The Efficiency of Aggressive Hydration With Lactated Ringer Solution for the Prevention of Post-ERCP Pancreatitis: A Systematic Review and Meta-analysis

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

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).

Predictive models in EUS/ERCP

Predictive models (PMs) in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) have the potential to improve patient outcomes, enhance diagnostic accuracy, and guide therapeutic interventions. This review aims to summarize the current state of predictive models in ERCP and EUS and their clinical implications. To be considered useful in clinical practice a PM should be accurate, easy to perform, and may consider objective variables. PMs in ERCP estimate correct indication, probability of success, and the risk of developing adverse events. These models incorporate patient-related factors and technical aspects of the procedure. In the field of EUS, these models utilize clinical and imaging data to predict the likelihood of malignancy, presence of specific lesions, or risk of complications related to therapeutic interventions. Further research, validation, and refinement are necessary to maximize the utility and impact of these models in routine clinical practice.

Radiation-free endoscopic papillectomy for ampullary adenoma: experience from a Chinese tertiary hospital

BACKGROUND

Conventional endoscopic papillectomy (ESP) for ampullary adenoma is performed as a hybrid endoscopy and fluoroscopy guided procedure. In this study, we report our preliminary experience of non-radiation ESP.

METHODS

The present method includes endoscopic snare resection, non-radiation endoscopic biliary and pancreatic stenting and endoclipping. Data from ten patients who underwent non-radiation ESP due to ampullary adenoma were collected. Procedure details, adverse events and follow-up were analyzed.

RESULTS

Complete resection was accomplished in all patients, with en bloc resection and piecemeal resection in nine and one patient(s), respectively. Both biliary and pancreatic stenting and biliary stenting alone were achieved in eight and two patients, respectively. Endoclipping was performed in all patients. Hyperleukocytosis and hyperamylasemia occurred in two and one patient(s), respectively. No other complications occurred. No lesion residual or recurrence occurred during follow-up.

CONCLUSIONS

Radiation-free ESP can be technically feasible and safely executed by experienced endoscopists. Our study provides a novel strategy for endoscopic resection of major papilla adenoma.

Comparison of endoscopic retrograde cholangiopancreatography outcomes between cap-fitted forward and side viewing endoscopes in patients with Billroth II anastomosis

BACKGROUND

There have been no previous studies that directly compared outcomes between cap-fitted forward-viewing and side viewing endoscopes (SE). This study aimed to compare the technical success rate and occurrence of adverse events between the side viewing and cap-fitted forward-viewing endoscope (CE) groups among patients with Billroth II anatomy who underwent ERCP.

METHODS

The medical records of patients with a previous history of subtotal gastrectomy using Billroth II reconstruction who underwent ERCP at Yeungnam University Hospital between January 2004 and December 2020 were reviewed retrospectively. The patients were divided into CE and SE group. Propensity score matching analysis was performed to minimize selection bias.

RESULTS

Propensity score matching resulted in 55 matched pairs for further analysis. Patients' characteristics were comparable in the matched cohorts. Final success rate of selective bile duct cannulation was not significantly different between the SE and CE groups (98.2% vs. 94.5%, p = 0.308). The complete CBD stone removal rate in CBD stone and successful biliary drainage rate in malignant biliary obstruction were not significantly different between the two groups. The rate of total ERCP-related adverse events was higher in the CE group than in the SE group, but the difference was not statistically significant (10.9% vs. 7.3%, p = 0.507). Among adverse events, the rate of post-ERCP pancreatitis showed higher tendency in the CE group than in the SE group (10.9% vs. 5.5%, p = 0.297).

CONCLUSION

In conclusion, CE seems to be equally effective as SE for ERCP in patients with Billroth II anatomy. However, attention should be paid to development of post ERCP complications, especially pancreatitis, when performed by CE.

The safety and efficacy of Ringer's solution loading with rectal diclofenac for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: The RESOLUTION-PEP study

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.

Aggressive hydration for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: trial sequential analysis

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.

An Insight on Pharmacological and Mechanical Preventive Measures of Post-ERCP PANCREATITIS (PEP)—A Review

Pancreatitis is the most common complication following endoscopic retrograde cholangio-pancreatography (ERCP). With the progress of research in many drugs and technologies, promising efficacy has been achieved in preventing post-ERCP pancreatitis (PEP). Recently, combined prevention has received more attention in order to further reduce the incidence of PEP. However, there is no review about the combined prevention of PEP. This review summarizes the medication and ERCP techniques that are used to prevent PEP and emphasizes that appropriate combination prevention approaches should be based on risk stratification.

Current approaches and questions yet to be resolved for the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis

Prophylaxis is important for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), which is the most common and serious complication of ERCP. Although the current guidelines include independent patient- and procedure-related risk factors for PEP and available PEP prophylactic measures, the synergistic effect of these risk factors on PEP should also be considered, given that patients often harbor multiple risk factors. Furthermore, a combination of prophylactic measures is often selected in clinical practice. However, established methods estimating the synergistic effect of independent risk factors on PEP incidence are lacking, and evidence on the impact of combining prophylactic measures on PEP should be discussed. Selection of appropriate candidate patients for ERCP is also important to reduce the incidence of PEP associated with unnecessary ERCP. ERCP indications in patients with asymptomatic common bile duct stones (CBDSs) and in those with suspected CBDSs with no imaging-based evidence of stones are controversial. Further studies are warranted to predict the synergistic effect of independent risk factors on PEP, determine the best prophylactic PEP measures, and identify appropriate candidates for ERCP in patients with asymptomatic CBDSs and those with suspected CBDSs.

