Role of ulinastatin in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: the Emperor's New Clothes or Aladdin's Magic Lamp?

Nafamostat Mesylate is Not Effective in Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications such as post-ERCP pancreatitis (PEP). Protease inhibitors, including nafamostat mesylate (NM), have been evaluated for prophylaxis against PEP.

AIM

We describe the first multicenter randomized controlled trial assessing the prophylactic efficacy of NM against PEP.

METHODS

In this multicenter prospective study, we aimed to enroll 800 patients aged ≥ 20 years with a planned ERCP between December 2012 and March 2019. The primary outcome was the incidence and severity of PEP in patients who did not receive NM (non-NM) versus those who did (NM; 20 mg). Secondary outcomes included the incidence of PEP by NM initiation (pre- and post-ERCP), risk factors for PEP, and NM-related adverse events.

RESULTS

Only 441 of the planned 800 patients were enrolled (non-NM: n = 149; NM: n = 292 [pre-ERCP NM: n = 144; post-ERCP NM: n = 148]). Patient characteristics were balanced at baseline with no significant differences between groups. PEP occurred in 40/441 (9%) patients (non-NM: n = 15 [10%]; NM: n = 25 [9%]), including 17 (12%) and eight (8%) in the pre-ERCP and post-ERCP NM groups, respectively. In the NM group, the incidence of PEP was lower in the low-risk group than in the high-risk group. Pancreatic injection and double-guidewire technique were independent risk factors for PEP. NM-related adverse events of hyperkalemia occurred in two (0.7%) patients.

CONCLUSIONS

We found no evidence for the prophylactic effect of NM against PEP, regardless of the timing of administration; however, further studies are needed.

Pancreatitis after endoscopic retrograde cholangiopancreatography: A narrative review

Acute post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a feared and potentially fatal complication that can be as high as up to 30% in high-risk patients. Pre-examination measures, during the examination and after the examination are the key to technical and clinical success with a decrease in adverse events. Several studies have debated on the subject, however, numerous topics remain controversial, such as the effectiveness of prophylactic medications and the amylase dosage time. This review was designed to provide an update on the current scientific evidence regarding PEP available in the literature.

Predicative values of C-reactive protein for the therapeutic effects of ulinastatin combined with somatostatin in severe acute pancreatitis and for the severity of gastrointestinal failure

Severe acute pancreatitis (SAP) is a serious systemic disease with high mortality. Ulinastatin is a drug widely used for patients with SAP and multiple organ failure syndrome. The present study aimed to investigate the capacity of the serum C-reactive protein (CRP) levels to predict the therapeutic effects of ulinastatin combined with somatostatin as well as determine the severity of SAP. SAP patients were treated with ulinastatin combined with somatostatin and serum CRP levels were measured. The computed tomography severity index (CTSI), acute physiology and chronic health evaluation II (APACHE II) and gastrointestinal failure scores were used to determine the therapeutic effects. All patients were assigned to the effective group and the ineffective group. Receiver operating characteristic curve analysis was performed to determine the sensitivity and specificity of CRP levels in predicting the severity of SAP and patient prognosis. Logistic regression analysis was adopted to investigate the factors influencing the therapeutic effects. Prior to and after treatment, serum CRP levels in patients of the effective and ineffective groups were significantly different. After treatment, serum CRP levels in patients of the effective group exhibited a more obvious reduction. The sensitivity and specificity of serum CRP levels in predicting the therapeutic effects of ulinastatin combined with somatostatin in SAP patients upon hospital admission were 0.813 and 0.934, respectively. Serum CRP levels were positively correlated with APACHE II, CTSI and gastrointestinal failure scores of SAP patients. The logistic regression demonstrated that serum albumin, creatinine and CRP levels on admission were factors influencing the therapeutic effects of ulinastatin combined with somatostatin in SAP patients. These results indicate that serum CRP levels may have a predictive value regarding the therapeutic effects of ulinastatin combined with somatostatin and are an indicator of the severity of gastrointestinal failure in SAP.

