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Horváth IL, Kleiner D, Nagy R, Fehérvári P, Hankó B, Hegyi P, Csupor D. Nafamostat Reduces the Incidence of post-ERCP Pancreatitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Pharmacol Ther 2024; 115:206-212. [PMID: 38032816 DOI: 10.1002/cpt.3118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/21/2023] [Indexed: 12/02/2023]
Abstract
Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). As the management of pancreatitis is limited, clinical approaches focus on the prevention of post-ERCP pancreatitis (PEP). In theory, the serine protease inhibitor nafamostat can reduce circulating inflammatory mediators in pancreatitis. We aimed to investigate the effect of nafamostat in the prevention of PEP in this systematic review and meta-analysis. The protocol for this review was registered in PROSPERO (CRD42022367988). We systematically searched 5 databases without any filters on September 26, 2022. The eligible population was adult patients undergoing ERCP. We compared the PEP preventive effect of nafamostat to placebo. The main outcome was the occurrence of PEP. We calculated the pooled odds ratios (ORs), mean differences, and corresponding 95% confidence intervals (95% CIs) and multilevel model. The risk of bias was assessed using the Rob2 tool. Seven randomized controlled trials involving 2,962 patients were eligible for inclusion. Nafamostat reduced the overall incidence rate of PEP (20 mg, OR: 0.50, 95% CI: 0.30-0.82 and 50 mg, OR: 0.48, 95% CI: 0.24-0.96). However, the occurrence of mild PEP was significantly reduced only in the subgroup receiving 20 mg nafamostat (OR, 0.49, 95% CI: 0.31-0.77). Overall, nafamostat therapy reduced moderate PEP in high-risk patients (OR: 0.18, 95% CI: 0.0.4-0.84) and mild PEP in low-risk patients (OR: 0.32, 95% CI: 0.17-0.61). Nafamostat is an effective therapy in the prevention of mild post-ERCP pancreatitis. Further research is required to determine the cost-effectiveness of this therapy.
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Affiliation(s)
- István László Horváth
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- University Pharmacy, Department of Pharmacy Administration, Semmelweis University, Budapest, Hungary
| | - Dénes Kleiner
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- University Pharmacy, Department of Pharmacy Administration, Semmelweis University, Budapest, Hungary
| | - Rita Nagy
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Fehérvári
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biostatistics, University of Veterinary Medicine, Budapest, Hungary
| | - Balázs Hankó
- University Pharmacy, Department of Pharmacy Administration, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Dezső Csupor
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, Szeged, Hungary
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Predictive factors of postendoscopic retrograde cholangiopancreatography pancreatitis for biliary complications in living-donor liver transplantation recipients. Eur J Gastroenterol Hepatol 2023; 35:359-364. [PMID: 36827529 DOI: 10.1097/meg.0000000000002521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
OBJECTIVES Endoscopic retrograde cholangiopancreatography (ERCP) has shown great safety and efficacy in the management of post-living-donor liver transplantation (LDLT) biliary complications. Pancreatitis is the most commonest and the most feared complication after ERCP. METHODS We reviewed the data of liver transplant recipients who underwent ERCP for biliary complications after LDLT between 2011 and 2022. RESULTS In total 63 patients underwent ERCP after LDLT. They were targeted to 134 set of ERCP. Pancreatitis occurred in 52 sets (38.8%). We subclassified the patients into two groups, without pancreatitis: 31 patients (49.2%) and with pancreatitis 32 patients (50.8%). A higher incidence of pancreatitis was noticed with the first ERCP set (P = 0.04). Biliary strictures were more noted in the pancreatitis group (P = 0.025). Difficult cannulation requiring precut was more observed in the pancreatitis group (P = 0.007). Also, more frequent sphincterotomy was observed in the pancreatitis group (P = 0.003). Longer hospital stay, more fever, abdominal pain and vomiting were noted in the pancreatitis group (P = 0.001). Higher post-ERCP serum amylase (P = 0.001) and creatinine (P = 0.021), while lower serum calcium (P = 0.21) were noticed in the pancreatitis group. On multivariate analysis, preoperative diabetes, number of biliary anastomoses (single/multiple) and difficult cannulation requiring precut were significant predictors of post-ERCP pancreatitis. CONCLUSION Patient-related risk factors and bedside procedure-related risk factors play an essential role in the development of pancreatitis after ERCP for LDLT recipients. Endoscopists should be mindful by those high-risk patients during ERCP to apply appropriate techniques to prevent the development of this serious complication.