Continuous Infusion of Fluid Hydration Over 24 Hours Does Not Prevent Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

BACKGROUND

Aggressive intravenous fluid hydration, by administering 3500 mL of lactated Ringer's solution (LRS) in 9 h with a peri-procedural bolus, reduces post-ERCP pancreatitis (PEP) incidence. A concern of this strategy is adverse events related to volume overload; however, the impact of fluid hydration over an extended period without a bolus on PEP is unknown.

AIM

To assess the effect of continuous infusion of high-volume fluid at a constant rate over 24 h on PEP incidence and severity.

METHODS

Two-hundred patients were randomly assigned (1:1) to receive either 3600 mL of LRS in 24 h starting 2 h before the ERCP (high-volume group) or maintenance fluid hydration calculated by the Holliday-Segar method (control group).

RESULTS

The mean age of the patients was 50.6 ± 11.6 years. The predominant indications were choledocholithiasis (48%) and malignancies (32%). Patient demographics and PEP risk factors were similar in both groups. Patients in the high-volume group received significantly more fluid than the control group (3600 vs. 2413 ml, P < 0.001). PEP incidence was not different between the high-volume and the control group (14% vs. 15%; relative risk 0.93: 95% CI 0.48-1.83, P = 0.84). There were no differences in moderate to severe PEP (3% vs. 4%; relative risk 0.75: 95% CI, 0.17-3.27, P = 1.00). Subgroup analysis did not show a benefit in high-risk patients. Only one patient in the control group developed peripheral edema.

CONCLUSIONS

An infusion of high-volume hydration over 24 h is not sufficient to provide optimal hydration for PEP prevention.

CLINICAL TRIAL REGISTRY NUMBER

No. NCT02821546.

Efficacy of aggressive hydration with normal saline versus lactated Ringer's solution for the prevention of post-ERCP pancreatitis in high-risk patients: a randomized controlled trial

Background and study aims  Post-ERCP pancreatitis (PEP) is a common adverse event in high-risk patients. Current intervention known to reduce the incidence and severity of PEP include pancreatic duct stent placement, nonsteroidal anti-inflammatory drugs per rectum, and intravenous (IV) fluids. We compared aggressive normal saline (NS) vs aggressive lactated Ringer's (LR) infusion for the prevention of PEP in high-risk patients undergoing ERCP. Patients and methods  Patients were randomized to receive either an aggressive infusion of NS or LR. The infusion was started at a rate of 3 mL/kg/hr and continued throughout the ERCP procedure. A 20 mL/kg bolus was given at the end of the procedure, then continued at a rate of 3 mL/kg/hr. Results  A total of 136 patients were included in our analysis. The incidence of PEP was 4 % (3/72 patients) in the LR group versus 11 % (7/64 patients) in the NS group resulting in a relative risk (RR) of 0.38 (95 % confidence interval [CI] 0.10 to 1.42; P  = 0.19). The relative risk reduction (RRR) was 0.62 (95 % CI -0.41 to 0.90) along with an absolute risk reduction (ARR) of 0.07 (95 % CI -0.025 to 0.17) and an number needed to treat of 15 (95 % CI -41 to 6). Conclusions  To our knowledge, this is the first study comparing aggressive IV NS to aggressive IV LR in high-risk patients. The incidence of PEP was lower in the group receiving an aggressive LR infusion (4 %) compared to NS infusion (11 %). However, the difference was not statistically significant likely due to poor accrual thereby impacting the power of the study.

Rectal NSAIDs-based combination modalities are superior to single modalities for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a network meta-analysis

BACKGROUND/AIMS

Different modalities have been employed to reduce the risk and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, there has been a paucity of studies comparing the efficacy of various prophylactic modalities for preventing PEP. This network meta-analysis (NMA) aimed to determine the relative efficacy of pancreatic duct stents and pharmacological modalities for preventing PEP.

METHODS

We performed a systematic and comprehensive search to identify and analyze all randomized controlled studies published until June 2020 that examined the effectiveness of pancreatic duct stents, rectal non-steroidal anti-inflammatory drugs (NSAIDs) based regimens, hydration, and their combinations for the prevention of PEP. The primary outcome was the frequency of PEP. An NMA was performed to combine direct and indirect comparisons of different prophylactic modalities.

RESULTS

The NMA included 46 studies evaluating 18 regimens in 16,241 patients. Based on integral analysis of predictive interval plots, and expected mean ranking and surface under the cumulative ranking curve values, combination prophylaxis with indomethacin + lactated Ringer's solution (LR), followed by diclofenac + nitrate and indomethacin + normal saline, was found to be the most efficacious modality for the overall prevention of PEP. Indomethacin + LR, followed by diclofenac and pancreatic duct stents, was the most efficacious modality for high-risk groups.

