in high-risk patients who routinely received prophylactic pancreatic stent placement. Therefore, the additional administration of rectal indomethacin to further mitigate PEP appears to be not necessary.
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Affiliation(s)
- Bingqing Bai
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Shaofei Wang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
- Department of Gastroenterology, Suzhou First People's Hospital, Suzhou, 234000, Anhui, China
| | - Yemei Du
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
- Department of Gastroenterology, Xuancheng People's Hospital, Xuancheng, 242000, Anhui, China
| | - Mengwen Li
- Department of Gastroenterology, Fuyang People's Hospital, Fuyang, 236012, Anhui, China
| | - Qiming Huang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Sisi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Chenyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Yuanyuan Fang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Xinwen Chen
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Jianglong Hong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Yang Li
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Zhangwei Xu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Xiaochang Liu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Rutao Hong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Junjun Bao
- Department of Endoscopy, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Qiao Mei
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China.
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Kant K, Ahmed Z, Dama R, Karunakaran M, Arora P, Rebala P, Rao GV. Does perioperative hydrocortisone or indomethacin improve pancreatoduodenectomy outcomes? A triple arm, randomized placebo-controlled trial. Ann Hepatobiliary Pancreat Surg 2024; 28:350-357. [PMID: 38679455 PMCID: PMC11341883 DOI: 10.14701/ahbps.24-021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/14/2024] [Accepted: 04/02/2024] [Indexed: 05/01/2024] Open
Abstract
Backgrounds/Aims This trial evaluated whether anti-inflammatory agents hydrocortisone (H) and indomethacin (I) could reduce major complications after pancreatoduodenectomy (PD). Methods Between June 2018 and June 2020, 105 patients undergoing PD with > 40% of acini on the intraoperative frozen section were randomized into three groups (35 patients per group): 1) intravenous H 100 mg 8 hourly, 2) rectal I suppository 100 mg 12 hourly, and 3) placebo (P) from postoperative day (POD) 0-2. Participants, investigators, and outcome assessors were blinded. The primary outcome was major complications (Clavien-Dindo grades 3-5). Secondary outcomes were overall complications (Clavien-Dindo grades 1-5), Clinically relevant postoperative pancreatic fistula (CR-POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), surgical site infections (SSI), length of stay, POD-3 serum amylase, readmission rate, and mortality. Results Major complications were comparable (8.6%, 5.7%, and 8.6% in groups H, I, and P, respectively). However, overall complications were significantly lower in group H than in group P (45.7% vs. 80.0%, p = 0.006). CR-POPF (14.3% vs. 25.7%, p = 0.371), PPH (8.6% vs. 14.3%, p = 0.710), DGE (8.6% vs. 22.9%, p = 0.188), and SSI (14.3% vs. 25.7%, p = 0.371) were comparable between groups H and P. Major complications and overall complications in group I were 5.7% and 60.0%, respectively, which were comparable to those in groups P and H. CR-POPF rates in groups H, I, and P were 14.3%, 17.1%, and 25.7%, respectively, which was comparable. Conclusions H and I did not decrease major complications in PD.
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Affiliation(s)
- Kislay Kant
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Zeeshan Ahmed
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rohit Dama
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Monish Karunakaran
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Prateek Arora
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Pradeep Rebala
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Guduru Venkat Rao
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Janssens LP, Yamparala A, Martin J, O'Meara J, Harmsen WS, Sathi T, Lemke E, Abu Dayyeh BK, Bofill-Garcia A, Petersen BT, Storm AC, Topazian M, Vargas EJ, Chandrasekhara V, Law RJ. Incidence of Post-ERCP Pancreatitis in Patients Receiving Rectal Indomethacin vs. Compounded Rectal Diclofenac Prophylaxis. Dig Dis Sci 2024:10.1007/s10620-024-08604-5. [PMID: 39215866 DOI: 10.1007/s10620-024-08604-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND AIMS Endoscopic retrograde cholangiopancreatography (ERCP) carries a 3-15% risk of post-ERCP pancreatitis (PEP). Rectal indomethacin reduces the risk of PEP, but its cost has increased more than 20-fold over the past decade. Rectal diclofenac is also used to prevent PEP but is not commercially available in the United States. The aim of this study is to compare the incidence of PEP after administration of commercially available rectal indomethacin versus compounded rectal diclofenac and assess financial implications. METHODS ERCP cases at our institution with administration of 100 mg rectal indomethacin or 100 mg compounded rectal diclofenac between May 2018 and January 2022 were retrospectively reviewed. The incidence and severity of PEP was compared between the indomethacin (n = 728) and diclofenac (n = 304) groups. Risk factors (young age, female sex, history of pancreatitis or PEP, sphincterotomy during procedure, pancreatic indication, trainee involvement) and protective factors (prior sphincterotomy, pancreatic duct stenting) for PEP were compared between groups. RESULTS 60 patients (8.2%) in the rectal indomethacin group and 25 patients (8.2%) in the compounded rectal diclofenac group developed PEP, resulting in moderate or severe PEP in 9 (15.0%) and 2 (8.0%) patients, respectively. The compounded rectal diclofenac group had more trainee involvement (46.1% vs. 32.8%, p = 0.0001) and more prior sphincterotomy cases (15.8% vs. 10.6%, p = 0.0193) compared to the rectal indomethacin group; no statistically significant differences were observed in all other risk and protective factors. Following switch to compounded rectal diclofenac, institutional annual cost savings amounted to $441,460.62 and patient charge decreased 45-fold. CONCLUSION This retrospective single-center real-world analysis showed similar efficacy of rectal indomethacin and compounded rectal diclofenac in preventing PEP but demonstrates substantial cost savings after switching to compounded rectal diclofenac.
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Affiliation(s)
- Laurens P Janssens
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Aishwarya Yamparala
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John Martin
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John O'Meara
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Thanmay Sathi
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elizabeth Lemke
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Aliana Bofill-Garcia
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Bret T Petersen
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mark Topazian
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Eric J Vargas
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ryan J Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Kotha R, Saad-Omer SI, Singh S, Olayinka OT, Orelus J, Nisar MR, Nassar ST. Efficacy of Diclofenac and Indomethacin for Prevention of Post-Endoscopic Cholangiopancreatography (ERCP) Pancreatitis: A Systematic Review. Cureus 2024; 16:e66386. [PMID: 39246923 PMCID: PMC11379097 DOI: 10.7759/cureus.66386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 08/07/2024] [Indexed: 09/10/2024] Open
Abstract
Endoscopic cholangiopancreatography (ERCP) is a widely used diagnostic and therapeutic tool for pancreaticobiliary conditions. One of its major complications is pancreatitis. This study aims to understand the incidence of post-ERCP pancreatitis after using rectal diclofenac and Indomethacin as prophylactic measures. We retrieved 2870 articles from the PubMed, ScienceDirect, and Google Scholar databases. Using the Medical Subject Headings (MeSH) strategy in PubMed, we chose research articles published in the last five years. Exclusion criteria included paid full-text articles, abstracts, letters to editors, patients not undergoing ERCP, ages more than 45 years, animal studies, and non-English studies. The 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) criteria were used in the design of our systematic reviews. It was found that the medical world is still debating whether rectal diclofenac and Indomethacin are beneficial in avoiding post-ERCP pancreatitis (PEP). Rectal diclofenac is used. Although its effectiveness is debated due to mixed findings and concerns about certain outcomes, it is also considered beneficial in specific circumstances, such as before ERCP. Studies on rectal Indomethacin also yield contradictory results; while some emphasize the drug's large reduction in PEP incidence, especially in low-risk people, others question its efficacy. We need further studies to clarify the remaining uncertainties.
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Affiliation(s)
- Rudrani Kotha
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sabaa I Saad-Omer
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Shivani Singh
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Oluwatoba T Olayinka
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jaslin Orelus
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mah Rukh Nisar
- Neurology/Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sondos T Nassar
- Medicine and Surgery, Jordan University of Science and Technology, Amman, JOR
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8
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Razjouyan H, Maranki JL. Endoscopic Retrograde Cholangiopancreatography for the Management of Pancreatic Duct Leaks and Fistulas. Gastrointest Endosc Clin N Am 2024; 34:405-416. [PMID: 38796289 DOI: 10.1016/j.giec.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Pancreatic duct (PD) leaks are a common complication of acute and chronic pancreatitis, trauma to the pancreas, and pancreatic surgery. Diagnosis of PD leaks and fistulas is often made with contrast-enhanced pancreatic protocol computed tomography or magnetic resonance imaging with MRCP. Endoscopic retrograde pancreatography with pancreatic duct stenting in appropriately selected patients is often an effective treatment, helps to avoid surgery, and is considered first-line therapy in cases that fail conservative management.
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Affiliation(s)
- Hadie Razjouyan
- Division of Gastroenterology and Hepatology, Penn State College of Medicine, Penn State Health, 500 University Drive, HU850, Hershey, PA 17033, USA
| | - Jennifer L Maranki
- Division of Gastroenterology and Hepatology, Penn State College of Medicine, Penn State Health, 500 University Drive, HU850, Hershey, PA 17033, USA.
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Cho IR, Choi JH, Park JK, Huh G, Lee SH, Paik WH, Park DH. Aggressive hydration with lactated Ringer's solution versus plasma solution for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (ALPS study): protocol for a multicentre, double-blind, randomised controlled trial. BMJ Open 2024; 14:e084052. [PMID: 38955368 PMCID: PMC11218011 DOI: 10.1136/bmjopen-2024-084052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) plays an indispensable role in treating pancreato-biliary diseases but carries a risk of post-ERCP pancreatitis (PEP). Despite advances in the prevention strategies, prevention of PEP remains imperfect, necessitating more refined hydration methods. This study investigates the effectiveness of lactated Ringer's solution versus plasma solution in preventing PEP. METHOD AND ANALYSIS This multicentre, double-blind, randomised controlled trial, will be initiated by the investigator-sponsor, and conducted in three tertiary centres in South Korea. The aim of this study is to assess the effectiveness of hydration in preventing PEP in patients with naïve papillae. It will target patients with naïve papillae, focusing on those at medium to high risk of PEP. Patients aged ≤18 years and those with serious comorbidities, acute/chronic pancreatitis and various other medical conditions will be excluded. Eligible participants will be randomly assigned into two arms in equal numbers: (1) PEP prevention using lactated Ringer's solution and (2) PEP prevention using plasma solution. The primary outcome of this study will be the occurrence of PEP, and secondary outcomes will be additional risk factors and potential adverse events related to ERCP. With a total enrolment of 844 patients, the study will be able to detect significant differences between the intervention arms. ETHICS AND DISSEMINATION Ethical approval is obtained from each institution (Asan Medical Centre, 2023-0382; Seoul National University Hospital, H-2302-05-1404; Samsung Medical Centre, SMC 2023-02-001-009). All participants provided informed consent following clear explanation of the study procedures. The results of the study will be disseminated in peer-reviewed journals and research conferences. TRIAL REGISTRATION NUMBER NCT05832047. PROTOCOL VERSION Ver 4.1 (2023).