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Alavinejad P, Tran NPN, Eslami O, Shaarawy OE, Hormati A, Seiedian SS, Parsi A, Ahmed MH, Behl NS, Abravesh AA, Tran QT, Vignesh S, Salman S, Sakr N, Ara TF, Hajiani E, Hashemi SJ, Patai ÁV, Butt AS, Lee SH. ORAL N-ACETYL CYSTEINE VERSUS RECTAL INDOMETHACIN FOR PREVENTION OF POST ERCP PANCREATITIS: A MULTICENTER MULTINATIONAL RANDOMIZED CONTROLLED TRIAL. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:508-512. [PMID: 36383882 DOI: 10.1590/s0004-2803.202204000-90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/03/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND This multicenter multinational RCT designed to compare the efficacy of suppository indomethacin and NAC for prevention of PEP. METHODS During a 6-month period, all of the ERCP cases in seven referral centers were randomly assigned to receive either 1200 mg oral NAC, indomethacin suppository 100 mg, 1200 mg oral NAC plus indomethacin suppository 100 mg or placebo 2 hours before ERCP. The primary outcomes were the rate and severity of any PEP. RESULTS A total of 432 patients included (41.4% male). They were originally citizens of 6 countries (60.87% Caucasian). They were randomly allocated to receive either NAC (group A, 84 cases), rectal indomethacin (group B, 138 cases), NAC + rectal indomethacin (group C, 115 cases) or placebo (group D, 95 cases). The rate of PEP in groups A, B and C in comparison with placebo were 10.7%, 17.4%, 7.8% vs 20% (P=0.08, 0.614 & 0.01 respectively). The NNT for NAC, indomethacin and NAC + indomethacin was 11, 38 and 8 respectively. CONCLUSION Oral NAC is more effective than rectal indomethacin when compared to placebo for prevention of PEP and the combination of NAC and Indomethacin had the lowest incidence of PEP and may have synergistic effect in preventing of PEP (IRCT20201222049798N1; 29/12/2020).
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Affiliation(s)
- Pezhman Alavinejad
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
- World Endoscopy Organization emerging star group, WEO, Munich, Germany
| | | | - Omid Eslami
- Clinical Research Development Unit, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
- Gastroenterology and Hepatology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Omar El Shaarawy
- Lecturer and consultant of Hepatology, Gastroenterology and Endoscopy, National Liver institute, Menoufia University, Egypt
| | - Ahmad Hormati
- Gastrointestinal and liver Diseases Research Center, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Seied Saeed Seiedian
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
| | - Abazar Parsi
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
| | - Mohammed Hussien Ahmed
- Lecturer Hepatology Gastroenterology and infectious diseases, Faculty of Medicine, Kafrelsheikh University, Cairo, Egypt
| | - Nitin Shanker Behl
- Institute of Gastro and Liver diseases, Fortis Hospital, Ludhiana, India
| | - Ali Akbar Abravesh
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
| | - Quang Trung Tran
- Department of Internal Medicine, University of Medicine and Pharmacy, Hue University, Vietnam
- Department of Internal Medicine A, University Medicine Greifswald, Germany
- World Endoscopy Organization emerging star group, WEO, Munich, Germany
| | - Shivakumar Vignesh
- Division of gastroenterology, Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA
- World Endoscopy Organization emerging star group, WEO, Munich, Germany
| | - Saif Salman
- Hashemite University, Faculty of Medicine, Alzarqa, Jordan
| | - Naemt Sakr
- Assistant Lecturer and specialist of Hepatology and Gastroenterology at the National Liver Institute, Menoufia University, Egypt
| | - Tahmineh Farbod Ara
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
| | - Eskandar Hajiani
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
| | - Seyed Jalal Hashemi
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
| | - Árpád V Patai
- Gastroenterology Division, Internal Medicine and Hematology Department, Semmelweis University, Budapest, Hungary
- Interdisciplinary Gastroenterology Working Group, Semmelweis University, Budapest, Hungary
| | - Amna Subhan Butt
- World Endoscopy Organization emerging star group, WEO, Munich, Germany
- Consultant Gastroenterologist, Section of Gastroenterology, Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi, Pakistan
| | - Sang Hyub Lee
- World Endoscopy Organization emerging star group, WEO, Munich, Germany