CONCLUSION

Rectal NSAIDs-based combination regimens with aggressive hydration or nitrate are superior to single modalities for the prevention of PEP.

Combined use of indomethacin and hydration is the best conservative approach for post-ERCP pancreatitis prevention: A network meta-analysis

OBJECTIVES

Post-ERCP pancreatitis (PEP) is a life-threatening complication. Given the lack of a causative treatment for pancreatitis, it is of vital importance to minimize this risk of PEP. Multi-target preventive therapy may be the best choice for PEP prevention as disease development is multifactorial.

AIM

We aimed to assess the efficacy of a combination of indomethacin and hydration - type and amount - for PEP prevention via a network meta-analysis.

METHODS

Through a systematic search in three databases, we searched all randomized controlled trials involving hydration and indomethacin and ranked the PEP preventive efficacy with a Bayesian network meta-analysis using the PRISMA for Network Meta-Analyses (PRISMA-NMA) guideline. The RoB2 tool was used for risk of bias assessment, surface under the cumulative ranking curve (SUCRA) for ranking and PROSPERO for the study protocol [reg. no. CRD42018112698]. We used risk ratios (RR) for dichotomous data with 95% credible intervals (95% CrI).

RESULTS

The quantitative analysis included 7559 patients from 24 randomized controlled trials. Based on the SUCRA values, a combination of lactated Ringer's and indomethacin is more effective than single therapy with a 94% certainty. The percent relative risk ratios estimate preventive efficacy 70-99% higher for combinations than single therapies. Aggressive hydration with indomethacin (SUCRA 100%) is also significantly more effective than all other interventions (percent relative effect 94.3-98.1%).

CONCLUSIONS

A one-hit-on-each-target therapeutic approach is recommended in PEP prevention with an easily accessible combination of indomethacin and aggressive hydration for all average and high-risk patients without contraindication.

New practical scoring system to predict post-endoscopic retrograde cholangiopancreatography pancreatitis: Development and validation

Background and Aim

Post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most serious adverse event of ERCP. Therefore, it is important to identify high‐risk patients who require prophylactic measures. The aim of this study was to develop a practical prediction model for PEP that identifies high‐risk patients.

Methods

Patients who underwent ERCP at three tertiary hospitals between April 2010 and September 2012 were enrolled. The dataset was divided into a training set (two centers) and validation set (one center). Using the training set, univariable and multivariable analyses were performed to identify predictive factors for PEP. We constructed a scoring system and evaluated reproducibility using the validation set.

Results

A total of 2719 ERCPs were analyzed. PEP developed in 133 cases (4.9%). Risk factors (adjusted odds ratios [OR]) in the training set were a history of PEP (OR: 4.2), intact papilla (OR: 2.4), difficult cannulation (OR: 1.9), pancreatic guidewire‐assisted biliary cannulation (OR: 2.2), pancreatic injection (OR: 2.1), pancreatic intraductal ultrasonography (IDUS)/sampling from the pancreatic duct (OR: 2.2), and biliary IDUS/sampling from the biliary tract (OR: 2.8). A scoring system was constructed using these seven clinical variables. The areas under the receiver‐operating characteristic curve of this model were 0.799 in the training set and 0.791 in the validation set. In the high‐risk group at a score of 3 or higher, the incidence of PEP was 13.4%, and all severe/fatal cases were in the high‐risk group.

Conclusions

This scoring system helps to predict each patient's risk and select preventive measures.

Is the Combination of Rectal Diclofenac and Intravenous Ringer Lactate Superior to Individual Therapy for Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Prospective, Open-Label, Single-Center Randomized Trial

METHODS

This was single-center, open-label, randomized trial. Patients who were undergoing ERCP and who were at high risk for the development of PEP were selected for the study. Patients were randomized into 3 treatment groups: diclofenac suppository group, RL group, and a combination group.

RESULTS

Eight of 57 patients (14.03%) in the diclofenac group, 9 of 57 patients (15.78%) in the RL group, and 6 of 57 patients (10.52%) in the combination group developed PEP. The incidence of PEP between the three groups was not statistically significant (P = 0.70). Serum amylase level of >252 U/L had 91.3% sensitivity and 92.6% specificity for the diagnosis of PEP.

CONCLUSIONS

Post-ERCP pancreatitis is usually mild to moderate 95% times. Female sex, age younger than 50 years, a benign indication of ERCP, and low bilirubin levels have higher chances of PEP. A combination of rectal diclofenac and hydration with RL does not offer better protection for PEP, as compared with individual prophylaxis.

Best practices for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Acute pancreatitis is of one the most common gastroenterology-related indications for hospital admissions worldwide. With the widespread reliance on endoscopic retrograde cholangiopancreatography (ERCP) for the management of pancreaticobiliary conditions, post-ERCP pancreatitis (PEP) has come to represent an important etiology of acute pancreatitis. Despite many studies aiming to better understand the pathogenesis and prevention of this iatrogenic disorder, findings have been heterogeneous, and considerable variation in clinical practice exists. Herein, we review the literature regarding PEP with the goal to raise awareness of this entity, discuss recent data, and present evidence-based best practices. We believe this manuscript will be useful for gastrointestinal endoscopists as well as other specialists involved in the management of patients with PEP.