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Affiliation(s)
- In Rae Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, Korea (the Republic of)
| | - Jin Ho Choi
- Department of Internal Medicine, Samsung Medical Center, Gangnam-gu, Seoul, Korea (the Republic of)
| | - Joo Kyung Park
- Division of Gastroenterology, Deparent of Medicine, Samsung Medical Center, Seoul, Korea (the Republic of)
| | - Gunn Huh
- Department of Gastroenterology, Asan Medical Center, Songpa-gu, Seoul, Korea (the Republic of)
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, Korea (the Republic of)
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, Korea (the Republic of)
| | - Do Hyun Park
- Department of Internal Medicine, Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea (the Republic of)
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Al Nakshabandi A, Ali FS, Albustami I, Hwang H, Qiao W, Johnston NC, Shaikh AS, Coronel E, Ge PS, Ross W, Weston B, Lee JH. Biliary drainage in hilar and perihilar cholangiocarcinoma: 25-year experience at a tertiary cancer center. Gastrointest Endosc 2024; 99:938-949.e15. [PMID: 38092128 DOI: 10.1016/j.gie.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 05/20/2024]
Abstract
BACKGROUND AND AIMS This study analyzed the optimal biliary stenting strategy for palliation in cholangiocarcinoma (CCA). METHODS This was a retrospective study of patients with CCA who underwent biliary drainage from 1997 to 2023. A per-patient analysis of percutaneous transhepatic biliary drainage (PTBD) rates, the median number of ERCPs, and overall survival (OS) and a per-procedure analysis of clinical success (CS), stent-specific adverse events (AEs), and mean time to repeat ERCP by stent type and laterality (unilateral and bilateral) are presented. RESULTS A total of 333 patients underwent 1050 ERCPs, 85% with plastic stents (PSs). PTBD was eventually done in 23% of PS patients, 35% of whom had their PS removed before PTBD. ERCPs with the use of self-expandable metal stents (SEMSs)/unilateral SEMSs had higher CS (89%/91%) versus PSs/unilateral plastic stents (uPSs) (85% both) and PSs within SEMSs (PS-SEMSs)/uPS-SEMSs (71%/74%; P = .013/P = .054). Compared with PSs, SEMSs and PS-SEMSs were associated with higher stent-specific AEs (odds ratios [ORs]: SEMSs 4.85 [95% confidence interval (CI), 3.23-7.27], PS-SEMSs 9.99 [95% CI, 5.33-18.71]; P < .001). Straight PSs were associated with more stent-specific AEs compared with double-pigtail stents (OR 6.74 [95% CI, 3.95-11.45]; P < .001). More 7F stents were used in cases with balloon dilation (BD) (109 with BD vs 88 without BD; P < .001). BD had a 79% CS rate versus 87% without BD (P < .001). Cases with pus on ERCP and those with BD had a shorter mean time to repeat ERCP. On regression analyses, higher Bismuth class, PS use, and PS-SEMS use were associated with a shorter mean time to repeat ERCP. Fifty-two percent of patients in the bilateral SEMS arm died from cholangitis (P = .005). CONCLUSIONS The relatively higher CS rate of SEMSs is countered by the higher stent-specific AE rate. PSs can be removed and may better facilitate PTBD. Within PS types, double-pigtail stents may have fewer stent-specific AEs. Cases requiring BD and with endoscopic evidence of pus may benefit from earlier reintervention.
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Affiliation(s)
- Ahmad Al Nakshabandi
- Gastroenterology, Hepatology, and Nutrition Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Faisal S Ali
- Gastroenterology, Hepatology, and Nutrition Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Iyad Albustami
- Gastroenterology, Hepatology, and Nutrition Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hyunsoo Hwang
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wei Qiao
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicole C Johnston
- Gastroenterology, Hepatology, and Nutrition Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Abdullah S Shaikh
- Gastroenterology, Hepatology, and Nutrition Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Emmanuel Coronel
- Gastroenterology, Hepatology, and Nutrition Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Phillip S Ge
- Gastroenterology, Hepatology, and Nutrition Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - William Ross
- Gastroenterology, Hepatology, and Nutrition Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brian Weston
- Gastroenterology, Hepatology, and Nutrition Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey H Lee
- Gastroenterology, Hepatology, and Nutrition Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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11
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Gellért B, Patai ÁV, Hritz I. Update in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis. Ann Gastroenterol 2024; 37:266-279. [PMID: 38779635 PMCID: PMC11107403 DOI: 10.20524/aog.2024.0870] [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] [Received: 08/27/2023] [Accepted: 12/06/2023] [Indexed: 05/25/2024] Open
Abstract
Of all the possible complications associated with endoscopic retrograde cholangiopancreatography (ERCP), acute pancreatitis undoubtedly represents the heaviest burden for patients and healthcare professionals. The overall incidence, ranging from 3.5% to around 10%, and annual estimated costs exceeding $150 million in the USA should signal caution for everyone carrying out ERCP. In-depth knowledge of the risk factors and the pharmacological and endoscopic treatment options is required to avoid this adverse event. In this review, we evaluate the relevant data published in the literature since the appearance of the latest recommendations of the leading gastroenterological societies. Thus, we intend to provide a comprehensive and up-to-date overview of the factors to consider and possible interventions applicable before and after the intervention to prevent the development of post-ERCP pancreatitis.
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Affiliation(s)
- Bálint Gellért
- Department of Surgery, Transplantation and Gastroenterology, Division of Interventional Gastroenterology, Semmelweis University, Budapest, Hungary (Bálint Gellért, Árpád V. Patai, István Hritz)
| | - Árpád V. Patai
- Department of Surgery, Transplantation and Gastroenterology, Division of Interventional Gastroenterology, Semmelweis University, Budapest, Hungary (Bálint Gellért, Árpád V. Patai, István Hritz)
| | - István Hritz
- Department of Surgery, Transplantation and Gastroenterology, Division of Interventional Gastroenterology, Semmelweis University, Budapest, Hungary (Bálint Gellért, Árpád V. Patai, István Hritz)
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12
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Muniraj T, Desir G, Gorelick FS, Guo X, Ciarleglio MM, Deng Y, Jamidar PA, Farrell J, Aslanian HR, Laine L. Clinical predictive value of renalase in post-ERCP pancreatitis. Gastrointest Endosc 2024; 99:822-825.e1. [PMID: 38103747 DOI: 10.1016/j.gie.2023.12.020] [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] [Received: 06/05/2023] [Revised: 11/17/2023] [Accepted: 12/09/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND AND AIMS Plasma levels of renalase decrease in acute experimental pancreatitis. We aimed to determine if decreases in plasma renalase levels after ERCP predict the occurrence of post-ERCP pancreatitis (PEP). METHODS In this prospective cohort study conducted at a tertiary hospital, plasma renalase was determined before ERCP (baseline) and at 30 and 60 minutes after ERCP. Native renalase levels, acidified renalase, and native-to-acidified renalase proportions were analyzed over time using a longitudinal regression model. RESULTS Among 273 patients, 31 developed PEP. Only 1 PEP patient had a baseline native renalase >6.0 μg/mL, whereas 38 of 242 without PEP had a native renalase > 6.0 μg/mL, indicating a sensitivity of 97% (30/31) and specificity of 16% (38/242) in predicting PEP. Longitudinal models did not show differences over time between groups. CONCLUSIONS Baseline native renalase levels are very sensitive for predicting PEP. Further studies are needed to determine the potential clinical role of renalase in predicting and preventing PEP.
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Affiliation(s)
- Thiruvengadam Muniraj
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gary Desir
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Fred S Gorelick
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Xiaojia Guo
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Maria M Ciarleglio
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Yanhong Deng
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Priya A Jamidar
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James Farrell
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Harry R Aslanian
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Loren Laine
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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13
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Yared RA, Chen CC, Vandorpe A, Arvanitakis M, Delhaye M, Viesca MFY, Huberty V, Blero D, Toussaint E, Hittelet A, Verset D, Margos W, Le Moine O, Njimi H, Liao WC, Devière J, Lemmers A. Intravenous Hemin, a potential heme oxygenase-1 activator, does not protect from post-ERCP acute pancreatitis in humans: Results of a randomized multicentric multinational placebo-controlled trial. Pancreatology 2024; 24:363-369. [PMID: 38431445 DOI: 10.1016/j.pan.2024.02.009] [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: 08/18/2023] [Revised: 02/06/2024] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Hemin, a heme oxygenase 1 activator has shown efficacy in the prevention and treatment of acute pancreatitis in mouse models. We conducted a randomized controlled trial (RCT) to assess the protective effect of Hemin administration to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in patients at risk. METHODS In this multicenter, multinational, placebo-controlled, double-blind RCT, we assigned patients at risk for PEP to receive a single intravenous dose of Hemin (4 mg/kg) or placebo immediately after ERCP. Patients were considered to be at risk on the basis of validated patient- and/or procedure-related risk factors. Neither rectal NSAIDs nor pancreatic stent insertion were allowed in randomized patients. The primary outcome was the incidence of PEP. Secondary outcomes included lipase elevation, mortality, safety, and length of stay. RESULTS A total of 282 of the 294 randomized patients had complete follow-up. Groups were similar in terms of clinical, laboratory, and technical risk factors for PEP. PEP occurred in 16 of 142 patients (11.3%) in the Hemin group and in 20 of 140 patients (14.3%) in the placebo group (p = 0.48). Incidence of severe PEP reached 0.7% and 4.3% in the Hemin and placebo groups, respectively (p = 0.07). Significant lipase elevation after ERCP did not differ between groups. Length of hospital stay, mortality and severe adverse events rates were similar between groups. CONCLUSION We failed to detect large improvements in PEP rate among participants at risk for PEP who received IV hemin immediately after the procedure compared to placebo. TRIAL REGISTRATION NUMBER ClinicalTrials.gov number, NCT01855841).
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Affiliation(s)
- Rawad A Yared
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Chieh-Chang Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taiwan
| | - Astrid Vandorpe
- Pharmacy, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles (ULB) Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Myriam Delhaye
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Michael Fernandez Y Viesca
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Vincent Huberty
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Daniel Blero
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium; Department of Gastroenterology, CHU Charleroi, Charleroi, Belgium
| | - Emmanuel Toussaint
- Department of Gastroenterology, CHU Charleroi, Charleroi, Belgium; CHU Brugmann, Department of Gastroenterology, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Axel Hittelet
- Department of Gastroenterology, Hôpital Ambroise Paré, Mons, Belgium
| | - Didier Verset
- Department of Gastroenterology, CH Jolimont, La Louvière, Belgium
| | - Walter Margos
- Department of Gastroenterology, CH Jolimont, La Louvière, Belgium
| | - Olivier Le Moine
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Hassane Njimi
- Intensive Care Unit, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles (ULB) Brussels, Belgium
| | - Wei-Chih Liao
- Department of Internal Medicine, National Taiwan University Hospital, Taiwan
| | - Jacques Devière
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Arnaud Lemmers
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
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14
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Tien A, Kwok K. Response. Gastrointest Endosc 2024; 99:862-863. [PMID: 38649227 DOI: 10.1016/j.gie.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Andy Tien
- Department of Gastroenterology, Kaiser Permanente Baldwin Park Medical Center, Los Angeles, California, USA
| | - Karl Kwok
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
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15
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Bi YZ, Yan SJ, Zhou LM, Sun Y, Zhang J. Instant duodenal decompression after endoscopic retrograde cholangiopancreatography can effectively reduce the incidence of post-ERCP pancreatitis and hyperamylasemia. Gastroenterol Rep (Oxf) 2024; 12:goae025. [PMID: 38586538 PMCID: PMC10997411 DOI: 10.1093/gastro/goae025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/29/2023] [Accepted: 03/11/2024] [Indexed: 04/09/2024] Open
Abstract
Background Post-ERCP pancreatitis (PEP) is significantly influenced by the reflux of duodenal fluid. While gastrointestinal decompression represents a fundamental approach in acute pancreatitis management, the effectiveness of immediate duodenal decompression following ERCP to prevent PEP remains uncertain. This study aimed to investigate the impact of immediate duodenal decompression after ERCP on reducing the incidence of hyperamylasemia and PEP. Methods This retrospective study encompassed patients with native papilla who underwent therapeutic ERCP for choledocholithiasis at the Department of Gastroenterology, Chun'an Branch of Zhejiang Provincial People's Hospital (Zhejiang, China) between January 2020 and June 2023. Based on the immediate placement of a duodenal decompression tube post-ERCP, patients were categorized into two groups: the duodenal decompression group and the conventional procedure group. Primary outcomes included the incidence of PEP and hyperamylasemia. Results A total of 195 patients were enrolled (94 in the duodenal decompression group and 101 in the conventional procedure group). Baseline clinical and procedural characteristics exhibited no significant differences between the two groups. PEP occurred in 2 patients (2.1%) in the duodenal decompression group, in contrast to 11 patients (10.9%) in the conventional procedure group (Risk difference [RD] 8.8%; 95% confidence interval [CI] 1.7%-16.5%, P = 0.014). Hyperamylasemia was observed in 8 patients (8.5%) in the duodenal decompression group, compared to 20 patients (19.8%) in the conventional procedure group (RD 11.3%; 95% CI 1.4%-21.0%; P = 0.025). Patients with PEP in both groups showed improvement after receiving active treatment. No severe cases of PEP occurred in either group, and no serious adverse events related to duodenal catheter decompression were reported. Conclusion Immediate duodenal decompression following ERCP demonstrates an effective reduction in the incidence of hyperamylasemia and PEP.