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Zhang X, Yue P, Zhang J, Yang M, Chen J, Zhang B, Luo W, Wang M, Da Z, Lin Y, Zhou W, Zhang L, Zhu K, Ren Y, Yang L, Li S, Yuan J, Meng W, Leung JW, Li X. A novel machine learning model and a public online prediction platform for prediction of post-ERCP-cholecystitis (PEC). EClinicalMedicine 2022; 48:101431. [PMID: 35706483 PMCID: PMC9112124 DOI: 10.1016/j.eclinm.2022.101431] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/31/2022] [Accepted: 04/12/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is an established treatment for common bile duct (CBD) stones. Post- ERCP cholecystitis (PEC) is a known complication of such procedure and there are no effective models and clinical applicable tools for PEC prediction. METHODS A random forest (RF) machine learning model was developed to predict PEC. Eligible patients at The First Hospital of Lanzhou University in China with common bile duct (CBD) stones and gallbladders in-situ were enrolled from 2010 to 2019. Logistic regression analysis was used to compare the predictive discrimination and accuracy values based on receiver operation characteristics (ROC) curve and decision and clinical impact curve. The RF model was further validated by another 117 patients. This study was registered with ClinicalTrials.gov, NCT04234126. FINDINGS A total of 1117 patients were enrolled (90 PEC, 8.06%) to build the predictive model for PEC. The RF method identified white blood cell (WBC) count, endoscopic papillary balloon dilatation (EPBD), increase in WBC, residual CBD stones after ERCP, serum amylase levels, and mechanical lithotripsy as the top six predictive factors and has a sensitivity of 0.822, specificity of 0.853 and accuracy of 0.855, with the area under curve (AUC) value of 0.890. A separate logistic regression prediction model was built with sensitivity, specificity, and AUC of 0.811, 0.791, and 0.864, respectively. An additional 117 patients (11 PEC, 9.40%) were used to validate the RF model, with an AUC of 0.889 compared to an AUC of 0.884 with the logistic regression model. INTERPRETATION The results suggest that the proposed RF model based on the top six PEC risk factors could be a promising tool to predict the occurrence of PEC.
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Affiliation(s)
- Xu Zhang
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
| | - Ping Yue
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
- Gansu Province Key Laboratory of Biological Therapy and Regenerative Medicine Transformation, Lanzhou,730030, Gansu, China
| | - Jinduo Zhang
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
- Gansu Province Key Laboratory of Biological Therapy and Regenerative Medicine Transformation, Lanzhou,730030, Gansu, China
| | - Man Yang
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Clinical Research Center, Big Data Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Jinhua Chen
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
| | - Bowen Zhang
- State Key Laboratory of Applied Organic Chemistry, Lanzhou University, Lanzhou, 730030 , Gansu, China
| | - Wei Luo
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
| | - Mingyuan Wang
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of Ultrasonography, The First Hospital of Lanzhou University, Lanzhou, 730030, Gansu, China
| | - Zijian Da
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
| | - Yanyan Lin
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
- Gansu Province Key Laboratory of Biological Therapy and Regenerative Medicine Transformation, Lanzhou,730030, Gansu, China
| | - Wence Zhou
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
- Gansu Province Key Laboratory of Biological Therapy and Regenerative Medicine Transformation, Lanzhou,730030, Gansu, China
| | - Lei Zhang
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
- Gansu Province Key Laboratory of Biological Therapy and Regenerative Medicine Transformation, Lanzhou,730030, Gansu, China
| | - Kexiang Zhu
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
- Gansu Province Key Laboratory of Biological Therapy and Regenerative Medicine Transformation, Lanzhou,730030, Gansu, China
| | - Yu Ren
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
| | - Liping Yang
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
| | - Shuyan Li
- School of Medical Information and Engineering, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
- Corresponding author.
| | - Jinqiu Yuan
- Clinical Research Center, Big Data Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
- Corresponding author.