Aggressive Hydration With Ringer's Lactate in the Prevention of Post-ERCP Pancreatitis: A Meta-Analysis

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a dangerous complication and occurs in a considerable number of patients. However, since well-randomized controlled trials investigating aggressive hydration with Ringer's lactate are lacking, this meta-analysis assessed the role of aggressive hydration with Ringer's lactate alone or in combination with other therapies in the prevention of PEP.

We searched PubMed, Cochrane Library, and Google Scholar for relevant articles. The search engine was set to randomize controlled trials and prospective cohorts assessing Ringer's lactate in PEP prevention either alone or in combination with non-steroidal anti-inflammatory drugs (NSAIDs) and stent. The keywords "aggressive hydration," "Ringer's lactate," "post-ERCP pancreatitis," "NSAIDs," "stent placement," and "somatostatin analogs" were used. The search was limited to a study on humans published in English with no limitation to the study period.

Two hundred and six articles were retrieved. Only eight articles fulfilled the inclusion criteria. The studies showed a reduction of post-ERCP pancreatitis using aggressive hydration with Ringer's lactate alone (odds ratio 0.23, 95% CI 0.13 - 0.40, P-value < 0.001, I² for heterogeneity = 0%, P-value = 0.61, Chi-square value 1.83, and degrees of freedom (df) 3. In addition, the combination of Ringer's lactate with stents or NSAIDs was superior to Ringer's lactate alone (odds ratio 0.63, 95% CI 0.41 - 0.98, P-value < 0.04, I² for heterogeneity = 0%, P-value = 0.48, Chi-square value 2.47, and df 3). Aggressive hydration with Ringer's lactate alone was effective in the prevention of PEP with a superior effect when combined with stents and NSAIDs.

Aggressive hydration with lactated ringer solution in prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis

BACKGROUND

Acute pancreatitis is the most common complication of Endoscopic Retrograde Cholangiopancreatography (ERCP). There was no conclusion on the prevention of Post-ERCP Pancreatitis (PEP) by Lactated Ringer Solution.

AIM

The purpose of this meta analyses is to determine whether aggressive hydration with Lactated Ringer Solution reduced the incidence of PEP.

METHODS

We retrieved randomized clinical trials comparing the preventive effects of aggressive hydration with Lactated Ringer Solution and standard hydration on PEP from PubMed, the Cochrane Library, Embase, the Web of Science, Clinical Trial.gov, Scopus database, CNKI, CQVIP and WanFang Data. Primary outcome was incidence of PEP. Secondary outcomes included incidence of hyperamylasemia, abdominal pain and adverse events.

RESULTS

Ten randomized controlled trials with 2200 patients were included in this meta-analysis. Meta-analysis showed that compared with standard hydration, aggressive hydration reduced the incidence of PEP (odds ratio [OR], 0.40; 95% confidence intervals [CI], 0.26-0.63; P < .0001). Compared with standard hydration, aggressive hydration also reduced the incidence of hyperamylasemia after ERCP (OR, 0.48; 95% CI, 0.38-0.60; P < .0001). There was significant difference between aggressive hydration and standard hydration in the incidence of abdominal pain (OR, 0.29; 95% CI, 0.11-0.73; P = .008). There was no difference in adverse events between aggressive hydration and standard hydration (OR, 0.93; 95% CI, 0.21-4.13; P = .93). Sensitivity analyses showed that neither alternative effect measures nor statistical models regarding heterogeneity affected the conclusions of this meta-analysis.

CONCLUSION

Aggressive hydration with Lactated Ringer Solution during perioperative period of ERCP can prevent PEP.

A National Survey on the Environment and Basic Techniques of Endoscopic Retrograde Cholangiopancreatography in Korea

Background/Aims

The work environment in which endoscopic retrograde cholangiopancreatography (ERCP) is conducted has influence on its efficacy and safety. We aimed to assess the current status of ERCP work environments and to investigate the trends associated with the basic techniques of ERCP in Korea.

Methods

The work environment and information on the basic techniques of ERCP were acquired by the Korean Pancreatobiliary Association (KPBA) through a national survey in 2019. The survey was performed at the KPBA conference in 2019. The contents of survey comprised of the current environment of ERCP, preparation before ERCP, and the preferred basic techniques used in ERCP.

Results

Completed questionnaires were returned from 84 KPBA members. The mean ERCP volume per year was approximately 500. About 60% (50/84) reported that they worked with a dedicated ERCP team with experienced nurses. Two-thirds (57/84, 68%) answered that they had a fluoroscopy room used solely for ERCP procedures. All respondents intravenously hydrated the patient to prevent post-ERCP pancreatitis (84/84, 100%). The preferred procedural sedations were balanced propofol sedation (50%) and midazolam-only sedation (47%). Wire-guided cannulation was most commonly used for selective cannulation (81%). Endoscopic retrograde biliary drainage was preferred over endoscopic nasobiliary drainage (60% vs 22%). The initial method of ampullary intervention was endoscopic sphincterotomy in 60%.