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Affiliation(s)
- Yu-Zhen Bi
- Department of Gastroenterology, Chun’an Country First People’s Hospital (Zhejiang Provincial People’s Hospital, Chun’an Branch), Hangzhou, Zhejiang, P. R. China
| | - Si-Jia Yan
- Department of Gastroenterology, Chun’an Country First People’s Hospital (Zhejiang Provincial People’s Hospital, Chun’an Branch), Hangzhou, Zhejiang, P. R. China
| | - Li-Min Zhou
- Department of Gastroenterology, Chun’an Country First People’s Hospital (Zhejiang Provincial People’s Hospital, Chun’an Branch), Hangzhou, Zhejiang, P. R. China
| | - Yan Sun
- Key Laboratory of Gastroenterology of Zhejiang Province, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, P. R. China
| | - Jun Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang, P. R. China
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16
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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.
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Affiliation(s)
| | | | - Herney Andrés García-Perdomo
- Division of Urology/Urooncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
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17
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Taniguchi T, Ideno N, Araki T, Miura S, Yamamoto M, Nakafusa T, Higashijima N, Yamamoto T, Tamura K, Nakamura S, Abe T, Ikenaga N, Nakata K, Ohuchida K, Oda Y, Ohtsuka T, Nakamura M. MicroRNA-20a in extracellular vesicles derived from duodenal fluid is a possible biomarker for pancreatic ductal adenocarcinoma. DEN OPEN 2024; 4:e333. [PMID: 38434144 PMCID: PMC10908371 DOI: 10.1002/deo2.333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/27/2023] [Accepted: 12/30/2023] [Indexed: 03/05/2024]
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) has a high mortality rate owing to its late diagnosis and aggression. In addition, there are relatively few minimally invasive screening methods for the early detection of PDAC, making the identification of biomarkers for this disease a critical priority. Recent studies have reported that microRNAs in extracellular vesicles (EV-miRs) from bodily fluids can be useful for the diagnosis of PDACs. Given this, we designed this study to evaluate the utility of cancer EVs extracted from duodenal fluid (DF) and their resident EV-miRs as potential biomarkers for the detection of PDAC. Methods EV-miRs were evaluated and identified in the supernatants of various pancreatic cancer cell lines (Panc-1, SUIT2, and MIAPaca2), human pancreatic duct epithelial cells, and the DF from patients with PDAC and healthy controls. EVs were extracted using ultracentrifugation and the relative expression of EV-miR-20a was quantified. Results We collected a total of 34 DF samples (27 PDAC patients and seven controls) for evaluation and our data suggest that the relative expression levels of EV-miR-20a were significantly higher in patients with PDAC than in controls (p = 0.0025). In addition, EV-miR-20a expression could discriminate PDAC from control patients regardless of the location of the tumor with an area under the curve values of 0.88 and 0.88, respectively. Conclusions We confirmed the presence of EVs in the DF and suggest that the expression of EV-miR-20a in these samples may act as a potential diagnostic biomarker for PDAC.
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Affiliation(s)
- Takashi Taniguchi
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Noboru Ideno
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Tomoyuki Araki
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Shun Miura
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Masahiro Yamamoto
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Tomoki Nakafusa
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Nobuhiro Higashijima
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Takeo Yamamoto
- Department of Anatomic PathologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Koji Tamura
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - So Nakamura
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Toshiya Abe
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Naoki Ikenaga
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Kohei Nakata
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Kenoki Ohuchida
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Yoshinao Oda
- Department of Anatomic PathologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Takao Ohtsuka
- Department of Digestive SurgeryBreast and Thyroid SurgeryGraduate School of Medical and Dental SciencesKagoshima UniversityKagoshimaJapan
| | - Masafumi Nakamura
- Department of Surgery and OncologyGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
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18
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Liu KJ, Hu Y, Guo SB. Effect of rectal indomethacin on the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography for choledocholithiasis: a prospective randomized clinical trial. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:20-208. [PMID: 37982566 DOI: 10.17235/reed.2023.9899/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
BACKGROUND AND AIM the aim of this study was to evaluate the efficacy and safety of rectal indomethacin for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in patients with common bile duct (CBD) stones. METHODS a total of 167 patients undergoing ERCP between November 2019 and November 2022 for CBD stones in the First Affiliated Hospital of Dalian Medical University were prospectively analyzed. The patients were divided into an indomethacin group (n = 58) and a control group (n = 109). The primary endpoint was the percent of patients who experienced PEP. RESULTS PEP was observed in a total of 26 patients (15.57 %); four patients (6.90 %) in the indomethacin group and 22 (20.18 %) in the control group (p = 0.042). Mild, moderate and severe PEP was observed in three (5.17 %), one (1.72 %) and zero patients, respectively, in the indomethacin group, and in eleven (10.09 %), nine (8.26 %) and two (1.83 %) patients, respectively, in the control group. There was one case (0.92 %) of death due to PEP in the control group. No cases of moderate or severe bleeding were observed in either group. CONCLUSIONS rectal indomethacin is an effective and safe method to prevent PEP for patients with CBD stones undergoing ERCP.
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Affiliation(s)
- Kai-Ji Liu
- Gastroenterology, The Fifth Affiliated Hospital of Southern Medical University
| | - Yang Hu
- Gastroenterology, The First Affiliated Hospital of Dalian Medical University
| | - Shi-Bin Guo
- Gastroenterology, The First Affiliated Hospital of Dalian Medical University, China
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19
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Tenner S, Vege SS, Sheth SG, Sauer B, Yang A, Conwell DL, Yadlapati RH, Gardner TB. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol 2024; 119:419-437. [PMID: 38857482 DOI: 10.14309/ajg.0000000000002645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/08/2023] [Indexed: 06/12/2024]
Abstract
Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.
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Affiliation(s)
- Scott Tenner
- State University of New York, Health Sciences Center, Brooklyn, New York, USA
| | | | - Sunil G Sheth
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Bryan Sauer
- University of Virginia, Charlottesville, Virginia, USA
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Matsumoto K, Noma H, Fujita K, Tomoda T, Onoyama T, Hanada K, Okazaki A, Hirao K, Goto D, Moriyama I, Kushiyama Y, Takenaka M, Maruo T, Matsumoto H, Asada M, Nebiki H, Katayama T, Kawamura T, Kurita A, Ueki T, Tsujimae M, Matsubara T, Yamada S, Tamura T, Marui S, Mitoro A, Isomoto H, Yazumi S, Kawamoto H. Prognostic Factors for Severe-to-Fatal Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Multicenter Prospective Cohort Study. J Clin Med 2024; 13:1135. [PMID: 38398448 PMCID: PMC10889235 DOI: 10.3390/jcm13041135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/07/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
The prognostic factors associated with severe-to-fatal post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remain unclear despite the extensive number of studies on PEP. In total, 3739 ERCP patients with biliary disease with an intact papilla and indicated for ERCP were prospectively enrolled at 36 centers from April 2017 to March 2018. Those with acute pancreatitis diagnosed before ERCP, altered gastrointestinal anatomy, and an American Society of Anesthesiologists (ASA) physical status > 4 were excluded. Univariate and multivariate logistic regression analyses were performed on patient-related factors, operator-related factors, procedure-related factors, and preventive measures to identify potential prognostic factors for severe-to-fatal PEP. Multivariate analyses revealed pancreatic guidewire-assisted biliary cannulation (OR 13.59, 95% CI 4.21-43.83, p < 0.001), post-ERCP non-steroidal anti-inflammatory drug (NSAID) administration (OR 11.54, 95% CI 3.83-34.81, p < 0.001), and previous pancreatitis (OR 6.94, 95% CI 1.45-33.33, p = 0.015) as significant risk factors for severe-to-fatal PEP. Preventive measures included endoscopic biliary sphincterotomy (EST; OR 0.29, 95% CI, 0.11-0.79, p = 0.015) and prophylactic pancreatic stents (PPSs; OR 0.11, 95% CI, 0.01-0.87, p = 0.036). In biliary ERCP, pancreatic guidewire-assisted biliary cannulation, NSAID administration after ERCP, and previous pancreatitis were risk factors for severe-to-fatal PEP, whereas EST and PPS were significant preventive measures for severe-to-fatal PEP.
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Affiliation(s)
- Kazuya Matsumoto
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.O.); (H.I.)
- Irisawa Medical Clinic, Matsue 690-0025, Japan
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tachikawa 190-8562, Japan;
| | - Koichi Fujita
- Department of Gastroenterology and Hepatology, Yodogawa Christian Hospital, Osaka 533-0024, Japan
- First Research Department, Medical Research Institute, Kitano Hospital, PIIF Tazuke-Kofukai, Osaka 530-8480, Japan
| | - Takeshi Tomoda
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan;
| | - Takumi Onoyama
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.O.); (H.I.)