| | - Wenbo Meng
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
- Gansu Province Key Laboratory of Biological Therapy and Regenerative Medicine Transformation, Lanzhou,730030, Gansu, China
- Corresponding author at: The First School of Clinical Medcine, Lanzhou University. Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
| | - Joseph W. Leung
- Division of Gastroenterology, UC Davis Medical Center and Sacramento VA Medical Center, Sacramento, 95817, CA, USA
| | - Xun Li
- The First School of Clinical Medicne, Lanzhou University, Lanzhou,730030, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, 730030,Gansu, China
- Gansu Province Key Laboratory of Biological Therapy and Regenerative Medicine Transformation, Lanzhou,730030, Gansu, China
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He QB, Zheng RH, Wang Y, Wang L, Tan LX, Meng GX, Zhong H, Duan J, Gu AD. Using air cholangiography to reduce postendoscopic retrograde cholangiopancreatography cholangitis in patients with malignant hilar obstruction. Quant Imaging Med Surg 2022; 12:1698-1705. [PMID: 35284261 PMCID: PMC8899942 DOI: 10.21037/qims-21-462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 11/02/2021] [Indexed: 10/08/2023]
Abstract
BACKGROUND Cholangitis after endoscopic retrograde cholangiopancreatography (ERCP) is a major problem for patients with hilar biliary obstruction. To date, it remains unclear whether air-contrast cholangiography (ACC) can reduce cholangitis in these patients. For this reason, our study assesses the efficacy of reducing cholangitis through ACC. METHODS This paper presents a retrospective study conducted at a tertiary university hospital. We enrolled patients who were diagnosed with hilar structures and underwent ERCP between January 2012 and December 2018. From 2015 onwards, ACC was performed following the successful selective cannulation into the dilated intrahepatic bile duct of these patients. The primary aim was to assess patients with cholangitis in both an ACC group and iodine contrast cholangiography (ICC) group. RESULTS This study included 80 patients, 35 of whom received ACC and 45 who received ICC. There were no differences between the 2 groups in terms of the number of patients who underwent endoscopic papillotomy, endoscopic nasobiliary drainage, endoscopic biliary stent placement, or other technical procedures or complications. A total of 19 patients (23.8%) presented with fever (cholangitis) after the ERCP procedure (4 ACC, 15 ICC; 11.4% vs. 33.3%, respectively; P=0.03). One patient in the ICC group who obtained a plastic stent for palliative drainage died 2 weeks post-ERCP. Among the other 18 cholangitis patients, 8 (1 ACC, 7 ICC) were treated with additional ERCP or percutaneous transhepatic biliary drainage (PTBD), while the remaining 10 only received antibiotics. One patient in the ICC group who obtained a plastic stent for palliative drainage died 2 weeks post-ERCP. CONCLUSIONS We found that ACC significantly reduced the incidence of cholangitis in patients with hilar obstruction.
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Affiliation(s)
- Qi-Bin He
- Department of Gastroenterology, Nanjing Jiangning Hospital, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Ru-Hua Zheng
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Yi Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Lu-Xuan Tan
- Department of Gastroenterology, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Gui-Xia Meng
- Department of Gastroenterology, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Huan Zhong
- Department of Gastroenterology, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jie Duan
- Department of Hepatobiliary Surgery, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Ai-Dong Gu
- Department of Hepatobiliary Surgery, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
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Dar HA, Shah A, Javid G, Khan MA, Singh B, Sheikh NA, Ashraf A, Mohammad S. Randomized trial of high-dose rectal diclofenac suppository and epinephrine spray on duodenal papilla for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Indian J Gastroenterol 2021; 40:483-491. [PMID: 34767149 DOI: 10.1007/s12664-021-01161-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 02/22/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS High-dose rectal diclofenac suppository and epinephrine spray on duodenal papilla during endoscopic retrograde cholangiopancreatography (ERCP) may reduce the incidence of post-ERCP pancreatitis. We performed randomized trial to compare the effect of combination of rectal diclofenac and epinephrine spray on papilla (group A) vs. combination of rectal diclofenac with saline spray (group B) for prevention of post-ERCP pancreatitis. METHODS We performed a double-blind trial at tertiary care center from April 2018 to May 2020 on 882 patients with naive papilla undergoing ERCP. The patients were randomly assigned to groups, A (n=437) or B (n=445). All patients received a single dose of rectal diclofenac 100 mg within 30 minutes before ERCP; 20 mL of diluted epinephrine 0.02% (group A) or saline (group B) was then sprayed on the duodenal papilla at the end of ERCP. The primary outcome was to compare incidence of post-ERCP pancreatitis (PEP) in two groups. RESULTS The groups had similar baseline characteristics. PEP developed in 28 patients in group A (6.4%) and 35 patients in group B (7.9%) (relative risk, 1.1; 95% CI, 0.87-1.39; p=0.401). CONCLUSION Our study showed that addition of epinephrine spray on duodenal papilla did not reduce the risk of post-ERCP pancreatitis. There is need for further studies to evaluate the role of different concentrations of epinephrine spray on papilla for prevention of post-ERCP pancreatitis. TRIAL REGISTRATION Clinical Trials Registry- India (CTRI/2018/04/013396).