Prophylactic ulinastatin administration for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis

The objective of the present study was to perform a meta-analysis of all available studies on the effect of prophylactic ulinastatin administration on preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The PubMed, Web of Knowledge and Chinese National Knowledge Infrastructure databases were searched to identify all relevant studies published in English or Chinese prior to April 2016. Cochrane Review Manager was used to calculate the pooled risk ratio (RR) and 95% confidence interval (CI) to determine the effect of prophylactic ulinastatin on PEP, post-ERCP hyperamylasemia (PEHA) and post-ERCP abdominal pain. The analysis revealed that prophylactic ulinastatin administration significantly reduced the PEP risk (RR=0.49; 95% CI: 0.33–0.74; P=0.0006; I²=24); however, such significant risk reduction occurred only in patients with low or average risk for PEP and high-dosage ulinastatin (150,000 or 200,000 U) administration, and when the ulinastatin administration began prior to or during ERCP. Pre-ERCP ulinastatin administration alone without additional administration after ERCP was sufficient. Prophylactic ulinastatin also significantly reduced the PEHA risk (RR=0.68; 95% CI: 0.56–0.83; P=0.0001; I²=19) and marginally reduced the incidence of post-ERCP abdominal pain (RR=0.67; 95% CI: 0.45–1.00; P=0.05; I²=67). In conclusion, prophylactic ulinastatin administration significantly reduced the risk of PEP in patients with low or average risk for PEP when administered at a high dosage prior to or during ERCP. High-quality studies, particularly on high-risk patients, are warranted.

The "Scope" of Post-ERCP Pancreatitis

Pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography, with the potential for clinically significant morbidity and mortality. Several patient and procedural risk factors have been identified that increase the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Considerable research efforts have identified several pharmacologic and procedural interventions that can drastically affect the incidence of PEP. This review article addresses the underlying mechanisms at play for the development of PEP, identifying patient and procedural risk factors and meaningful use of risk-stratification information, and details current interventions aimed at reducing the risk of this complication.

Endoscopic and pharmacological treatment for prophylaxis against postendoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis and systematic review

BACKGROUND AND AIM

Postendoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP) is the most common complication following ERCP. We carried out a systematic review and meta-analysis of the global literature on PEP prevention to provide clinical guidance and a framework for future research in this important field.

METHODS

PubMed, Embase, Science Citation Index, Ovid, and the Cochrane Controlled Trials Register were searched by two independent reviewers to identify full-length, prospective, randomized controlled trials (RCTs) published up until March 2016 investigating the use of pancreatic duct stents and pharmacological agents to prevent PEP.

RESULTS

Twelve RCTs comparing the risk of PEP after pancreatic duct stent placement (1369 patients) and 30 RCTs comparing pharmacological agents over placebo (10251 patients) fulfilled the inclusion criteria and were selected for final review and analysis. Meta-analysis showed that prophylactic pancreatic stents significantly decreased the odds of post-ERCP pancreatitis [odds ratio (OR), 0.28; 95% confidence interval (CI), 0.18-0.42]. Significant OR reduction of PEP was also observed in relation to rectal administration of diclofenac (OR, 0.24; 95% CI, 0.12-0.48) and rectal administration of indometacin (OR, 0.59; 95% CI, 0.44-0.79) compared with placebo. Subgroup analysis showed a significant reduction with bolus-administered somatostatin (OR, 0.23; 95% CI, 0.11-0.49). Subgroup analysis showed a significant reduction with bolus-administered somatostatin (OR, 0.23; 95% CI, 0.11-0.49).

CONCLUSION

Pancreatic stent placement, rectal diclofenac, and bolus administration of somatostatin appear to be most effective in preventing post-ERCP pancreatitis.

Effect of Somatostatin, Ulinastatin and Gabexate on the Treatment of Severe Acute Pancreatitis

OBJECTIVE

The objective of this study is to evaluate the efficacy of somatostatin, ulinastatin and gabexate for the treatment of severe acute pancreatitis.

MATERIALS AND METHODS

A total of 492 patients with severe acute pancreatitis were assigned randomly into the following 4 groups: (1) somatostatin; (2) somatostatin + ulinastatin; (3) somatostatin + gabexate and (4) somatostatin + ulinastatin + gabexate. Acute physiology and chronic health evaluation II scores; clinical parameters including time of abdominal pain and distention extinct; recovering to normality of heart rate and respiration rate; amylase and blood glucose; ratios of efficacy; multiple organ dysfunction syndrome (MODS); mortality; complication; levels of endotoxin; tumor necrosis factor alpha; interleukin-6 (IL-6), IL-8 and IL-10 and side effects were analyzed.