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, Onomichi, Hiroshima 722-8508, Japan;
| | - Akihito Okazaki
- Department of Gastroenterology, Hiroshima Atomic Bomb Survivor Hospital, Hiroshima 730-0052, Japan;
| | - Ken Hirao
- Department of Internal Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima 730-8518, Japan;
| | - Daisuke Goto
- Department of Internal Medicine, Tottori Red Cross Hospital, Tottori 680-8517, Japan;
| | - Ichiro Moriyama
- Department of Hematology/Oncology, Shimane University Hospital, Innovative Cancer Center, Izumo 693-8501, Japan;
| | - Yoshinori Kushiyama
- Department of Gastroenterology, Matsue Red Cross Hospital, Matsue 690-8506, Japan;
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kinki University, Osaka 589-8511, Japan;
| | - Toru Maruo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka 814-0180, Japan; (T.M.); (T.U.)
| | - Hisakazu Matsumoto
- Department of Gastroenterology, Japan Red Cross Hospital Wakayama Medical Center, Wakayama 640-8558, Japan;
| | - Masanori Asada
- Department of Gastroenterology and Hepatology, Japan Red Cross Osaka Hospital, Osaka 543-8555, Japan;
| | - Hiroko Nebiki
- Department of Gastroenterology, Osaka City General Hospital, Osaka 534-0021, Japan;
| | - Toshihiro Katayama
- Help Center of Medical Research, Medical Research Institute, Kitano Hospital, PIIF Tazuke-Kofukai, Osaka 530-8480, Japan;
| | - Takashi Kawamura
- Department of Preventive Services, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto 606-8303, Japan;
| | - Akira Kurita
- Kitano Hospital, Tazuke-Kofukai Medical Research Institute, Kyoto 530-8480, Japan;
| | - Toshiharu Ueki
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka 814-0180, Japan; (T.M.); (T.U.)
| | - Masahiro Tsujimae
- Department of Gastroenterology, Osaka Saiseikai Nakatsu Hospital, Osaka 530-0012, Japan;
| | - Tokuhiro Matsubara
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Osaka 560-8565, Japan;
| | - Satoshi Yamada
- Department of Gastroenterology, Kobe City Medical Center West Hospital, Kobe 650-0047, Japan;
| | - Takashi Tamura
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama 641-8510, Japan;
| | - Saiko Marui
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan;
| | - Akira Mitoro
- Department of Gastroenterology, Nara Medical University, Nara 634-8522, Japan;
| | - Hajime Isomoto
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.O.); (H.I.)
| | - Shujiro Yazumi
- Department of Gastroenterology and Hepatology, Medical Research Institute, Kitano Hospital, PIIF Tazuke-Kofukai, Osaka 530-8480, Japan;
| | - Hirofumi Kawamoto
- General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama 701-0192, Japan;
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21
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Elmunzer BJ, Foster LD, Serrano J, Coté GA, Edmundowicz SA, Wani S, Shah R, Bang JY, Varadarajulu S, Singh VK, Khashab M, Kwon RS, Scheiman JM, Willingham FF, Keilin SA, Papachristou GI, Chak A, Slivka A, Mullady D, Kushnir V, Buxbaum J, Keswani R, Gardner TB, Forbes N, Rastogi A, Ross A, Law J, Yachimski P, Chen YI, Barkun A, Smith ZL, Petersen B, Wang AY, Saltzman JR, Spitzer RL, Ordiah C, Spino C, Durkalski-Mauldin V. Indomethacin with or without prophylactic pancreatic stent placement to prevent pancreatitis after ERCP: a randomised non-inferiority trial. Lancet 2024; 403:450-458. [PMID: 38219767 PMCID: PMC10872215 DOI: 10.1016/s0140-6736(23)02356-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND The combination of rectally administered indomethacin and placement of a prophylactic pancreatic stent is recommended to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients. Preliminary evidence suggests that the use of indomethacin might eliminate or substantially reduce the need for stent placement, a technically complex, costly, and potentially harmful intervention. METHODS In this randomised, non-inferiority trial conducted at 20 referral centres in the USA and Canada, patients (aged ≥18 years) at high risk for post-ERCP pancreatitis were randomly assigned (1:1) to receive rectal indomethacin alone or the combination of indomethacin plus a prophylactic pancreatic stent. Patients, treating clinicians, and outcomes assessors were masked to study group assignment. The primary outcome was post-ERCP pancreatitis. To declare non-inferiority, the upper bound of the two-sided 95% CI for the difference in post-ERCP pancreatitis (indomethacin alone minus indomethacin plus stent) would have to be less than 5% (non-inferiority margin) in both the intention-to-treat and per-protocol populations. This trial is registered with ClinicalTrials.gov (NCT02476279), and is complete. FINDINGS Between Sept 17, 2015, and Jan 25, 2023, a total of 1950 patients were randomly assigned. Post-ERCP pancreatitis occurred in 145 (14·9%) of 975 patients in the indomethacin alone group and in 110 (11·3%) of 975 in the indomethacin plus stent group (risk difference 3·6%; 95% CI 0·6-6·6; p=0·18 for non-inferiority). A post-hoc intention-to-treat analysis of the risk difference between groups showed that indomethacin alone was inferior to the combination of indomethacin plus prophylactic stent (p=0·011). The relative benefit of stent placement was generally consistent across study subgroups but appeared more prominent among patients at highest risk for pancreatitis. Safety outcomes (serious adverse events, intensive care unit admission, and hospital length of stay) did not differ between groups. INTERPRETATION For preventing post-ERCP pancreatitis in high-risk patients, a strategy of indomethacin alone was not as effective as a strategy of indomethacin plus prophylactic pancreatic stent placement. These results support prophylactic pancreatic stent placement in addition to rectal indomethacin administration in high-risk patients, in accordance with clinical practice guidelines. FUNDING US National Institutes of Health.
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Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA.
| | - Lydia D Foster
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jose Serrano
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Gregory A Coté
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, Portland, OR, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Raj Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ji Young Bang
- Orlando Health Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Shyam Varadarajulu
- Orlando Health Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mouen Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Richard S Kwon
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - James M Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Field F Willingham
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven A Keilin
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - James Buxbaum
- Division of Gastroenterology, University of Southern California, Los Angeles, CA, USA
| | - Rajesh Keswani
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - Nauzer Forbes
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - Amit Rastogi
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Andrew Ross
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Joanna Law
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yen-I Chen
- Division of Gastroenterology, McGill University, Montreal, QC, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University, Montreal, QC, Canada
| | - Zachary L Smith
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bret Petersen
- Department of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Andrew Y Wang
- Division of Gastroenterology, University of Virginia, Charlottesville, VA, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Rebecca L Spitzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Collins Ordiah
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Cathie Spino
- Department of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Valerie Durkalski-Mauldin
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
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22
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Kaimakliotis PI, Kochman ML. Prophylactic pancreatic stent placement to prevent pancreatitis after ERCP. Lancet 2024; 403:411-413. [PMID: 38219770 DOI: 10.1016/s0140-6736(23)02719-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 01/16/2024]
Affiliation(s)
- Pavlos I Kaimakliotis
- Gastroenterology Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael L Kochman
- Gastroenterology Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
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23
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El Kurdi B, Imam Z, Abonofal A, Babar S, Shah P, Pannala R, Papachristou G, Echavarria J, Pisipati S, Jahangir S, Rajalingamgari P, Chang YHH, Singh VP. NSAIDs do not reduce severity among post-ERCP pancreatitis patients. Pancreatology 2024; 24:14-23. [PMID: 37981523 PMCID: PMC11298787 DOI: 10.1016/j.pan.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/05/2023] [Accepted: 11/01/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE Non-steroidal anti-inflammatory drugs (NSAIDs) are the most studied chemoprophylaxis for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). While previous systematic reviews have shown NSAIDs reduce PEP, their impact on moderate to severe PEP (MSPEP) is unclear. We conducted a systematic review and meta-analysis to understand the impact of NSAIDs on MSPEP among patients who developed PEP. We later surveyed physicians' understanding of that impact. DESIGN A systematic search for randomized trials using NSAIDs for PEP prevention was conducted. Pooled-prevalence and Odds-ratio of PEP, MSPEP were compared between treated vs. control groups. Analysis was performed using R software. Random-effects model was used for all variables. Physicians were surveyed via email before and after reviewing our results. RESULTS 7688 patients in 25 trials were included. PEP was significantly reduced to 0.598 (95%CI, 0.47-0.76) in the NSAIDs group. Overall burden of MSPEP was reduced among all patients undergoing ERCP: OR 0.59 (95%CI, 0.42-0.83). However, NSAIDs didn't affect the proportion of MSPEP among those who developed PEP (p = 0.658). Rectal Indomethacin and diclofenac reduced PEP but not MSPEP. Efficacy didn't vary by risk, timing of administration, or bias-risk. Survey revealed a change in the impression of the effect of NSAIDs on MSPEP after reviewing our results. CONCLUSIONS Rectal diclofenac or indomethacin before or after ERCP reduce the overall burden of MSPEP by reducing the pool of PEP from which it can arise. However, the proportion of MSPEP among patients who developed PEP is unaffected. Therefore, NSAIDs prevent initiation of PEP, but do not affect severity among those that develop PEP. Alternative modalities are needed to reduce MSPEP among patients who develop PEP.
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Affiliation(s)
- Bara El Kurdi
- Department of Internal Medicine East Tennessee State University, Johnson City, TN, USA; Division of Gastroenterology and Hepatology, University of Texas Health at San Antonio, TX, USA.
| | - Zaid Imam
- Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Abdulrahman Abonofal
- Department of Internal Medicine East Tennessee State University, Johnson City, TN, USA
| | - Sumbal Babar
- Department of Internal Medicine East Tennessee State University, Johnson City, TN, USA
| | - Pir Shah
- Division of Gastroenterology and Hepatology, University of Texas Health at San Antonio, TX, USA
| | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Georgios Papachristou
- Division of Gastroenterology and Hepatology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Juan Echavarria
- Division of Gastroenterology and Hepatology, University of Texas Health at San Antonio, TX, USA
| | - Sailaja Pisipati
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Sarah Jahangir
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Prasad Rajalingamgari
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Yu-Hui H Chang
- Department of Biostatistics, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Vijay P Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ, USA.
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24
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Paik WH, Park DH. Endoscopic Management of Malignant Biliary Obstruction. Gastrointest Endosc Clin N Am 2024; 34:127-140. [PMID: 37973224 DOI: 10.1016/j.giec.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used for managing malignant biliary obstruction; however, it is impossible if the endoscope cannot reach the ampulla of Vater, and it carries a risk of procedure-related pancreatitis. Percutaneous approach is a traditional rescue method when ERCP fails and can be useful in advanced malignant hilar biliary obstruction; however, it is invasive and carries risks of tube dislodgement, recurrent infection, and tract seeding. Endoscopic ultrasound approach may be attempted if ERCP fails and is free from the risk of pancreatitis; however, it is only possible in limited centers, and training is still difficult. Malignant biliary obstruction should be managed by leveraging the complementary strengths of these methods.
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Affiliation(s)
- Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-Gil, Songpa-gu, Seoul 05505, Korea.
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25
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Kumar AH, Pamecha V, Patil NS, Mohapatra N, Kilambi R, Sinha PK. Efficacy of rectal indomethacin in prevention of post-operative hyperamylasemia following pancreatoduodenectomy: a randomized controlled trial. Langenbecks Arch Surg 2023; 409:23. [PMID: 38157074 DOI: 10.1007/s00423-023-03212-9] [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: 09/19/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Post-operative hyperamylasemia (POH) following pancreatoduodenectomy (PD) may play a key role in pathogenesis of post-operative pancreatic fistula (POPF). Aim of the current study was to evaluate efficacy of perioperative administration of indomethacin in preventing POH. METHODS Single-center, double-blind, randomized controlled trial (RCT) conducted on consecutive patients undergoing PD. Patients received either 100 mg of indomethacin per-rectally at induction of anesthesia or standard care. Primary endpoint was incidence of POH in the two arms. POH was defined as postoperative day (POD) 1 serum amylase (S. amylase) levels greater than the upper limit of normal. RESULTS After exclusion 44 patients were randomized. The two arms were comparable for preoperative and intraoperative parameters. POH was noted in 20/44 (45.5%) with significantly lower incidence of POH (60.9% vs. 28.6%, p = 0.032) in intervention arm (IA). Median S. amylase, POD 1, 3, and 5 drain amylase, and incidence of clinically relevant POPF (CR-POPF) were lower in IA but failed to reach statistical significance (30.4% vs. 14.3%, p = 0.18). The severity of delayed gastric emptying (DGE) was significantly lower in the IA (grade B/C DGE 23.8% vs. 47.8%, p = 0.023). Evaluation of risk factors for POH showed IA to confer an independent protective effect and increased risk with soft pancreas. CONCLUSION Perioperative per-rectal indomethacin administration is effective in decreasing the incidence of POH following pancreatoduodenectomy.