Conclusions

Data from the survey involving a large number of Korean ERCP doctors revealed considerable variabilities with regard to the work environment and basic techniques of ERCP in Korea. The study provides information regarding the current trends of ERCP that can be used to establish ERCP standards in Korea.

Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: An Updated Review of Current Preventive Strategies

Pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography, with incidence rates as high as 16% in some centers. Recent studies have also shown an upward trend in hospitalization due to endoscopic retrograde cholangiopancreatography-related pancreatitis. Early interventions taken before, during, and after the procedure can significantly reduce the risk of pancreatitis and decrease morbidity and mortality of the patients. To select appropriate patients for endoscopic retrograde cholangiopancreatography, in-depth knowledge of the patient-related and procedure-related risk factors is required. This updated clinical review outlines various pharmacological agents and surgical methods used for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Current evidence supports the use of rectal non-steroidal anti-inflammatory drugs and pancreatic stent placement as an effective preventive strategy. Further research is needed to compare these preventive modalities to improve patient outcomes after endoscopic retrograde cholangiopancreatography.

Clinical impact of endoscopic ultrasound-guided through-the-needle microbiopsy in patients with pancreatic cysts

BACKGROUND

The limited data on the utility of endoscopic ultrasound (EUS)-guided through-the-needle biopsies (TTNBs) in patients with pancreatic cystic lesions (PCLs) originate mainly from retrospective studies. Our aim was to determine the clinical impact of TTNBs, their added diagnostic value, and the adverse event rate in a prospective setting.

METHODS

This was a prospective, single-center, open-label controlled study. Between February 2018 and August 2019, consecutive patients presenting with a PCL of 15 mm or more and referred for EUS were included. Primary outcome was a change in clinical management of PCLs following TTNB compared with cross-sectional imaging and cytology. Adverse events were defined according to the ASGE lexicon.

RESULTS

101 patients were included. TTNBs led to a change in clinical management in 11.9 % of cases (n = 12). Of these, 10 had serous cysts and surveillance was discontinued, while one of the remaining two cases underwent surgery following diagnosis of a mucinous cystic neoplasm. The diagnostic yield of TTNBs for a specific cyst diagnosis was higher compared with FNA cytology (69.3 % vs. 20.8 %, respectively; P < 0.001). The adverse event rate was 9.9 % (n = 10; 95 % confidence interval 5.4 % - 17.3 %), with the most common event being acute pancreatitis (n = 9). Four of the observed adverse events were severe, including one fatal outcome.

CONCLUSIONS

TTNBs resulted in a change of clinical management in about one in every 10 patients; however, the associated adverse event risk was substantial. Further studies are warranted to elucidate in which subgroups of patients the clinical benefit outweighs the risks.

Ringer's Lactate Hydration and Incidence of Post ERCP Pancreatitis: A Descriptive Cross-sectional Study

Introduction:

Endoscopic retrograde cholangiopancreatography is one of the most frequently used treatment modality for various pancreatobiliary problems. Frequent complications of endoscopic retrograde cholangiopancreatography include pancreatitis, cholangitis, hemorrhage and perforation. This study was done to see the prevalence of post endoscopic retrograde cholangiopancreatography pancreatitis in patient aggressively hydrated with Ringer's Lactate solution.

Methods:

A descriptive cross sectional study was carried out on patient undergoing endoscopic retrograde cholangiopancreatography at Bharatpur Hospital from June 2018 to August 2020. Ethical clearance was taken from Institutional Review Committee Bharatpur Hospital (reference number 16/076/77). The convenient sampling method was applied. Data were collected and analyzed in statistical package for the social sciences version 16. Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data.

Results:

Pain abdomen was assessed using Visual Analogue Scale and it was found that 8.1% of patients (15 patients) complained of pain abdomen with visual analogue scale > 3. Serum amylase was sent only in those patients who complained of pain abdomen and only in three patients (1.6%) serum amylase was increased more than 3 times the upper limit of normal value suggestive of pancreatitis. All three patients who had pancreatitis had precut sphincterotomy.

Conclusions:

In this study we found that incidence of pancreatitis slumped after aggressive hydration with Ringer's lactate solution and adjunct use of other prophylactic measures for prevention of post endoscopic retrograde cholangiopancreatography pancreatitis might yield further better results.

Taiwanese consensus recommendations for acute pancreatitis

The incidence of acute pancreatitis and related health care utilization are increasing. Acute pancreatitis may result in organ failure and various local complications with risks of morbidity and even mortality. Recent advances in research have provided novel insights into the assessment and management for acute pancreatitis. This consensus is developed by Taiwan Pancreas Society to provide an updated, evidence-based framework for managing acute pancreatitis.

Rectal versus intramuscular diclofenac in prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: experience of a Greek tertiary referral center

Background:

Independent patient-related and procedure-related factors increase the risk of pancreatitis after endoscopic retrograde cholangiopancreatography (post-ERCP pancreatitis [PEP]). Non-steroidal anti-inflammatory drugs (NSAIDs) have demonstrated efficacy in reducing the incidence of PEP. This study investigated the difference in the incidence of PEP between intramuscular and rectal prophylactic administration of diclofenac before ERCP.