RESULTS

Acute physiology and chronic health evaluation II scores, time of abdominal pain extinct and distention extinct, time of recovering to normality of heart rate, time of recovering to normality of respiration rate and time of recovering to normality of amylase and blood glucose were significantly decreased in the somatostatin + ulinastatin, the somatostatin + gabexate and the somatostatin + ulinastatin + gabexate subgroups compared with the somatostatin subgroup. Ratios of efficacy were significantly improved, whereas ratios of MODS, mortality and complication were significantly decreased in the somatostatin + ulinastatin and the somatostatin + ulinastatin + gabexate subgroups compared with the somatostatin subgroup. Tumor necrosis factor alpha, IL-6 and IL-8 levels on the fourth day after treatment showed significant decrease in the somatostatin + ulinastatin, the somatostatin + gabexate and the somatostatin + ulinastatin + gabexate subgroups compared with the somatostatin subgroup. The IL-10 levels on the fourth day were significantly improved in the somatostatin + ulinastatin, the somatostatin + gabexate and the somatostatin + ulinastatin + gabexate subgroups compared with the somatostatin subgroup.

CONCLUSIONS

Somatostatin is effective for the treatment of acute pancreatitis, ulinastatin demonstrates improvement in therapeutic benefits and gabexate can relieve the clinical symptoms and shorten the course of disease but cannot improve the effective ratio or decrease MODS, mortality and complication.

A Meta-analysis on the Effect of Ulinastatin on Serum Levels of C-Reactive Protein, Interleukin 6, and Tumor Necrosis Factor Alpha in Asian Patients with Acute Pancreatitis

OBJECTIVES

We aimed to investigate the influence of ulinastatin (UTI) on the serum levels of C-reactive protein (CRP), interleukin 6 (IL-6), and tumor necrosis factor alpha (TNF-α) in Asian patients with acute pancreatitis (AP) by performance of a meta-analysis.

METHODS

Two investigators independently searched 11 databases, including PUBMED, EBSCO, Ovid, SpringerLink, Wiley, Web of Science, Cochrane Library, Wanfang database, China National Knowledge Infrastructure (CNKI), Chinese Journal Full-text Database, and China Biomedicine Database. The full-text articles were screened and the data were extracted using a standardized data extraction form. All statistical analyses were conducted with Stata software, version 12.0 (Stata Corporation, College Station, TX).

RESULTS

A total of 94 studies were initially retrieved, and 10 studies containing 424 Asian patients with AP were ultimately enrolled in this meta-analysis. The results revealed that the serum levels of CRP, IL-6, and TNF-α in Asian AP patients significantly decreased after UTI therapy (CRP: standardized mean difference [SMD] = 3.26, 95% confidence interval [CI] = 1.69-4.83, p < 0.001; IL-6: SMD = 5.92, 95% CI = 2.09-9.75, p = 0.002; TNF-α: SMD = 4.07, 95% CI = 0.79-7.35, p = 0.015).

CONCLUSION

The results of this meta-analysis suggest that UTI can effectively depress the serum levels of CRP, IL-6, and TNF-α in Asian patients with AP, and thereby inhibit inflammation.

Prevention and treatment of post-ERCP pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) is widely used in the diagnosis and treatment of cholangiopancreatic diseases, and pancreatitis remains the most common and severe complication. It is therefore important to minimize the incidence and severity of pancreatitis. This paper discusses the recent progress in the prevention and treatment of post-ERCP pancreatitis.

Ulinastatin activates the renin-angiotensin system to ameliorate the pathophysiology of severe acute pancreatitis

BACKGROUND AND AIM

Ulinastatin is a drug used effectively to alleviate symptoms and improve the pathophysiology of various types of pancreatitis. However, the molecular mechanism responsible for its action remains unknown. Therefore, we further explore the therapeutic effects of ulinastatin and investigate possible molecular pathways modulated by this drug in the development of severe acute pancreatitis (SAP).

METHODS

SAP mouse model was created by administering intraperitoneal injections of cerulein and lipopolysaccharide. Pancreatic injury was assessed by performing biochemical and histological assays and by measuring the inflammatory response of the pancreas. Specifically, we examined changes in the expression of components of the rennin-angiotensin system (RAS), including angiotensin-converting enzyme (ACE)-angiotensin II (Ang II)-angiotensin type 1 receptor (AT-1R), and ACE2-Ang-(1-7)-Mas receptor.

RESULTS

When SAP mouse models were treated with ulinastatin at a dosage of 50,000 U/kg body weight, we found, through biochemical and histopathological analyses, that the pancreatic injury was significantly ameliorated. Administration of ulinastatin to SAP mice led to increased expression of ACE2, Ang-(1-7), and Mas receptor, decreased expression of serum Ang II and pancreatic AT-1R, and no alterations in the expression of pancreatic ACE and Ang II when compared to cerulein-treated control group that did not receive ulinastatin.