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Affiliation(s)
- Anubhav Harshit Kumar
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Viniyendra Pamecha
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
| | - Nilesh Sadashiv Patil
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Nihar Mohapatra
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Ragini Kilambi
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Piyush Kumar Sinha
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
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26
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Lin YC, Ni J, Swaminathan G, Khalid A, Barakat MT, Frymoyer AR, Tsai CY, Ding Y, Murayi JA, Jayaraman T, Poropatich R, Bottino R, Wen L, Papachristou GI, Sheth SG, Yu M, Husain SZ. Rectal administration of tacrolimus protects against post-ERCP pancreatitis in mice. Pancreatology 2023; 23:777-783. [PMID: 37778935 DOI: 10.1016/j.pan.2023.09.080] [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: 08/11/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE There is an unmet clinical need for effective, targeted interventions to prevent post-ERCP pancreatitis (PEP). We previously demonstrated that the serine-threonine phosphatase, calcineurin (Cn) is a critical mediator of PEP and that the FDA-approved calcineurin inhibitors, tacrolimus (Tac) or cyclosporine A, prevented PEP. Our recent observations in preclinical PEP models demonstrating that Cn deletion in both pancreatic and hematopoietic compartments is required for maximal pancreas protection, highlighted the need to target both systemic and pancreas-specific Cn signaling. We hypothesized that rectal administration of Tac would effectively mitigate PEP by ensuring systemic and pancreatic bioavailability of Tac. We have tested the efficacy of rectal Tac in a preclinical PEP model and in cerulein-induced experimental pancreatitis. METHODS C57BL/6 mice underwent ductal cannulation with saline infusion to simulate pressure-induced PEP or were given seven, hourly, cerulein injections to induce pancreatitis. To test the efficacy of rectal Tac in pancreatitis prevention, a rectal Tac suppository (1 mg/kg) was administered 10 min prior to cannulation or first cerulein injection. Histological and biochemical indicators of pancreatitis were evaluated post-treatment. Pharmacokinetic parameters of Tac in the blood after rectal delivery compared to intravenous and intragastric administration was evaluated. RESULTS Rectal Tac was effective in reducing pancreatic injury and inflammation in both PEP and cerulein models. Pharmacokinetic studies revealed that the rectal administration of Tac helped achieve optimal blood levels of Tac over an extended time compared to intravenous or intragastric delivery. CONCLUSION Our results underscore the effectiveness and clinical utility of rectal Tac for PEP prophylaxis.
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Affiliation(s)
- Yu-Chu Lin
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA, USA
| | - Jianbo Ni
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA, USA; Department of Gastroenterology and Shanghai Key Laboratory of Pancreatic Disease, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gayathri Swaminathan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA, USA
| | - Asna Khalid
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA, USA
| | - Monique T Barakat
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA, USA; Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Adam R Frymoyer
- Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Cheng-Yu Tsai
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA, USA
| | - Ying Ding
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Judy-April Murayi
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Thottala Jayaraman
- Department of Oral and Craniofacial Sciences, School of Dental Medicine, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Rita Bottino
- Imagine Islet Center, Imagine Pharma, 1401 Forbes Avenue, Pittsburgh, PA, USA
| | - Li Wen
- Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | | | - Sunil G Sheth
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mang Yu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA, USA.
| | - Sohail Z Husain
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA, USA.
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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.
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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
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28
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Lee H, Kukreja Y, Niraj G. Interventional pathway in the management of refractory post cholecystectomy pain (PCP) syndrome: a 6-year prospective audit in 60 patients. Scand J Pain 2023; 23:712-719. [PMID: 36779538 DOI: 10.1515/sjpain-2022-0090] [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: 07/06/2022] [Accepted: 01/20/2023] [Indexed: 02/14/2023]
Abstract
OBJECTIVES Post cholecystectomy pain syndrome can affect over a third of patients undergoing laparoscopic cholecystectomy. Acute exacerbations can result in recurrent emergency admission with excessive healthcare utilization. Standard surgical management appears to focus on visceral aetiology. Abdominal myofascial pain syndrome is a poorly recognised somatic pathology that can cause refractory pain in this cohort. It develops as a result of trigger points in the abdominal musculature. The report describes the pathophysiology and a novel interventional pathway in the management of post cholecystectomy pain secondary to abdominal myofascial pain syndrome. METHODS The prospective longitudinal audit was performed at a tertiary pain medicine clinic in a university teaching hospital. Over a six-year period, adult patients with refractory abdominal pain following laparoscopic cholecystectomy were included in a structured interventional management pathway. The pathway included two interventions. Intervention I was a combination of abdominal plane blocks and epigastric port site trigger injection with steroids. Patients who failed to report durable relief (>50% pain relief at 12 weeks) were offered pulsed radiofrequency treatment to the abdominal planes (Intervention II). Outcomes included patient satisfaction, change in opioid consumption and impact on emergency visits. RESULTS Sixty patients who failed to respond to standard management were offered the pathway. Four patients refused due to needle phobia. Fifty-six patients received Intervention I. Failure rate was 14% (8/56). Forty-eight patients (48/56, 86%) reported significant benefit at 12 weeks while 38 patients reported durable relief at 24 weeks (38/56, 68%). Nine patients received Intervention II and all (100%) reported durable relief. Emergency admissions and opioid consumption were reduced. CONCLUSIONS Abdominal myofascial pain syndrome is a poorly recognised cause of post cholecystectomy pain. The novel interventional management pathway could be an effective solution in patients who fail to benefit from standard management.
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Affiliation(s)
- Hayun Lee
- Specialty Trainee, Department of Pain Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Yuvraj Kukreja
- Advanced Pain Medicine Fellow, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - G Niraj
- Consultant Department of Pain Medicine, Clinical Research Unit in Pain Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
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29
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Inamdar S, Cote GA, Yadav D. Endotherapy for Pancreas Divisum. Gastrointest Endosc Clin N Am 2023; 33:789-805. [PMID: 37709411 DOI: 10.1016/j.giec.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pancreas divisum (PD) is a common anatomic variant of the pancreatic duct. Causal association between PD and pancreatitis has been debated for many years. Minor papilla sphincterotomy (miES) is offered in clinical practice to patients with idiopathic acute recurrent pancreatitis (iRAP) and PD. However, available data originate mainly from observational studies with many limitations. An ongoing international, multicenter, sham-controlled trial is evaluating the efficacy of miES in iRAP and PD. Endoscopic therapy for pain relief has limited to no benefit in patients with chronic abdominal pain or chronic pancreatitis who have PD and is not recommended.
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Affiliation(s)
- Sumant Inamdar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences, Shorey Building, 8th Floor, 4301 West Markham Street, Little Rock, AR 72205, USA.
| | - Gregory A Cote
- Division of Gastroenterology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L461, Portland, OR, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburg Medical Center, 200 Lothrop Street, M2, C-wing, Pittsburgh, PA 15213, USA
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30
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Akshintala VS, Singh VK. Postendoscopic Retrograde Cholangiopancreatography Pancreatitis Pathophysiology and Prevention. Gastrointest Endosc Clin N Am 2023; 33:771-787. [PMID: 37709410 DOI: 10.1016/j.giec.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreato-biliary disorders. Pancreatitis remains the most frequent complication of the ERCP procedure, and it is, therefore, necessary to recognize the pathophysiology and risk factors contributing to the development of pancreatitis and understand the methods to prevent this complication.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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31
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Choi JH, Lee SH, Kim JS, Park N, Lee MH, Lee MW, Cho IR, Paik WH, Ryu JK, Kim YT. Combinatorial Effect of Prophylactic Interventions for Post-ERCP Pancreatitis among Patients with Risk Factors: A Network Meta-Analysis. Gut Liver 2023; 17:814-824. [PMID: 36510779 PMCID: PMC10502499 DOI: 10.5009/gnl220268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/19/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022] Open
Abstract
Background/Aims The combinatorial effects of prophylactic methods for postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) in patients with risk factors remain unclear. In this network meta-analysis, we compared the efficacy of various prophylactic strategies to decrease the risk of PEP among patients with risk factors. Methods A systematic review was performed to identify randomized controlled trials from PubMed, Embase, and the Cochrane Library through July 2021. We used frequentist network meta-analysis to compare the rates of PEP among patients who received prophylactic treatments as follows: class A, rectal nonsteroidal anti-inflammatory drugs; class B, prophylactic pancreatic stent; class C, aggressive hydration; or control, no prophylaxis or active control. We selected those studies that included patients with risk factors for PEP. Results We identified 19 trials, comprising 4,328 participants. Class ABC (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.03 to 0.24), class AC (OR, 0.10; 95% CI, 0.02 to 0.47), class AB (OR, 0.12; 95% CI, 0.05 to 0.26), class BC (OR, 0.13; 95% CI, 0.04 to 0.41), class A (OR, 0.16; 95% CI, 0.05 to 0.50), and class B (OR, 0.26; 95% CI, 0.14 to 0.46), were associated with a reduced risk of PEP as compared to that of the control. The most effective prophylaxis was ABC (0.87), followed by AC (0.68), AB (0.65), BC (0.56), A (0.49), and B (0.24) according to P-score. Conclusions The results of this network meta-analysis suggest that the more prophylactic methods are employed, the better the outcomes. It appears that for patients with risk factors, we need to prevent PEP through the use of these well proven combination strategies.
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Affiliation(s)
- Jin Ho Choi
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Seong Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Namyoung Park
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Myoeng Hwan Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Min Woo Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - In Rae Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yong-Tae Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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32
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Srivastava RP, Nietert PJ, Bobo JFG, Haj M, Forbes N, Elmunzer BJ. Serum Amylase as a Biomarker for Proof-of-Concept Studies in Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis Prevention. Clin Gastroenterol Hepatol 2023; 21:2676-2678.e2. [PMID: 36029968 PMCID: PMC9958270 DOI: 10.1016/j.cgh.2022.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/13/2022] [Accepted: 08/18/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Romik P Srivastava
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Paul J Nietert
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - John F G Bobo
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Mona Haj
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
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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.
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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
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Rivas A, Pherwani S, Mohamed R, Smith ZL, Elmunzer BJ, Forbes N. ERCP-related adverse events: incidence, mechanisms, risk factors, prevention, and management. Expert Rev Gastroenterol Hepatol 2023; 17:1101-1116. [PMID: 37899490 DOI: 10.1080/17474124.2023.2277776] [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: 08/29/2023] [Accepted: 10/27/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure for pancreaticobiliary disease. While ERCP is highly effective, it is also associated with the highest adverse event (AE) rates of all commonly performed endoscopic procedures. Thus, it is critical that endoscopists and caregivers of patients undergoing ERCP have clear understandings of ERCP-related AEs. AREAS COVERED This narrative review provides a comprehensive overview of the available evidence on ERCP-related AEs. For the purposes of this review, we subdivide the presentation of each ERCP-related AE according to the following clinically relevant domains: definitions and incidence, proposed mechanisms, risk factors, prevention, and recognition and management. The evidence informing this review was derived in part from a search of the electronic databases PubMed, Embase, and Cochrane, performed on 1 May 20231 May 2023. EXPERT OPINION Knowledge of ERCP-related AEs is critical not only given potential improvements in peri-procedural quality and related care that can ensue but also given the importance of reviewing these considerations with patients during informed consent. The ERCP community and researchers should aim to apply standardized definitions of AEs. Evidence-based knowledge of ERCP risk factors should inform patient care decisions during training and beyond.