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Affiliation(s)
- Hilal Ahmad Dar
- Department of Gastroenterology, Sher- i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, 190 011, India. .,Department of Internal Medicine, Government Medical College, Baramulla, Kashmir, 193 101, India.
| | - Altaf Shah
- Department of Gastroenterology, Sher- i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, 190 011, India
| | - Gul Javid
- Department of Gastroenterology, Sher- i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, 190 011, India
| | - Mushtaq Ahmad Khan
- Department of Gastroenterology, Sher- i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, 190 011, India
| | - Bhagat Singh
- Department of Gastroenterology, Sher- i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, 190 011, India
| | - Nadeem Ahmad Sheikh
- Department of Gastroenterology, Sher- i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, 190 011, India
| | - Aadil Ashraf
- Department of Gastroenterology, Sher- i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, 190 011, India
| | - Sozia Mohammad
- Department of Microbiology, Sher- i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, 190 011, India
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Romano-Munive AF, García-Correa JJ, García-Contreras LF, Ramírez-García J, Uscanga L, Barbero-Becerra VJ, Moctezuma-Velázquez C, Ochoa-Rubí JA, Toledo-Cuque J, Vázquez-Anaya G, Keil-Ríos D, Grajales-Figueroa G, Ramírez-Luna MÁ, Valdovinos-Andraca F, Zamora-Nava LE, Tellez-Avila F. Can topical epinephrine application to the papilla prevent pancreatitis after endoscopic retrograde cholangiopancreatography? Results from a double blind, multicentre, placebo controlled, randomised clinical trial. BMJ Open Gastroenterol 2021; 8:bmjgast-2020-000562. [PMID: 33558263 PMCID: PMC7871689 DOI: 10.1136/bmjgast-2020-000562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/23/2022] Open
Abstract
Background and study aims Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a complication associated with important morbidity, occasional mortality and high costs. Preventive strategies are suboptimal as PEP continues to affect 4% to 9% of patients. Spraying epinephrine on the papilla may decrease oedema and prevent PEP. This study aimed to compare rectal indomethacin plus epinephrine (EI) versus rectal indomethacin plus sterile water (WI) for the prevention of PEP. Patients and methods This multicentre randomised controlled trial included patients aged >18 years with an indication for ERCP and naive major papilla. All patients received 100 mg of rectal indomethacin and 10 mL of sterile water or a 1:10 000 epinephrine dilution. Patients were asked about PEP symptoms via telephone 24 hours and 7 days after the procedure. The trial was stopped half way through after a new publication reported an increased incidence of PEP among patients receiving epinephrine. Results Of the 3602 patients deemed eligible, 3054 were excluded after screening. The remaining 548 patients were randomised to EI group (n=275) or WI group (n=273). The EI and WI groups had similar baseline characteristics. Patients in the EI group had a similar incidence of PEP to those in the WI group (3.6% (10/275) vs 5.12% (14/273), p=0.41). Pancreatic duct guidewire insertion was identified as a risk factor for PEP (OR 4.38, 95% CI (1.44 to 13.29), p=0.009). Conclusion Spraying epinephrine on the papilla was no more effective than rectal indomethacin alone for the prevention of PEP. Trial registration number This study was registered with ClinicalTrials.gov (NCT02959112).
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Affiliation(s)
| | | | | | | | - Luis Uscanga
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | | | | | - Jorge A Ochoa-Rubí
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Julio Toledo-Cuque
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Gerardo Vázquez-Anaya
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Daniel Keil-Ríos
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | | | | | | | | | - Felix Tellez-Avila
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
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8
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Bai Y, Li DF, Wang SL, Zhao SB, Ma SR, Zhang ST, Li ZS. Chinese expert consensus on perioperative medications for endoscopic retrograde cholangiopancreatography (ERCP). J Dig Dis 2019; 20:103-113. [PMID: 30604509 DOI: 10.1111/1751-2980.12699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 12/22/2018] [Accepted: 01/02/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Yu Bai
- Department of Gastroenterology, Changhai Hospital, The Naval Medical University (Second Military Medical University), Shanghai, China
| | - De Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital (Second Clinical Medical College of Jinan University, Shenzhen, Guangdong Province, China
| | - Shu Ling Wang
- Department of Gastroenterology, Changhai Hospital, The Naval Medical University (Second Military Medical University), Shanghai, China
| | - Sheng Bing Zhao
- Department of Gastroenterology, Changhai Hospital, The Naval Medical University (Second Military Medical University), Shanghai, China
| | - Shu Ren Ma
- Department of Gastroenterology, The General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Shu Tian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, The Naval Medical University (Second Military Medical University), Shanghai, China
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9
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Wang Z, Wang Q, Song J, Yao W, Lei P, Tang C, Yuan P, Leng J. Treatment of severe acute pancreatitis via endoscopic pancreatic stenting and nasopancreatic drainage: Case reports. Exp Ther Med 2019; 17:432-436. [PMID: 30651817 PMCID: PMC6307471 DOI: 10.3892/etm.2018.6958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 11/06/2018] [Indexed: 01/12/2023] Open
Abstract
Severe acute pancreatitis (SAP) is associated with high mortality. SAP is generally treated by conservative management at the early phase, and removal of the pancreatic and peripancreatic necrotic tissue at the late phase. However, studies have suggested that the surgical treatment of SAP should focus on pressure reduction and drainage. In this case report, 3 SAP patients of 44, 30 and 60 years of age were treated at the General Hospital of Ningxia Medical University. They underwent emergency endoscopic pancreatic stenting at the early phase and nasopancreatic drainage at the late phase when peripancreatic encapsulated effusion was observed. All patients were successfully treated and discharged from the hospital. The disease duration of the patients was 71, 58, and 88 days, respectively. Our cases suggested that the surgical strategy of endoscopic pancreatic stenting at the early phase and nasopancreatic drainage at the late phase is promising for the treatment of SAP.