Methods:

We performed a retrospective analysis of data from 516 patients who underwent ERCP during the period 2014-2017. The route of diclofenac administration (rectal or intramuscular), patient-related and procedure-related risk factors, as well as serum amylase levels 18 h after the endoscopic procedure and immediate bleeding during ERCP were recorded and evaluated.

Results:

The overall incidence of PEP was 4.5%, without significant differences between the rectal (5.2%) and intramuscular (3.9%) routes of administration. The factor that appeared to be of significance was pre-cut sphincterotomy, since patients who underwent that procedure showed a higher probability of PEP (P=0.05; odds ratio 2.67, 95% confidence interval). Intraprocedural bleeding was almost twice as frequent in the rectal compared to the intramuscular group. Pancreatic stent placement did not appear to be statistically significant in the prevention of PEP, either alone or in combination with diclofenac administration.

Conclusions:

The results of our study did not reveal any statistically significant difference between the rectal or intramuscular administration of diclofenac in the prevention of PEP, contradicting the results of the majority of studies and meta-analyses published so far. One of the known risk factors associated with increased risk of PEP was also confirmed.

Is Needle Knife Fistulotomy a Shortcut to Preventing Postendoscopic Retrograde Pancreatitis?

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) remains a common and potentially severe adverse event, with continued research efforts to reduce PEP incidence. Robust evidence exists supporting the selective use of pancreatic duct stent placement, administration of rectal indomethacin, wire-guided cannulation technique, and aggressive fluid hydration using lactated Ringer solution. Jang et al. presented a randomized control trial describing primary needle-knife fistulotomy and its benefit for biliary access and reduced PEP incidence. Although these data are compelling, we discuss the key study limitations and the need for further studying the role of primary needle-knife fistulotomy.

Aggressive hydration compared to standard hydration with lactated ringer's solution for prevention of post endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND AND AIMS

Previous studies have suggested that aggressive hydration with lactated ringer solution are one of the protective factors in preventing post endoscopic retrograde cholangiopancreatography (post-ERCP). We conducted a systematic review and meta-analysis to examine the efficacy aggressive hydration with lactated Ringer solution in preventing PEP.

METHODS

All published and unpublished articles on aggressive hydration with lactated ringer solution in those underwent ERCP procedure for any reasons were screened for eligibility. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. This paper doesn't need the IRB approval.

RESULTS

Seven RCTs met the inclusion criteria. Meta-analysis indicates that aggressive hydration with lactated Ringer solution were associated with lower PEP rate.[odds ratio (OR) 0.29; 95% confidence interval (CI) 0.18-0.48]; lower incidence of hyperamylasemia (OR 0.49; 95% CI 0.35, 0.69) and lower risk of pain (OR 0.28; 95% CI 0.10-0.81). The association between aggressive hydration with lactated Ringer solution and incidence of moderate severity PEP were unclear (OR 0.57; 95% CI 0.22, 1.45). Sensitivity analyses also showed that omitting 1 study from analysis of PEP rate could reduce the heterogeneity but did not change the conclusion of this meta-analysis. A cumulating meta-analysis was performed statistically which showed a stable result of overall incidence of PEP.

CONCLUSIONS

Aggressive hydration with lactated Ringer solution was a protective factor in reducing the overall incidence of PEP, hyperamylasemia and risk of abdominal pain.

Endoscopic Retrograde Cholangiopancreatography-Related Complications and Their Management Strategies: A "Scoping" Literature Review

Endoscopic retrograde cholangiopancreatography (ERCP) is a well-known procedure with both diagnostic and therapeutic utilities in managing pancreaticobiliary conditions. With the advancements of endoscopic techniques, ERCP has become a relatively safe and effective procedure. However, as ERCP is increasingly being utilized for different advanced techniques, newer complications have been noticed. Post-ERCP complications are known, and mostly include pancreatitis, infection, hemorrhage, and perforation. The risks of these complications vary depending on several factors, such as patient selection, endoscopist's skills, and the difficulties involved during the procedure. This review discusses post-ERCP complications and management strategies with new and evolving concepts.

Should we administer rectal anti-inflammatory drugs in all ERCPs in order to prevent pancreatitis? At least, it does not harm!

Acute pancreatitis is the most common complication of endoscopic retrograde cholangio-pancreatography (ERCP). The sensitivity of the pancreas, which may respond with such violence to the slightest pressure exerted at the entrance to its main duct in the papilla of Vater, is even philosophically surprising. In fact, each touch on the papilla increases the potential for pancreatitis development. The initial stimulus resulting in obstruction of pancreatic secretion may be the edema caused by the catheter's physical contact, the thermal effect of sphincterotomy, or the overdistension induced by the injected contrast. The triggering fact is followed by a release of inflammatory cytokines, which induce changes in pancreatic microcirculation.