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Affiliation(s)
- Angelica Rivas
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Simran Pherwani
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rachid Mohamed
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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35
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Wu CCH, Lim SJM, Khor CJL. Endoscopic retrograde cholangiopancreatography-related complications: risk stratification, prevention, and management. Clin Endosc 2023; 56:433-445. [PMID: 37460103 PMCID: PMC10393565 DOI: 10.5946/ce.2023.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/11/2023] [Indexed: 07/29/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) plays a crucial role in the management of pancreaticobiliary disorders. Although the ERCP technique has been refined over the past five decades, it remains one of the endoscopic procedures with the highest rate of complications. Risk factors for ERCP-related complications are broadly classified into patient-, procedure-, and operator-related risk factors. Although non-modifiable, patient-related risk factors allow for the closer monitoring and instatement of preventive measures. Post-ERCP pancreatitis is the most common complication of ERCP. Risk reduction strategies include intravenous hydration, rectal nonsteroidal anti-inflammatory drugs, and pancreatic stent placement in selected patients. Perforation is associated with significant morbidity and mortality, and prompt recognition and treatment of ERCP-related perforations are key to ensuring good clinical outcomes. Endoscopy plays an expanding role in the treatment of perforations. Specific management strategies depend on the location of the perforation and the patient's clinical status. The risk of post-ERCP bleeding can be attenuated by preprocedural optimization and adoption of intra-procedural techniques. Endoscopic measures are the mainstay of management for post-ERCP bleeding. Escalation to angioembolization or surgery may be required for refractory bleeding. Post-ERCP cholangitis can be reduced with antibiotic prophylaxis in high risk patients. Bile culture-directed therapy plays an important role in antimicrobial treatment.
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Affiliation(s)
- Clement Chun Ho Wu
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Samuel Jun Ming Lim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Christopher Jen Lock Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
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36
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Vázquez-Frias R, Rivera-Suazo Y, Aguayo-Elorriaga AK, Alfaro-Bolaños JE, Argüello-Arévalo GA, Cadena-León JF, Chávez-Sáenz JA, Consuelo-Sánchez A, Cruz-Romero EV, Espinosa-Saavedra D, Espriu-Ramírez MX, Flores-Calderón J, González-Ortiz B, Hernández-Rosiles V, Ignorosa-Arellano KR, Jaramillo-Esparza CM, Lozano-Hernández FR, Larrosa-Haro A, Leal-Quiroga U, Macias-Flores JA, Martínez-Leo BA, Martínez-Vázquez A, Mendoza-Tavera NMJ, Pacheco-Sotelo S, Reyes-Apodaca M, Sánchez-Ramírez CA, Sifuentes-Vela CA, Sosa-Arce M, Zárate-Mondragón FE. The Asociación Mexicana de Gastroenterología consensus on the diagnosis and treatment of acute pancreatitis in children and adolescents. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:267-281. [PMID: 37336694 DOI: 10.1016/j.rgmxen.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/12/2023] [Indexed: 06/21/2023]
Abstract
Acute pancreatitis (AP) and recurrent acute pancreatitis (RAP) are conditions, whose incidence is apparently on the rise. Despite the ever-increasing evidence regarding the management of AP in children and adults, therapeutic actions that could potentially affect having a poor prognosis in those patients, especially in the pediatric population, continue to be carried out. Therefore, the Asociación Mexicana de Gastroenterología convened a group of 24 expert pediatric gastroenterologists from different institutions and areas of Mexico, as well as 2 pediatric nutritionists and 2 specialists in pediatric surgery, to discuss different aspects of the epidemiology, diagnosis, and treatment of AP and RAP in the pediatric population. The aim of this document is to present the consensus results. Different AP topics were addressed by 6 working groups, each of which reviewed the information and formulated statements considered pertinent for each module, on themes involving recommendations and points of debate, concerning diagnostic or therapeutic approaches. All the statements were presented and discussed. They were then evaluated through a Delphi process, with electronic and anonymous voting, to determine the level of agreement on the statements. A total of 29 statements were formulated, all of which reached above 75% agreement in the first round of voting.
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Affiliation(s)
- R Vázquez-Frias
- Departamento de Gastroenterología y Nutrición, Hospital Infantil de México Federico Gómez, Instituto Nacional de Salud, Mexico City, Mexico.
| | - Y Rivera-Suazo
- Hospital Star Médica Infantil Privado, Mexico City, Mexico
| | - A K Aguayo-Elorriaga
- Hospital Pediátrico Coyoacán, Secretaría de Salud de la Ciudad de México, Mexico City, Mexico
| | - J E Alfaro-Bolaños
- Servicio de Gastroenterología, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | | | - J F Cadena-León
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, Mexico City, Mexico
| | | | - A Consuelo-Sánchez
- Departamento de Gastroenterología y Nutrición, Hospital Infantil de México Federico Gómez, Instituto Nacional de Salud, Mexico City, Mexico
| | - E V Cruz-Romero
- Servicio de Cirugía, Centro Médico Naval, Mexico City, Mexico
| | - D Espinosa-Saavedra
- Departamento de Gastroenterología, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - M X Espriu-Ramírez
- Servicio de Gastroenterología Pediátrica, Hospital General de Cancún Dr. Jesús Kumate Rodríguez, Cancún, Quintana Roo, Mexico
| | - J Flores-Calderón
- Departamento de Gastroenterología, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - B González-Ortiz
- Departamento de Gastroenterología, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - V Hernández-Rosiles
- Departamento de Gastroenterología y Nutrición, Hospital Infantil de México Federico Gómez, Instituto Nacional de Salud, Mexico City, Mexico
| | - K R Ignorosa-Arellano
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - C M Jaramillo-Esparza
- Departamento de Gastroenterología y Endoscopia Pediátrica, Hospital Ángeles Universidad, Mexico City, Mexico
| | - F R Lozano-Hernández
- Servicio de Gastroenterología Pediátrica, Centro Médico Naval, Mexico City, Mexico
| | - A Larrosa-Haro
- Instituto de Nutrición Humana, Centro Universitario de Ciencias de la Salud, Departamento de Reproducción Humana Crecimiento y Desarrollo Infantil, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - U Leal-Quiroga
- Servicio de Gastroenterología, Christus Muguerza Hospital Sur, Monterrey, Nuevo León, Mexico
| | - J A Macias-Flores
- Departamento de Gastroenterología, Hospital Infantil de Especialidades de Chihuahua, Chihuahua, Chihuahua, Mexico
| | - B A Martínez-Leo
- Hospital Pediátrico Moctezuma, Secretaría de Salud de la Ciudad de México, Mexico City, Mexico
| | - A Martínez-Vázquez
- Departamento de Gastroenterología y Nutrición Pediátrica, Hospital para el Niño Poblano, Puebla, Puebla, Mexico
| | | | - S Pacheco-Sotelo
- Servicio de Gastroenterología y Nutrición Pediátrica, UMAE, Hospital de Pediatría, Centro Médico Nacional de Occidente, Instituto Mexicano de Seguro Social, Guadalajara, Jalisco, Mexico
| | - M Reyes-Apodaca
- Programa de Maestría y Doctorado en Ciencias Médicas, Odontológicas y de la Salud, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | | | | | - M Sosa-Arce
- Departamento de Gastroenterología, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - F E Zárate-Mondragón
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, Mexico City, Mexico
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Goenka MK, Akshintala VS, Kamal A, Bhullar FA, Bush N, Kumar V, Chakraborty M, Gurakar M, Lakhtakia S, Talukdar R, Trikudanathan G, Khashab MA, Kalloo AN, Reddy DN, Sinha SK, Singh VK, Kochhar R. Frequent guidewire passage into the pancreatic duct is an independent risk factor for postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) among high-risk individuals: A post-hoc analysis of a randomized controlled trial data. J Dig Dis 2023; 24:427-433. [PMID: 37505932 DOI: 10.1111/1751-2980.13208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 02/12/2023] [Accepted: 07/25/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVES To systematically evaluate the patient and procedural risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) among patients receiving rectal indomethacin. METHODS Data from a randomized controlled trial (RCT) of high-risk patients undergoing ERCP who received rectal indomethacin with or without topical epinephrine was evaluated. PEP was defined based on the consensus criteria. Pancreatic stenting was excluded to avoid confounding results with the role of epinephrine spray. Multivariable logistic regression analysis was used to identify patient and procedural risk factors for PEP. RESULTS Among 960 patients enrolled in the RCT, the PEP incidence was 6.4%. An increased risk of PEP was seen with age <50 years and female gender (odds ratio [OR] 2.40, 95% confidence interval [CI] 1.35-4.26), malignant biliary stricture(s) (OR 3.51, 95% CI 1.52-8.10), >2 guidewire passes into the pancreatic duct (PD) (OR 2.84, 95% CI 1.43-5.64), and pancreatic brush cytology (OR 6.37, 95% CI 1.10-36.90), whereas a decreased risk of PEP was seen with contrast- over guidewire-assisted cannulation (OR 0.14, 95% CI 0.02-0.99) and the use of lactated Ringer's (LR) over other fluid types (OR 0.52, 95% CI 0.27-0.98). There was a significant trend between the number of guidewire passes into the PD and PEP risk (P = 0.002). CONCLUSIONS More than two guidewire passes into the PD and pancreatic brush cytology increased while the use of LR decreased the risk of PEP among high-risk patients receiving rectal indomethacin. Pancreatic stent placement and/or LR should be considered in patients with >2 guidewire passes into the PD.
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Affiliation(s)
- Mahesh K Goenka
- Institute of Gastrosciences and Liver, Apollo Gleneagles Hospital, Kolkata, India
| | - Venkata S Akshintala
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ayesha Kamal
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Furqan A Bhullar
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Nikhil Bush
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vijay Kumar
- Institute of Gastrosciences and Liver, Apollo Gleneagles Hospital, Kolkata, India
| | | | - Merve Gurakar
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Palomera-Tejeda E, Shah MP, Attar BM, Shah H, Sharma B, Oleas R, Kotwal V, Gandhi S, Mutneja HR. Pharmacological and Endoscopic Interventions for Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastroenterology Res 2023; 16:149-156. [PMID: 37351082 PMCID: PMC10284647 DOI: 10.14740/gr1620] [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] [Received: 03/31/2023] [Accepted: 05/15/2023] [Indexed: 06/24/2023] Open
Abstract
Background Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) represents the most common serious complication after endoscopic retrograde cholangiopancreatography (ERCP). Rectal non-steroidal anti-inflammatory drugs (NSAIDs) and pancreatic duct stenting (PDS) are the prophylactic interventions with more evidence and efficacy; however, PEP still represents a significant source of morbidity, mortality, and economic burden. Chronic statin use has been proposed as a prophylactic method that could be cheap and relatively safe. However, the evidence is conflicting. We aimed to evaluate the impact of endoscopic and pharmacological interventions including chronic statin and aspirin use, on the development of PEP. Methods A retrospective cohort study evaluated consecutive patients undergoing ERCP at John H. Stroger, Jr. Hospital of Cook County in Chicago from January 2015 to March 2018. Univariate and multivariate analyses were performed using logistic regression. Results A total of 681 ERCPs were included in the study. Twelve (1.76%) developed PEP. Univariate, multivariate, and subgroup analyses did not show any association between chronic statin or aspirin use and PEP. PDS and rectal indomethacin were protective in patients undergoing pancreatic duct injection. Pancreatic duct injection, female sex, and younger age were associated with a higher risk. History of papillotomy was associated with lower risk only in the univariate analysis (all P values < 0.05). Conclusion Chronic use of statins and aspirin appears to add no additional benefit to prevent ERCP pancreatitis. Rectal NSAIDs, and PDS after appropriate patient selection continue to be the main prophylactic measures. The lower incidence at our center compared with the reported data can be explained by the high rates of rectal indomethacin and PDS, the use of noninvasive diagnostic modalities for patient selection, and the expertise of the endoscopists.
