Hemodynamic Variation and Intravenous Fluids Administered During ERCP and the Association With Post-ERCP Pancreatitis

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.

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 fluid hydration plus non-steroidal anti-inflammatory drugs versus non-steroidal anti-inflammatory drugs alone for post-endoscopic retrograde cholangiopancreatography pancreatitis (FLUYT): a multicentre, open-label, randomised, controlled trial

BACKGROUND

Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Prophylactic rectal administration of non-steroidal anti-inflammatory drugs (NSAIDs) is considered as standard of care to reduce the risk of post-ERCP pancreatitis. It has been suggested that aggressive hydration might further reduce this risk. Guidelines already recommend aggressive hydration in patients who are unable to receive rectal NSAIDs, although it is laborious and time consuming. We aimed to evaluate the added value of aggressive hydration in patients receiving prophylactic rectal NSAIDs.

METHODS

FLUYT, a multicentre, open-label, randomised, controlled trial done across 22 Dutch hospitals, included patients aged between 18 and 85 years with moderate to high risk of post-ERCP pancreatitis. Patients were randomly assigned (1:1) by a web-based module with varying block sizes to a combination of aggressive hydration and rectal NSAIDs (100 mg diclofenac or indomethacin; aggressive hydration group) or rectal NSAIDs (100 mg diclofenac or indomethacin) alone (control group). Randomisation was stratified according to treatment centre. Aggressive hydration comprised 20 mL/kg intravenous Ringer's lactate solution within 60 min from the start of ERCP, followed by 3 mL/kg per h for 8 h. The control group received normal intravenous saline with a maximum of 1·5 mL/kg per h and 3 L per 24 h. The primary endpoint was post-ERCP pancreatitis and was analysed on a modified intention-to-treat basis (including all patients who underwent randomisation and an ERCP and for whom data regarding the primary outcome were available). The trial is registered with the ISRCTN registry, ISRCTN13659155.

FINDINGS

Between June 5, 2015, and June 6, 2019, 826 patients were randomly assigned, of whom 388 in the aggressive hydration group and 425 in the control group were included in the modified intention-to-treat analysis. Post-ERCP pancreatitis occurred in 30 (8%) patients in the aggressive hydration group and in 39 (9%) patients in the control group (relative risk 0·84, 95% CI 0·53-1·33, p=0·53). There were no differences in serious adverse events, including hydration-related complications (relative risk 0·99, 95% CI 0·59-1·64; p=1·00), ERCP-related complications (0·90, 0·62-1·31; p=0·62), intensive care unit admission (0·37, 0·07-1·80; p=0·22), and 30-day mortality (0·95, 0·50-1·83; p=1·00).

INTERPRETATION

Aggressive periprocedural hydration did not reduce the incidence of post-ERCP pancreatitis in patients with moderate to high risk of developing this complication who routinely received prophylactic rectal NSAIDs. Therefore, the burden of laborious and time-consuming aggressive periprocedural hydration to further reduce the risk of post-ERCP pancreatitis is not justified.

FUNDING

Netherlands Organisation for Health Research and Development and Radboud University Medical Center.

Systematic review: periprocedural hydration in the prevention of post-ERCP pancreatitis

BACKGROUND

With an overall incidence of 3.5%, pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Periprocedural hydration may prevent post-ERCP pancreatitis by maintaining pancreatic microperfusion, thereby inhibiting the pancreatic inflammatory response. However, the evidence for periprocedural hydration as a preventive measure is unclear.

AIM

To conduct a systematic review to assess the evidence regarding periprocedural hydration as a preventive measure for post-ERCP pancreatitis.

METHODS

We searched PubMed and EMBASE databases and adhered to the PRISMA guidelines. We included studies addressing periprocedural hydration as a preventive measure to reduce frequency and severity of post-ERCP pancreatitis. Study quality was assessed by using the MINORS and Cochrane Collaboration's tool.

RESULTS

Six studies with a total of 1102 patients were included. Two randomised controlled trials reported a decreased incidence of post-ERCP pancreatitis after hydration: 0% vs. 17% (P = 0.016) and 5.3% vs. 22.7% (P = 0.002). A third trial and two case-controls studies did not report significant differences. Two retrospective studies found that patients with mild post-ERCP pancreatitis had received significantly more fluids during (mean 940 mL vs. 810 mL; P = 0.031) or after ERCP (median 2834 mL vs. 2044 mL; P < 0.02) compared to patients with moderate/severe disease. Adverse events of periprocedural hydration were not reported in any of the included studies. The different methodologies of the included studies precluded a formal data synthesis.

CONCLUSIONS

There is some evidence to suggest that hydration affords protection against post-ERCP pancreatitis, but study heterogeneity precludes firm conclusions. Adequately powered randomised trials are needed to evaluate the preventive effect of periprocedural hydration.