CONCLUSIONS

This study shows that ulinastatin has differential effects on the two axes of the RAS during SAP. Our results further suggest that upregulation of components of the ACE2-Ang-(1-7)-Mas pathway might be an important mechanism contributing to the therapeutic role of ulinastatin in alleviating pancreatitis-associated symptoms.

Comparison between ulinastatin and nafamostat for prevention of post-endoscopic retrograde cholangiopancreatography complications: a prospective, randomized trial

OBJECTIVES

Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this prospective trial was to compare the effect of ulinastatin and nafamostat on the prophylaxis of post-ERCP complications.

METHODS

A total of 159 patients who underwent ERCP were divided into ulinastatin (n = 53), nafamostat (n = 53) and control (n = 53) groups. Each patient received ulinastatin (150,000 units), nafamostat (20 mg), or placebo from 2-4 h before ERCP to 6-8 h after ERCP. The primary endpoint was the incidence of PEP, and the secondary endpoints were the incidence of post-ERCP hyperamylasemia, hyperlipasemia and abdominal pain.

RESULTS

The overall incidence of PEP was 6.3% (10/159) and no significant differences were observed between ulinastatin and nafamostat groups in terms of the incidences of PEP (1.9% and 3.8%, P = 0.560), hyperamylasemia, hyperlipasemia, and abdominal pain, although these were significantly lower than those of the control group (P < 0.001).

CONCLUSIONS

There was no significant difference for preventing PEP between ulinastatin and nafamostat and both drugs were efficacious for preventing post-ERCP complications.

Pharmacologic prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis: protease inhibitors and NSAIDs in a meta-analysis

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is the most frequent complication of ERCP. Several meta-analyses have examined the effects of protease inhibitors (gabexate mesilate, ulinastatin, and nafamostat mesilate) and non-steroidal anti-inflammatory drugs (NSAIDs) on post-ERCP pancreatitis, but the results have been confusing. Since the previous meta-analysis, several new studies have been published on this topic. To provide an updated quantitative assessment of the effectiveness of protease inhibitors and NSAIDs in preventing post-ERCP pancreatitis, we conducted a meta-analysis of randomized trials for patients at risk of post-ERCP pancreatitis. Twenty-six articles were included in this meta-analysis. Nafamostat mesilate (summary RR = 0.41; 95 %CI 0.28-0.59; n = 4 studies) and NSAIDs (summary RR = 0.58; 95 %CI = 0.44-0.76; n = 7 studies) were associated with decreased risk of post-ERCP pancreatitis in the high-quality studies. However, gabexate mesilate (summary RR = 0.64; 95 %CI = 0.36-1.13; n = 6 studies) and ulinastatin (summary RR = 0.65; 95 %CI = 0.33-1.30; n = 2 studies) were not associated with decreased risk of post-ERCP pancreatitis in the high-quality studies. This is the first meta-analysis to compare the effects of three protease inhibitors. Solid evidence supports the use of nafamostat mesilate and NSAIDs for preventing post-ERCP pancreatitis.

The effect of somatostatin, ulinastatin and Salvia miltiorrhiza on severe acute pancreatitis treatment

BACKGROUND

The aim of this study was to evaluate the efficacy of somatostatin, ulinastatin and Salvia miltiorrhiza for treatment of severe acute pancreatitis.

METHODS

Three hundred six patients with severe acute pancreatitis were divided randomly into 5 groups: basic treatment, somatostatin, somatostatin + ulinastatin, somatostatin + S miltiorrhiza and somatostatin + ulinastatin + S miltiorrhiza. Amount of time for resolution of abdominal pain/distention, recovery to normal heart and respiratory rates, amylase and blood glucose levels, Acute Physiology and Chronic Health Evaluation II scores, and levels of tumor necrosis factor-α, interleukin (IL)-6, and IL-10 were analyzed and recorded for all 5 subgroups.

RESULTS

Tumor necrosis factor-α and IL-6 levels on the fourth and seventh days, and Acute Physiology and Chronic Health Evaluation II scores on the seventh day after treatment showed significant decrease in the somatostatin, somatostatin + ulinastatin, somatostatin + S miltiorrhiza and somatostatin + ulinastatin + S miltiorrhiza subgroups compared with the basic treatment subgroup. IL-10 levels on the fourth and seventh days were significantly improved in the somatostatin + ulinastatin, somatostatin + S miltiorrhiza and somatostatin + ulinastatin + S miltiorrhiza subgroups compared with the basic treatment subgroup. The incidences of pancreatic sepsis, multiple organ dysfunction syndrome and mortality were lower in the somatostatin, somatostatin + ulinastatin, somatostatin + S miltiorrhiza and somatostatin + ulinastatin + S miltiorrhiza subgroups compared with the basic treatment subgroup.