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Affiliation(s)
| | - Mihir Prakash Shah
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Bashar M. Attar
- Division of Gastroenterology and Hepatology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
- Division of Gastroenterology and Hepatology, Rush University Medical Center, Chicago, IL, USA
| | - Hassam Shah
- Division of Gastroenterology and Hepatology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Bharosa Sharma
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Roberto Oleas
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Vikram Kotwal
- Division of Gastroenterology and Hepatology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
- Division of Gastroenterology and Hepatology, Rush University Medical Center, Chicago, IL, USA
| | - Seema Gandhi
- Division of Gastroenterology and Hepatology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Hemant Raj Mutneja
- Division of Gastroenterology and Hepatology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
- Division of Gastroenterology and Hepatology, Rush University Medical Center, Chicago, IL, USA
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Ashat M, Kandula S, Cote GA, Gromski MA, Fogel EL, Sherman S, Lehman GA, Watkins JL, Bick BL, Easler JJ. Utilization pattern of prophylactic measures for prevention of post-ERCP pancreatitis: a National Survey Study. Gastrointest Endosc 2023; 97:1059-1066.e3. [PMID: 36738796 DOI: 10.1016/j.gie.2023.01.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/05/2023] [Accepted: 01/28/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Post-ERCP pancreatitis (PEP) is the most frequent adverse event of ERCP. Various prophylactic measures are endorsed by the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy to both lower the incidence of PEP and to decrease its severity. The extent to which these interventions are practiced throughout the United States is unclear. The aim of this study was to describe the utilization pattern of various PEP measures and determine factors that affect utilization of these measures. METHODS A 27-question electronic survey was distributed using a cloud-based program (Qualtrics). The questions assessed ERCP training, practice setting, experience, practice patterns, and perceptions for PEP prophylaxis interventions. Endoscopists with practices based in the United States listed in the American Society for Gastrointestinal Endoscopy member directory received a survey invitation via e-mail. The invitation outlined the study and contained a link with instructions to complete the voluntary survey if they had an active ERCP practice. Data were de-identified for the purposes of analysis. RESULTS Of survey respondents (N = 319), 46% reported therapeutic endoscopy fellowship training and 37% practiced in teaching programs. Annualized ERCP volume of >100 cases per year were reported by 47%, with pancreatic ERCP comprising ≤5% of procedure volume reported by the majority of respondents (61%). The majority of respondents used prophylactic pancreatic stent (PPS), and 54% reported frequent use during high-risk ERCP. The most common indications for PPS were difficult cannulation, to assist biliary access, and multiple pancreatic duct injections. Most respondents reported frequent use of indomethacin (89%). Of physicians who did not use PPS, use of indomethacin was the most common reason (80%). Variables associated with frequent use of PPS were ERCP fellowship training (P ≤ .001), practice at a teaching program (P ≤ .001), <10 years in practice (P = .005), higher procedure volume (P ≤ .001), and higher proportion of pancreatic cases (P ≤ .001). CONCLUSIONS Physicians with higher annual ERCP volume, who teach at hospital-based ERCP practices, and who regularly perform pancreatic ERCP are more likely to use PPS. Therapeutic ERCP fellowship training and recent entry into practice were also associated with PPS utilization. Indomethacin use seems to be more frequent than PPS. Our findings suggest that indomethacin is supplanting PPS as the preferred method of PEP prophylaxis.
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Affiliation(s)
- Munish Ashat
- Department of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
| | - Sailesh Kandula
- Department of Statistics and Data Science, The University of Texas at Austin, Austin, Texas, USA
| | - Gregory A Cote
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Glen A Lehman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - James L Watkins
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Benjamin L Bick
- Division of Gastroenterology and Hepatology, Rockford Gastroenterology Associates, Rockford, Illinois, USA
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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Gordon SR. Prevention of post-endscopic retrograde cholangiopancreatography pancreatitis: Do we practice what we preach? Gastrointest Endosc 2023; 97:1067-1069. [PMID: 37208040 DOI: 10.1016/j.gie.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 05/21/2023]
Affiliation(s)
- Stuart R Gordon
- Section of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Agarwal A, Mahapatra SJ, Sethia R, Agarwal S, Elhence A, Mohta S, Gunjan D, Garg PK. Universal prophylactic rectal nonsteroidal anti-inflammatory drugs with a policy of selective pancreatic duct stenting significantly reduce post-endoscopic retrograde cholangiopancreatography pancreatitis. Indian J Gastroenterol 2023; 42:370-378. [PMID: 37160838 DOI: 10.1007/s12664-023-01354-8] [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: 03/11/2022] [Accepted: 02/03/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Although rectal nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be effective for the prevention of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis (PEP) in high-risk patients, the benefit in average-risk patients is unclear. We aimed at assessing the benefit of prophylactic rectal NSAIDs in unselected consecutive patients to prevent PEP. METHODS All patients undergoing index ERCP procedures from January 2018 until March 2020 were included. All patients received prophylactic rectal diclofenac. A prophylactic pancreatic duct (PD) stent was placed if there was repeated PD cannulation, at the discretion of the endoscopist. The frequency of PEP was compared with historical controls. RESULTS Of 769 patients who underwent ERCP, 34 (4.4%) developed PEP (mild in 29 [85.3%], moderate in four [11.8%] and severe in one [2.9%]). Female gender, precut sphincterotomy, inadvertent PD cannulation and procedural time of > 30 minutes predicted PEP in univariate analysis. Inadvertent PD cannulation (OR 4.6, 95% CI: 1.8-11.7; p < 0.001) and procedural time of > 30 minutes (OR 8.5, 95% CI: 3.7-10.1; p < 0.001) were independent risk factors on multivariate analysis. When compared with historical controls, the odds of PEP with prophylactic use of rectal NSAIDs and selective PD stenting was 0.54 (CI: 0.31-0.93, p = 0.027). The number needed to treat (NNT) was 22 to prevent one PEP with prophylactic rectal NSAIDs. CONCLUSION Routine use of prophylactic rectal NSAIDs effectively prevents the occurrence of PEP in unselected consecutive patients in a real-world scenario.
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Affiliation(s)
- Ashish Agarwal
- Department of Gastroenterology, All India Institute of Medical Sciences, Jodhpur, 342 005, India
| | - Soumya Jagannath Mahapatra
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Rahul Sethia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Srikanth Mohta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Pramod Kumar Garg
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
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Hassan AM, Lin TK, Smith MT, Hornung L, Abu-El-Haija M, Nathan JD, Vitale DS. Risk Factors for Post-ERCP Pancreatitis in Pediatric and Young Adult Patients. J Pediatr Gastroenterol Nutr 2023; 76:807-812. [PMID: 36930983 DOI: 10.1097/mpg.0000000000003766] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
OBJECTIVES Post-ERCP pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Limited existing data suggest that prophylactic pancreatic duct (PD) stenting in pediatric patients may increase the risk of PEP. The aim of this study is to identify factors associated with PEP in pediatric patients. METHODS Patients at a single institution who underwent ERCP between 2012 and 2020 were retrospectively reviewed. Patient and procedure-related factors were collected. Data were analyzed using Chi-square or Fisher exact tests as appropriate and Mann-Whitney-Wilcoxon tests. RESULTS Seven hundred thirty-six ERCPs were performed for 402 unique patients. Ninety-four cases were complicated by PEP (12.8%), of which 91 were mild and 3 were moderately severe. Pancreatic indication, native major papilla, PD cannulation and injection, and higher American Society for Gastrointestinal Endoscopy (ASGE) complexity were associated with PEP. A higher proportion of patients who received rectal indomethacin (65% vs 47%, P = 0.002), or who had placement of a prophylactic (31% vs 20%, P = 0.01) or therapeutic PD stent (37% vs 27%, P = 0.04) developed PEP; however, in a subgroup analysis of high-risk patients, this association was not persistent. A smaller proportion of PEP patients had PRSS1 mutation compared to non-PEP patients (22% vs 40%, P = 0.04). CONCLUSIONS This study evaluates factors associated with developing PEP in a large pediatric cohort. A high rate of PEP was observed, likely secondary to higher rates of pancreatic indication and higher ASGE complexity scores compared to previously reported literature. Randomized prospective trials are needed to better define the utility of various interventions.
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Affiliation(s)
- Ahmad M Hassan
- From the Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
| | - Tom K Lin
- the Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH
- the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Milton T Smith
- From the Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
| | - Lindsey Hornung
- the Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Maisam Abu-El-Haija
- the Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH
- the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jaimie D Nathan
- the Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David S Vitale
- the Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH
- the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Kumar A, Sondhi P. A closer look at universal prophylactic rectal NSAIDs in prevention of post-ERCP pancreatitis. Indian J Gastroenterol 2023; 42:311-314. [PMID: 37314683 DOI: 10.1007/s12664-023-01404-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Ajay Kumar
- BLK Max Institute of Digestive and Liver Diseases, New Delhi, 110 005, India.
| | - Pulkit Sondhi
- BLK Max Institute of Digestive and Liver Diseases, New Delhi, 110 005, India
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Balan GG, Timofte O, Gilca-Blanariu GE, Sfarti C, Diaconescu S, Gimiga N, Antighin SP, Sandu I, Sandru V, Trifan A, Moscalu M, Stefanescu G. Predicting Hospitalization, Organ Dysfunction, and Mortality in Post-Endoscopic Retrograde Cholangiopancreatography Acute Pancreatitis: Are SIRS and qSOFA Reliable Tools? APPLIED SCIENCES 2023; 13:6650. [DOI: 10.3390/app13116650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Background: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has shown constant incidence throughout time, despite advances in endoscopic technology, devices, or personal skills of the operating endoscopists, with prevention and prediction of severity in PEP being constant concerns. Several prospective studies have investigated the role of systemic inflammatory response syndrome (SIRS) criteria or the quick Sequential Organ Failure Assessment (qSOFA) score in the PEP severity assessment. However, there are no clearly defined tools for the prediction of PEP severity. Methods: A total of 403 patients were prospectively monitored 60 days after ERCP for the detection of PEP development. Consequently, we evaluated the lengths of stay, incidence of organic dysfunction, and mortality rates of these patients. The predictive power of the univariate model was evaluated by using the receiver operating characteristic curve and analyzing the area under the curve (AUC). Results: Incidence of PEP was similar to that reported in the majority of trials. The 60-day survival rate of PEP patients reached 82.8%. A qSOFA score ≥ 1 is a very good predictor for organ dysfunction (AUC 0.993, p < 0.0001). SIRS can also be considered a significant predictor for organic dysfunctions in PEP patients (AUC 0.926, p < 0.0001). However, only qSOFA was found to significantly predict mortality in PEP patients (AUC 0.885, p = 0.003), with SIRS criteria showing a much lower predictive power. Neither SIRS nor qSOFA showed any predictive value for the length of stay of PEP patients. Conclusion: Our study offers novel information about severity prediction in PEP patients. Both SIRS criteria and qSOFA showed good predictive value for organic dysfunction, mortality, and hospitalization.