IV Ibuprofen for Prevention of Post-ERCP Pancreatitis in Children: A Randomized Placebo-controlled Feasibility Study

BACKGROUND

Post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP) is reported to occur in up to 11% of pediatric patients. To date, no study has prospectively evaluated an intervention to prevent PEP in children. It is unclear if such a study is even feasible.

OBJECTIVE

The aim of the study was to evaluate the feasibility of studying IV ibuprofen for PEP prevention in the pediatric population.

METHODS

This was a prospective randomized double-blind placebo-controlled feasibility study. Patients younger than 19 years of age undergoing ERCP were randomized to receive 10 mg/kg IV ibuprofen (max of 800 mg) or placebo (saline) at the time of ERCP. The primary outcome was PEP. Secondary outcomes included post-ERCP-related bleeding, rates of other procedural and medication-related adverse events.

RESULTS

Fifty-eight patients were randomized and received either IV ibuprofen or placebo. Preprocedure- and procedure-related factors were not significantly different between the groups except that patients in the placebo group tended to weigh less (48.7 vs 63.7 kg, P = 0.03). There were 7 episodes of PEP (12%). PEP was less frequently identified in the Ibuprofen group than in the control group (7% vs 17%), but this was not statistically significant (P = 0.42). Mean postprocedural abdominal pain scores were significantly lower in the IV Ibuprofen group than in the control group (1.1 vs 3.1, P = 0.01) and the number of patients who had increased abdominal pain after the procedure was significantly lower in ibuprofen group than in the control group (3% vs 38%, P = 0.002). There were no significant differences in procedure-related or drug-related adverse events.

CONCLUSIONS

Postprocedural pain scores and the number of patients who had increased abdominal pain after the procedure were significantly lower in the IV ibuprofen group. The current study provides encouraging, but only very weak evidence that IV ibuprofen decreases PEP in children. Power analysis suggests that a small handful of high-volume pediatric centers would be able to perform an adequate clinical trial in a reasonable time frame. Focusing on all cause postprocedural pain (PEP and non-PEP) may allow for a more efficiency study design and be just as clinically relevant.

EUS-guided through-the-needle microbiopsy of pancreatic cysts: Technical aspects (with video)

Pancreatic cystic lesions are frequently encountered and diagnostically challenging as some of the cysts may have malignant potential (mucinous) while others are completely benign (serous). EUS-guided through-the-needle biopsy (EUS-TTNB) of the cyst wall has recently been introduced as an alternative to cyst fluid cytology. Several studies have shown that microbiopsies outperform cytology in terms of distinction between mucinous and nonmucinous lesions, but also in determining the specific cyst diagnosis. However, little is known about the technical aspects of tissue sampling with TTNB. Herein, we summarize our experience with the procedure in a tertiary referral center and discuss indications, technical aspects, and safety of the procedure. Most adverse events (AEs) associated with the procedure are mild, but there is emerging evidence that the rate of postprocedural pancreatitis is higher compared to standard fine-needle aspiration. The added diagnostic yield should therefore be placed in perspective with an increased risk of AEs. Prospective studies are warranted to fully identify which patient groups could benefit from EUS-TTNB.

Criteria for difficult biliary cannulation: start to count

OBJECTIVE

In European Society of Gastrointestinal Endoscopy guidelines, biliary cannulation of native papilla is defined as difficult in the presence of >5 papilla contacts, >5 min cannulation time or >1 unintended pancreatic duct cannulation (5-5-2). The aim is to test 5-5-2-criteria in a single-center practice predicting the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), and to study the efficacy of transpancreatic biliary sphincterotomy (TPBS) as an advanced method for biliary cannulation.

METHODS

Prospectively collected data of 821 patients with native papilla were analyzed. Primary cannulation was the first method chosen for cannulation (sphincterotome and a guidewire). Advanced cannulation method was endoscopist-chosen cannulation method after failed primary cannulation.

RESULTS

Primary cannulation succeeded in 599 (73%) patients in a median of 2 min. TPBS ± needle knife resulted in a 90% success rate. The final cannulation success was 814 (99.1%) cases in a median of 5.3 min. PEP risk was 4.0%. When primary cannulation succeeded, the PEP rate was 2.3%. When advanced methods were needed, the PEP rate increased to 13.5%. Altogether 311 (37.9%) patients fulfilled at least one 5-5-2-criterion. In patients without 5-5-2-criteria, the primary cannulation succeeded in 79.6% (n = 477), compared to 20.4% (n = 122) with the criteria, P < 0.001, indicating the need to exchange the cannulation method instead of persistence. If all the 5-5-2-criteria were present, the risk of PEP was 12.7%.

CONCLUSION

The results support the use of the 5-5-2-criteria for difficult cannulation. TPBS is an effective advanced cannulation method with an acceptable complication rate.

Peri-Procedural Aggressive Hydration for Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis Prophylaxsis: Meta-analysis of Randomized Controlled Trials

BACKGROUND

Periprocedural intravenous hydration is suggested to decrease the risk of post-ERCP pancreatitis (PEP). However, quality of evidence supporting this suggestion remains poor. Here we hypothesized that aggressive hydration(AH) could be an effective preventive measure.