CONCLUSIONS

Somatostatin is effective for the treatment of acute pancreatitis and both ulinastatin and S miltiorrhiza demonstrate improvement in therapeutic benefits.

Systematic review with network meta-analysis: pharmacological prophylaxis against post-ERCP pancreatitis

BACKGROUND

The efficacy of many pharmacological agents for preventing post-ERCP pancreatitis (PEP) has been evaluated in randomised controlled trials (RCTs), but it is unclear which agent(s) should be used in clinical practice. Network meta-analyses of RCTs are used to simultaneously compare several agents to determine their relative efficacy and identify priority agents for comparison in future RCTs.

AIM

To evaluate pharmacological agents for the prevention of PEP by conducting a network meta-analysis of RCTs.

METHODS

We searched MEDLINE, EMBASE and Cochrane Library databases for RCTs that evaluated the efficacy of agents for preventing PEP. RCTs were simultaneously analysed using random-effects network meta-analysis under the Bayesian framework to identify the best agents. The efficacy of agents was ordered according to the probability of being ranked as any of the top three best performing agents.

RESULTS

The network meta-analysis included 99 RCTs evaluating 16 agents in 25 313 patients. Topical epinephrine (adrenaline) was the most efficacious agent with 85.9% probability of ranking among the top three agents, followed by nafamostat (51.4%), antibiotics (44.5%) and NSAIDs (42.8%). However, in a sensitivity analysis including only rectal NSAIDs, NSAIDs moved from fourth rank to second (58.1%). Patients receiving topical epinephrine, compared with placebo, had a 75% reduced risk of PEP (OR 0.25, 95% probability interval 0.06-0.66).

CONCLUSIONS

Topical epinephrine and rectal NSAIDs are the most efficacious agents for preventing post-ERCP pancreatitis, based on existing RCTs. Combinations of these agents, which act on different steps in the pathogenesis of post-ERCP pancreatitis, should be evaluated in future trials.

Post-ERCP pancreatitis: review of current preventive strategies

PURPOSE OF REVIEW

This article reviews the most recent literature with significant findings pertaining to the prevention of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

RECENT FINDINGS

Despite several promising reports of pharmacologic agents that have demonstrated the efficacy for prophylaxis against post-ERCP pancreatitis such as nonsteroidal anti-inflammatory drugs and secretin, there are currently no universally accepted agents for use in high-risk patients. The greatest reductions in the incidence of post-ERCP pancreatitis in high-risk patients have been demonstrated through advancements in endoscopic techniques such as pancreatic duct stenting and dye-free guidewire cannulation.

SUMMARY

Pancreatitis requiring hospitalization is the most common complication of ERCP. Numerous pharmaceutical and procedure related interventions have been studied in attempts to prevent this complication; however, morbidity associated with ERCP remains significant. The most effective methods for preventing post-ERCP pancreatitis are careful patient selection and identification of risk factors prior to procedure.

The use of gabexate mesylate and ulinastatin for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Background/Aims

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Only a few pharmacologic agents have been shown to have potential efficacy for the prophylactic treatment of post-ERCP pancreatitis (PEP). The aim of this study was to determine whether prophylactic gabexate and ulinastatin can decrease the incidence of PEP.

Methods

From January 2005 to April 2010, 1,679 patients undergoing ERCP treatment were consecutively enrolled in the study. After selective exclusion, a total of 1,480 patients were included in the analysis. The patients were separated into 3 groups according to the prophylactic administration of gabexate (593 patients), ulinastatin (229 patients), or saline solution (658 patients) and analyzed retrospectively. The primary outcome measurements were the incidence of pancreatitis and hyperamylasemia.

Results

PEP occurred in 21 of the 593 (3.5%) patients who received gabexate, 16 of the 229 (7.0%) patients who received ulinastatin, and 48 of the 658 (7.3%) patients who received a saline solution. The incidence of PEP was significantly different between the gabexate and ulinastatin or saline solution groups (p<0.05).

Conclusions

Gabexate prophylaxis is effective in preventing PEP. However, there is no difference in the beneficial effects of the prophylactic administration of ulinastatin and a saline solution.