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Affiliation(s)
- Zuozheng Wang
- Department of Hepatobiliary Surgery, The General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
| | - Qi Wang
- Department of Hepatobiliary Surgery, The General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
| | - Jianjun Song
- Department of Hepatobiliary Surgery, The General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
| | - Weijie Yao
- Department of Hepatobiliary Surgery, The General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
| | - Peng Lei
- Department of Hepatobiliary Surgery, The General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
| | - Chaofeng Tang
- Department of Hepatobiliary Surgery, The General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
| | - Peng Yuan
- Department of Hepatobiliary Surgery, The General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
| | - Junzhi Leng
- Department of Hepatobiliary Surgery, The General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
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10
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He Q, Wang L, Peng C, Zou X, Zhan Q, Xu Y, Liu Q, Qian J, Gong L, Shen Y, Chen J. Modified prophylactic 5-fr pancreatic duct stent enhances the rate of spontaneous dislodgement: A multicenter randomized controlled trial. United European Gastroenterol J 2018; 6:1519-1526. [PMID: 30574322 DOI: 10.1177/2050640618804729] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/27/2018] [Indexed: 12/13/2022] Open
Abstract
Background and objectives Prophylactic pancreatic duct stent placement effectively reduces post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients, but the optimal stent remains unclear. We modified a 5-Fr, 3 cm pancreatic stent by removing the flange on the pancreatic side and compared the rate of spontaneous dislodgement and complications with the ordinary stent. Methods This was a randomized controlled trial at six tertiary endoscopic centers. Patients deemed high risk for post-endoscopic retrograde cholangiopancreatography pancreatitis randomly received modified or ordinary pancreatic stent. The primary outcome was spontaneous stent dislodgement at five days and 14 days. Secondary outcomes were the success rate of stent placement and complications. Results A total of 276 patients were randomly assigned to receive modified stents (mS group) and ordinary stents (oS group). The placement of a pancreatic stent was successful in all 276 patients. There were no significant differences between groups with respect to age, sex, major diagnosis, or indications for stenting. At five days the spontaneous dislodgement rate was 47.72% for the mS group and 15.67% for the oS group (p<0.001); at 14 days the rates were 84.21% and 42.65%, respectively (p < 0.001). Post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in 6.52% of all patients. There were no significant differences regarding the incidences of post-endoscopic retrograde cholangiopancreatography pancreatitis, hemorrhage or fever. Conclusions The modified short 5-Fr stent has a higher spontaneous dislodgement rate than ordinary pancreatic stent, thus obviating the need for endoscopic removal. The modified pancreatic stent does not increase the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis or other complications. The endoscopist can consider removing the flange on the pancreatic duct side for prophylactic pancreatic duct manipulation.