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Affiliation(s)
- Gheorghe Gh. Balan
- Gastroenterology and Hepatology Clinic, “Sf. Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Oana Timofte
- Gastroenterology and Hepatology Clinic, “Sf. Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Georgiana-Emmanuela Gilca-Blanariu
- Gastroenterology and Hepatology Clinic, “Sf. Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Catalin Sfarti
- Gastroenterology and Hepatology Clinic, “Sf. Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | | | - Nicoleta Gimiga
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Clinical Department of Paediatric Gastroenterology, “Sf. Maria” Emergency Children’s Hospital, 700309 Iasi, Romania
| | | | - Ion Sandu
- Academy of Romanian Scientists (AORS), 54 Splaiul Independentei St., Sector 5, 050094 Bucharest, Romania
- Science Department, Interdisciplinary Research Institute, Alexandru Ioan Cuza University of Iasi, 11 Carol I Boulevard, 700506 Iasi, Romania
- Romanian Inventors Forum, 3 Sf. Petru Movilă St., L11, III/3, 700089 Iasi, Romania
| | - Vasile Sandru
- Gastroenterology and Hepatology Clinic, Floreasca Clinical Emergency Hospital, 014461 Bucharest, Romania
| | - Anca Trifan
- Gastroenterology and Hepatology Clinic, “Sf. Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihaela Moscalu
- Department of Preventive Medicine and Interdisciplinarity, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Gabriela Stefanescu
- Gastroenterology and Hepatology Clinic, “Sf. Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
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Deshmukh A, Desai PM, Chrusciel T, Nwankwo E, Tripathi R, Cheesman AR. Endoscopic retrograde cholangiopancreatography outcomes in inflammatory bowel disease patients: a 12-year analysis of a national database. Int J Colorectal Dis 2023; 38:137. [PMID: 37204502 DOI: 10.1007/s00384-023-04427-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Despite inflammatory bowel disease's (IBD) association with hepatobiliary disorders and the use of endoscopic retrograde cholangiopancreatography (ERCP) for both diagnostic and therapeutic evaluation of these diseases, it remains a poorly studied area within the literature. The purpose of this study is to examine the effect of IBD on the occurrence of adverse events (AE) pertaining to ERCP. METHODS This project utilized the National Inpatient Sample (NIS) database, the largest inpatient database in the USA. All patients 18 years or older with and without IBD undergoing ERCP were identified from 2008 to 2019. Post-ERCP AEs were analyzed using multivariate logistic or linear regression controlling for age, race, and existing comorbidities using the Charlson comorbidity index (CCI). RESULTS There was no difference in post-ERCP pancreatitis (PEP) or mortality. IBD patients were also found to have a lower risk of bleeding and decreased length of stay (LOS) despite adjustment for comorbidities. They also underwent less sphincterotomies when compared to the non-IBD cohort. Subgroup analysis between ulcerative colitis (UC) and Crohn's disease (CD) did not find any significant differences in outcomes. CONCLUSION To our knowledge, this is the largest study to date evaluating ERCP outcomes in IBD patients. After adjustment of co-variates, there was no difference in the occurrence of PEP, infections, and perforation. IBD patients were less likely to experience post-ERCP bleeding and mortality and had shorter LOS which may be due to the decreased frequency of sphincterotomy in this population.
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Affiliation(s)
- Ameya Deshmukh
- Department of Internal Medicine, Saint Louis University - SOM, 1201 South Grand Boulevard, St. Louis, MO, 63104, USA.
| | - Parth M Desai
- Division of Gastroenterology and Hepatology, Reading Hospital - Tower Health, PA, Reading, USA
| | - Timothy Chrusciel
- Advanced Health Data Research Institute (AHEAD), Saint Louis University, St. Louis, MO, USA
| | - Eugene Nwankwo
- Department of Internal Medicine, Saint Louis University - SOM, 1201 South Grand Boulevard, St. Louis, MO, 63104, USA
| | - Rohan Tripathi
- Department of Internal Medicine, Saint Louis University - SOM, 1201 South Grand Boulevard, St. Louis, MO, 63104, USA
| | - Antonio R Cheesman
- Division of Gastroenterology and Hepatology, Saint Louis University - SOM, St. Louis, MO, USA
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Keswani RN, Duloy A, Nieto JM, Panganamamula K, Murad MH, Bazerbachi F, Shaukat A, Elmunzer BJ, Day LW. Interventions to improve the performance of ERCP and EUS quality indicators. Gastrointest Endosc 2023; 97:825-838. [PMID: 36967249 DOI: 10.1016/j.gie.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/11/2022] [Indexed: 04/21/2023]
Affiliation(s)
- Rajesh N Keswani
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Anna Duloy
- Division of Gastroenterology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Jose M Nieto
- Digestive Disease Consultants, Jacksonville, Florida, USA
| | - Kashyap Panganamamula
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - M Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St Cloud Hospital, St Cloud, Minnesota, USA
| | - Aasma Shaukat
- Division of Gastroenterology and Hepatology, NYU Grossman School of Medicine, New York, New York, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, Zuckerberg San Francisco General Hospital and University of San Francisco, San Francisco, California, USA
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Hattori A, Yamada R, Murabayashi T, Sugimoto S, Imai H, Nojiri K, Kuroda N, Tano S, Tanaka H, Matsusaki S, Nishikawa K, Naota H, Moritani I, Kurata K, Fukui T, Tanaka K, Nakagawa H. The safety and efficacy of Ringer's solution loading with rectal diclofenac for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: The RESOLUTION-PEP study. DEN OPEN 2023; 3:e236. [PMID: 37125072 PMCID: PMC10131293 DOI: 10.1002/deo2.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/22/2023] [Accepted: 03/26/2023] [Indexed: 05/02/2023]
Abstract
Objectives We evaluated the safety and efficacy of aggressive hydration with rectal non-steroidal anti-inflammatory drugs for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Methods This prospective, single-arm, multicenter trial was conducted at 12 institutions between October 2020 and August 2021. We enrolled 231 patients who had intact papillae and were scheduled to undergo ERCP. All patients were administered rectal diclofenac before ERCP. They received aggressive hydration with intravenous lactated Ringer's solution in an initial bolus of 5 ml/kg at the start of ERCP, followed by 3 ml/kg/h for 8 h after the procedure. The primary outcome was the occurrence of PEP. Secondary outcomes included PEP severity, hyperamylasemia, and adverse events. Results The mean age of the patients was 68.8 ± 13.7 years, and 81 patients (35.1%) were 75 years or older. Thirteen patients developed PEP (5.6%, 95% confidence interval 3.0%-9.4%). There were 11 cases (4.8%) of mild pancreatitis and two cases (0.9%) of severe pancreatitis. Forty-five patients (19.5%) developed hyperamylasemia and one patient developed non-severe peripheral edema. Conclusions Aggressive hydration combined with rectal diclofenac may be a promising strategy for the prevention of PEP. Furthermore, it is safe even for older individuals.
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Affiliation(s)
- Aiji Hattori
- Department of Gastroenterology and HepatologyMie University HospitalMieJapan
- Department of GastroenterologyMatsusaka Municipal HospitalMieJapan
| | - Reiko Yamada
- Department of Gastroenterology and HepatologyMie University HospitalMieJapan
| | | | - Shinya Sugimoto
- Department of GastroenterologyIse Red Cross HospitalMieJapan
| | - Hajime Imai
- Department of GastroenterologyOkanami General HospitalMieJapan
| | - Keiichiro Nojiri
- Department of GastroenterologyKuwana City Medical CenterMieJapan
| | - Naoki Kuroda
- Department of GastroenterologySaiseikai Matsusaka General HospitalMieJapan
| | - Shunsuke Tano
- Department of GastroenterologySuzuka Kaisei HospitalMieJapan
| | - Hiroki Tanaka
- Department of GastroenterologySuzuka General HospitalMieJapan
| | | | | | - Hiroaki Naota
- Department of GastroenterologyMatsusaka Chuo General HospitalMieJapan
| | - Isao Moritani
- Department of GastroenterologyMie Prefectural General Medical CenterMieJapan
| | - Kazunari Kurata
- Department of GastroenterologyMie Chuo Medical CenterMieJapan
| | - Toshitaka Fukui
- Department of GastroenterologyYokkaichi Hazu Medical CenterMieJapan
| | - Kyosuke Tanaka
- Department of Endoscopic MedicineMie University HospitalMieJapan
| | - Hayato Nakagawa
- Department of Gastroenterology and HepatologyMie University HospitalMieJapan
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ERDOĞAN Ç, GÜVEN İE, BAŞPINAR B, KILIÇ ZMY. Evaluation of pancreatic stent and/or suppository indomethacin efficacy in post ERCP pancreatitis prophylaxis: a single center experience. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2023. [DOI: 10.32322/jhsm.1197804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Aim: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a serious complication of ERCP. In this study, we aimed to compare the use of rectal indomethacin, pancreatic stenting or both techniques for prevention of PEP.
Material and Method: Patients who underwent ERCP for the first time due to choledocholithiasis between January 2022 and June 2022 were retrospectively reviewed. The clinical findings, demographics, laboratory records, endoscopic intervention characteristics, whether rectal indomethacin was applied before the procedure, whether pancreatic stent was placed or not were evaluated.
Results: A total of 367 patients who underwent ERCP for the first time were included in the study. The mean age was 61 (28-92) years and 53.4% were female. In 124 (33.8%) patients, involuntary guide-wire insertion into the pancreatic duct occurred during canulation. Pancreatic stent was placed in 82 (22.3%) of the patients. Rectal indomethacin was administered to 288 patients (78.5%), while indomethacin could not be administered in 79 patients (21.5%), because they did not give consent. When patients with involuntarily pancreatic canulation were evaluated, the rate of PEP was 3.6% in the stented group, while it was 15.3% in the stent-free group (p
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Affiliation(s)
- Çağdaş ERDOĞAN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - İbrahim Ethem GÜVEN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - Batuhan BAŞPINAR
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
| | - Zeki Mesut Yalın KILIÇ
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
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Diagnosis and Management of Acute Pancreatitis in Pregnancy. Clin Obstet Gynecol 2023; 66:237-249. [PMID: 36044625 DOI: 10.1097/grf.0000000000000737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Acute pancreatitis is rare in pregnancy; however, the associated morbidity and mortality make prompt diagnosis and appropriate management essential. 1,2 Although most cases are mild and improve with limited interventions, severe cases require a multidisciplinary approach in a critical care setting. The main principles of management include identification of an etiology to guide therapy, fluid resuscitation, electrolyte repletion, early nutritional support, and pain management. Antibiotics are not indicated for prophylaxis and should be reserved for cases with a suspected infectious process. Surgical management is indicated in select cases. Management in pregnant patients has few differences which are outlined below.
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Park TY, Kang H, Choi GJ, Oh HC. Aggressive hydration for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: trial sequential analysis. Surg Endosc 2023; 37:1366-1375. [PMID: 36508009 DOI: 10.1007/s00464-022-09808-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) have demonstrated that aggressive hydration with lactated Ringer's (LR) solution reduces the frequency and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). In this trial sequential analysis (TSA), we aimed to evaluate the prophylactic effect of aggressive hydration on PEP in specific patient subgroups and to determine the need for additional RCTs. METHODS We conducted a systematic and comprehensive search to identify all randomized controlled studies published through August 2021 that examined the effectiveness of aggressive hydration for preventing PEP. The primary outcome was the frequency of PEP. We also performed TSA to calculate the required information size and assess whether our results were conclusive. RESULTS The analysis included 12 studies involving 2,501 patients. According to the TSA, the overall frequency of PEP was significantly lower in the aggressive hydration group (5.6%; 74 of 1,327 patients) than in the control group (13.1%; 154 of 1,174 patients) (risk ratio [RR]: 0.458; 95% confidence interval [CI]: 0.350-0.599). In the subgroup analysis of patients with average risk, the cumulative Z curve crossed both the conventional test boundary and the trial sequential monitoring boundary. However, in the high-risk group and in patients with moderate-to-severe PEP, the Z curve did not cross the trial sequential monitoring boundary. CONCLUSIONS This TSA indicates that aggressive hydration is effective in the overall prevention of PEP. However, additional RCTs are required to examine the prophylactic effect of aggressive hydration with LR on PEP in high-risk populations.
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Affiliation(s)
- Tae Young Park
- Division of Gastroenterology, Chung-Ang University College of Medicine, 102 Heukseok-ro Dongjak-gu, Seoul, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyoung-Chul Oh
- Division of Gastroenterology, Chung-Ang University College of Medicine, 102 Heukseok-ro Dongjak-gu, Seoul, Korea.
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