Infusion of ulinastatin via the pancreatic duct for prophylaxis of pancreatic injury after endoscopic retrograde cholangiopancreatography in dogs

AIM: To evaluate the prophylactic effect of infusion of ulinastatin via the pancreatic duct on pancreatic injury after endoscopic retrograde cholangiopancreatography (ERCP) in a canine model.

METHODS: Twenty-four dogs were randomized into three groups: ulinastatin group (group A), iobitridol group (group B) and normal group (group C). A duodenoscope was routinely inserted to the duodenal papilla under general anesthesia in dogs of each group. A guide wire was introduced into the bile duct in groups A and B to inject 10.0 mL of iobitridol, and the guide wire was then introduced into the pancreatic duct to slowly administer 100 000 units of ulinastatin and 8.0 mL of sodium chloride in group A and 10.0 mL of sodium chloride in group B. Five minutes later, 10.0 mL of iobitrdol was transfused into the pancreatic ducts in both groups within less than 1 min. A guide wire was introduced into the bile duct in group C to administer 10.0 mL of iobitridol. The contents of serum IL-6, IL-8, amylase and plasma TAP were determined by ELISA. Pancreatic tissues were pathologically examined 6 days after ERCP.

RESULTS: The contents of serum IL-6, IL-8, amylase and plasma TAP were significantly lower in group A than in group B (391.0 U/L ± 67.2 U/L vs 1 077.0 U/L ± 246.1 U/L, 51.91 ng/L ± 4.87 ng/L vs 78.11 ng/L ± 11.25 ng/L,

4.070 μg/L ± 0.089 μg/L vs 4.520 μg/L ± 0.195 μg/L, 3.234 nmol/L ± 0.185 nmol/L vs

4.001 nmol/L ± 0.237 nmol/L (all P < 0.05), and significantly higher in groups A and B than in group C. Under light microscopy, the pathological changes in pancreatic tissues in the ulinastatin group were less significant than those in other groups.

CONCLUSION: Pancreatic injury induced by ERCP could be ameliorated effectively and safety by infusion of ulinastatin via the pancreatic duct in dogs.

Prevention of Post-ERCP Pancreatitis

Pancreatitis is the most common complication of ERCP. It can be associated with substantial morbidity. Hence, the minimization of both the incidence and severity of post-ERCP pancreatitis is paramount. Considerable efforts have been made to identify factors that may be associated with an increased risk of this complication. In addition, both procedure- and pharmacological-related interventions have been proposed that may prevent this complication. This paper outlines these interventions and presents the evidence to support their use in the prevention of post-ERCP pancreatitis.

Protease inhibitors for preventing complications associated with ERCP: an updated meta-analysis

BACKGROUND AND OBJECTIVES

The prophylactic use of protease inhibitors in patients undergoing ERCP is still controversial. Our purpose was to evaluate the efficacy of protease inhibitors in preventing ERCP-associated complications.

DESIGN AND SETTING

Meta-analysis; randomized trials that evaluated the efficacy of protease inhibitors were identified.

PATIENTS

A total of 4966 patients were evaluated.

MAIN OUTCOME MEASUREMENTS

ERCP-associated pancreatitis, hyperamylasemia, abdominal pain, and death.

RESULTS

Eighteen studies (19 cohorts) met the inclusion criteria. Overall results for protease inhibitors showed a significant but small risk reduction in ERCP-associated pancreatitis (pooled risk difference [RD]: -0.029; 95% CI, -0.051 to -0.008 and the number needed to treat, 34.5; 95% CI, 19.6-125). Subgroup analysis in 8 high-quality studies showed a borderline significant efficacy (pooled RD, -0.027; 95% CI, -0.051 to -0.004). Subgroup analysis in 8 gabexate studies did not show significant efficacy (pooled RD, -0.030; 95% CI, -0.062 to 0.003). Subgroup analysis in 5 ulinastatin studies was significant (pooled RD, -0.035; 95% CI, -0.063 to -0.006). Two high-quality studies on ulinastatin yielded nonsignificant results. Analyses for the other outcomes were all nonsignificant. Sensitivity analysis showed that the effect size and level of statistical significance were decreased with increasing study quality.

CONCLUSIONS

At present, there is no solid evidence to support the use of protease inhibitors to prevent ERCP-associated complications. Although overall and ulinastatin subgroup analyses showed a small risk reduction for pancreatitis, it seems very possible that low-quality primary studies produced a veneer of efficacy.