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Affiliation(s)
- Qibin He
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China.,Department of Gastroenterology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China.,Department of Gastroenterology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Chunyan Peng
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China.,Department of Gastroenterology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiaoping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China.,Department of Gastroenterology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Qiang Zhan
- Department of Gastroenterology, Wuxi People's Hospital Affiliated with Nanjing Medical University, Nanjing, China
| | - Yaping Xu
- Department of Gastroenterology, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, China
| | - Qiang Liu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Junbo Qian
- Department of Gastroenterology, The Second Affiliated Hospital of Nantong University, Nantong, China
| | - Lei Gong
- Department of Gastroenterology, The Affiliated Wuxi NO.2 Hospital of Nanjing Medical University, Wuxi, China
| | - Yingzhou Shen
- Department of Gastroenterology, People's Hospital of Maanshan, Maanshan, China
| | - Jianping Chen
- Department of Gastroenterology, The Third Affiliated Hospital of Soochow University, Changzhou, China
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11
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Zheng L, Wang X, Tao Q, Liang S, Wang B, Luo H, Zhang R, Zheng L, Yang S, Chen J, Pan Y, Guo X. Different pattern of risk factors for post-ERCP pancreatitis in patients with biliary stricture. Scand J Gastroenterol 2018; 53:604-610. [PMID: 29117728 DOI: 10.1080/00365521.2017.1392599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To identify possible risk factors associated with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in biliary stricture (BS), common bile duct stone (CBDS) and unselected patients. MATERIALS AND METHODS Consecutive ERCP patients with native papilla from January 2010 to December 2014 in Xijing Hospital were eligible. Patient-related and procedure-related parameters were collected retrospectively. The primary outcome was PEP. Univariate and multivariate logistic regression were used for data analysis. RESULTS Totally 3133 unselected patients were included. 695 (22.2%) had BS alone and 1893 (60.4%) had CBDS alone. PEP incidence was higher in BS group compared with CBDS group (6.8% vs. 3.8%, p = .001). Among patient-related factors, duodenal stenosis (OR, 2.74; 95%CI, 1.14-6.59) and hilar stricture (OR, 2.59; 95%CI, 1.41-4.77) were found to be independently associated with PEP in BS group. While female gender (OR, 2.11; 95%CI, 1.20-3.73) and normal total bilirubin (OR, 1.93; 95%CI, 1.13-3.32) were related to PEP in CBDS group. Among procedure-related factors, cannulation time ≥ 5 min (OR, 2.38; 95%CI, 1.06-5.33) and precut (OR, 3.20; 95%CI, 1.35-7.59) was respectively the only independent risk factor for PEP in BS and CBDS group. CONCLUSIONS Patients with BS and CBDS had different patterns of patient-related and procedure-related risk factors for PEP. The prophylaxis of PEP may need to be individualized based on different indications.
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Affiliation(s)
- Liang Zheng
- a Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Shaanxi , China
| | - Xiangping Wang
- a Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Shaanxi , China
| | - Qin Tao
- a Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Shaanxi , China
| | - Shuhui Liang
- a Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Shaanxi , China
| | - Biaoluo Wang
- a Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Shaanxi , China
| | - Hui Luo
- a Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Shaanxi , China
| | - Rongchun Zhang
- a Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Shaanxi , China
| | - Liyue Zheng
- a Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Shaanxi , China
| | - Shengye Yang
- a Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Shaanxi , China
| | - Jie Chen
- a Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Shaanxi , China
| | - Yanglin Pan
- a Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Shaanxi , China
| | - Xuegang Guo
- a Xijing Hospital of Digestive Diseases , Fourth Military Medical University , Shaanxi , China
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12
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Jin Z, Bie LK, Tang YP, Ge L, Shen SS, Xu B, Li T, Gong B. Endoscopic therapy for patients with pancreaticobiliary maljunction: a follow-up study. Oncotarget 2018; 8:44860-44869. [PMID: 28415772 PMCID: PMC5546526 DOI: 10.18632/oncotarget.16228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 03/07/2017] [Indexed: 02/07/2023] Open
Abstract
Background Data on the experience of endoscopic retrograde cholangiopancreatography (ERCP) in the management of pancreaticobiliary maljunction (PBM) is limited. Methods A retrospective review of patients with PBM who underwent therapeutic ERCP at our endoscopy center between January 2008 and January 2016 was performed. Demographic, clinical, radiological and endoscopic data was documented. Patients who underwent sphincterotomy were divided into dilated group and undilated group based on their common channel diameter. Results Sixty-three PBM patients underwent 74 ERCP procedures. The technical success rate was 97.3%. ERCP therapy significantly decreased the levels of elevated liver enzymes and bilirubin. After an average of 27 months follow-up, 7 patients (11.1%) were lost. The overall effective rate of ERCP therapy was 60.7% (34/56). Decline in severity and frequency of abdominal pain was significant. Procedure-related complications were observed in 5 (6.8%) cases. Between the dilated group and undilated group, no significant difference was observed in effective rate, adverse events and follow-up results. Conclusions ERCP can serve as a transitional step to stabilize PBM patients before definitive surgery. PBM patients with undilated common channel could benefit from sphincterotomy as well as those with dilated common channel.