METHODS

Pubmed, EMBASE, CINAHL, Google Scholar, Clinical Trials. gov, Clinical Key, International Standard Randomized Trial Number registry as well as secondary sources were searched through January 2019 to identify randomized controlled studies comparing AH to standard hydration (SH) for prevention of PEP. Pooled odds ratio (OR) and 95% confidence intervals (CIs) were calculated using the random-effects model. RevMan 5.3 was used for analysis.

RESULTS

A total of 9 RCTs, with 2094 patients, were included in the meta-analysis. AH reduced incidence of PEP by 56% compared to SH (OR = 0.44, CI:0.28-0.69; p = 0.0004). The incidence of post-ERCP hyperamylasemia also decreased with AH compared to SH (OR = 0.51; p = 0.001). Length of stay decreased by 1 day with AH (Mean Difference (MD): -0.89 d; p = 0.00002). There was no significant difference in adverse events related to fluid overload between two groups (OR:1.29; p = 0.81) and post-ERCP abdominal pain (OR:0.35; p = 0.17). Numbers of patient to be treated with AH to prevent one episode of PEP was 17. Final results of the meta-analysis were not affected by alternative effect measures or statistical models of heterogeneity.

CONCLUSION

Aggressive hydration is associated with a significantly lower incidence of PEP and it appears to be an effective and safe strategy for the prevention of Post ERCP pancreatitis.

Endoscopic retrograde cholangiopancreatography, lights and shadows: Handle with care

The role of endoscopic retrograde cholangiopancreatography (ERCP) has dramatically changed in the last years, mainly into that of a therapeutic procedure. The treatment of benign biliary disease, like “difficult” choledocolithiasis, with endoscopic papillary large balloon dilation combined with endoscopic sphinterotomy has proven an effective and safe technique. Moreover, safety in ERCP has improved as well, with the prevention of post-ERCP pancreatitis and patient-to-patient transmission of infections. The advent of self-expandable metal stenting has radically changed the management of biliopancreatic malignant strictures, while the role for therapy of benign strictures is still controversial. In addition, cholangioscopy (though the direct visualization of the biliopancreatic ductal system) has allowed for characterization of indeterminate biliary strictures and facilitated rescue therapy of large biliary stones deemed removable. Encouraging data from tissue ablation techniques, such as photodynamic therapy and radiofrequency ablation, need to be confirmed by large sample size clinical controlled trials. On the other hand, we have no drug-coated stents yet available to implant and evidence for the use of biodegradable stents is still weak. The competency and privileging of ERCP and endoscopic ultrasonography have been analyzed longer but the switch between the two procedures, at the same time, is becoming ordinary; as such, the endoscopist interested in this field should undergo parallel edification through training plans. Finally, the American Society for Gastrointestinal Endoscopy’s statement on non-anesthesiologist administration of propofol for gastrointestinal endoscopy is not actually endorsed by the European Society of Anaesthesiology, having many medical-legal implications in some European countries.

ERCP in Portugal: A Wide Survey on the Prevention of Post-ERCP Pancreatitis and Papillary Cannulation Techniques

Background/Aims

Recently the European Society of Gastrointestinal Endoscopy delivered guidelines on the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and on the papillary cannulation and sphincterotomy techniques at endoscopic retrograde cholangiopancreatography (ERCP). There are no data concerning current practices in Portugal. The aim of this study was to capture practice patterns of Portuguese pancreaticobiliary endoscopists with special interest in the prevention of PEP and cannulation techniques.

Methods

A written survey was distributed to all pancreaticobiliary endoscopists attending the first Portuguese meeting dedicated to ERCP in November 2016. The main outcome measures were: technique used for standard biliary cannulation, use of nonsteroidal anti-inflammatory drugs (NSAIDs) in PEP, attempting prophylactic pancreatic stenting after using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation was difficult, and use of precut as the first rescue technique when biliary cannulation was difficult.

Results

Completed surveys were collected from 28 of the 32 pancreatobiliary endoscopists attending the meeting (answer rate 87.5%). Biliary cannulation was performed using a guidewire access technique by the majority (77%), usually with a sphincterotome. When cannulation was unsuccessful, precut was the first choice for 70%. NSAIDs were administered routinely for PEP by only 54%; PGW-assisted biliary cannulation was the first choice after failed standard cannulation for a minority of them, and only 27% reported to routinely attempt insertion of a pancreatic stent. High-volume endoscopists (> 150/year) tended to use NSAIDs and to insert a stent in PGW-assisted cannulation less often than low-volume-endoscopists (50 vs. 83.3%, p < 0.01, and 40 vs. 100%, p < 0.01, respectively). Precut was started without prior formal training by more than half of the endoscopists.

Conclusions

There is a pronounced discrepancy between evidence-based guidelines and current clinical practice. This discrepancy is more pronounced in PEP prophylaxis, especially among high-volume endoscopists. Some advanced techniques in ERCP are initiated unsupervised, without any previous formal training.

Key Message

There is a significant gap between guidelines and routine clinical practice.

Recent advances in understanding and managing acute pancreatitis

This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.

Recent advances in understanding and managing acute pancreatitis

This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.