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Affiliation(s)
- Zheng Jin
- Department of Gastroenterology, Digestive Endoscopy Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,First People's Hospital of Hangzhou, Hangzhou, Zhejiang, China
| | - Li-Ke Bie
- Department of Gastroenterology, Digestive Endoscopy Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan-Ping Tang
- First People's Hospital of Hangzhou, Hangzhou, Zhejiang, China
| | - Liang Ge
- Department of Gastroenterology, Shihezi People's Hospital, Shihezi, China
| | - Si-Si Shen
- The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Bin Xu
- Department of Gastroenterology, Digestive Endoscopy Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tao Li
- Department of Gastroenterology, Digestive Endoscopy Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Biao Gong
- Department of Gastroenterology, Digestive Endoscopy Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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13
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El Nakeeb A, El Hanafy E, Salah T, Atef E, Hamed H, Sultan AM, Hamdy E, Said M, El Geidie AA, Kandil T, El Shobari M, El Ebidy G. Post-endoscopic retrograde cholangiopancreatography pancreatitis: Risk factors and predictors of severity. World J Gastrointest Endosc 2016; 8:709-715. [PMID: 27909551 PMCID: PMC5114460 DOI: 10.4253/wjge.v8.i19.709] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 07/27/2016] [Accepted: 08/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To detect risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and investigate the predictors of its severity.
METHODS This is a prospective cohort study of all patients who underwent ERCP. Pre-ERCP data, intraoperative data, and post-ERCP data were collected.
RESULTS The study population consisted of 996 patients. Their mean age at presentation was 58.42 (± 14.72) years, and there were 454 male and 442 female patients. Overall, PEP occurred in 102 (10.2%) patients of the study population; eighty (78.4%) cases were of mild to moderate degree, while severe pancreatitis occurred in 22 (21.6%) patients. No hospital mortality was reported for any of PEP patients during the study duration. Age less than 35 years (P = 0.001, OR = 0.035), narrower common bile duct (CBD) diameter (P = 0.0001) and increased number of pancreatic cannulations (P = 0.0001) were independent risk factors for the occurrence of PEP.
CONCLUSION PEP is the most frequent and devastating complication after ERCP. Age less than 35 years, narrower median CBD diameter and increased number of pancreatic cannulations are independent risk factors for the occurrence of PEP. Patients with these risk factors are candidates for prophylactic and preventive measures against PEP.
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14
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Luo H, Zhao L, Leung J, Zhang R, Liu Z, Wang X, Wang B, Nie Z, Lei T, Li X, Zhou W, Zhang L, Wang Q, Li M, Zhou Y, Liu Q, Sun H, Wang Z, Liang S, Guo X, Tao Q, Wu K, Pan Y, Guo X, Fan D. Routine pre-procedural rectal indometacin versus selective post-procedural rectal indometacin to prevent pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography: a multicentre, single-blinded, randomised controlled trial. Lancet 2016; 387:2293-2301. [PMID: 27133971 DOI: 10.1016/s0140-6736(16)30310-5] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rectal indometacin decreases the occurrence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, the population most at risk and the optimal timing of administration require further investigation. We aimed to assess whether pre-procedural administration of rectal indometacin in all patients is more effective than post-procedural use in only high-risk patients to prevent post-ERCP pancreatitis. METHODS We did a multicentre, single-blinded, randomised controlled trial at six centres in China. Eligible patients with native papilla undergoing ERCP were randomly assigned in a 1:1 ratio (with a computer-generated list) to universal pre-procedural indometacin or post-procedural indometacin in only high-risk patients, with stratification by trial centres and block size of ten. In the universal indometacin group, all patients received a single dose (100 mg) of rectal indometacin within 30 min before ERCP. In the risk-stratified, post-procedural indometacin group, only patients at predicted high risk received rectal indometacin, immediately after ERCP. Investigators, but not patients, were masked to group allocation. The primary outcome was overall ocurrence of post-ERCP pancreatitis. The analysis followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT02002650. FINDINGS Between Dec 15, 2013, and Sept 21, 2015, 2600 patients were randomly assigned to universal, pre-procedural indometacin (n=1297) or risk-stratified, post-procedural indometacin (n=1303). Overall, post-ERCP pancreatitis occurred in 47 (4%) of 1297 patients assigned to universal indometacin and 100 (8%) of 1303 patients assigned to risk-stratified indometacin (relative risk 0·47; 95% CI 0·34-0·66; p<0·0001). Post-ERCP pancreatitis occurred in 18 (6%) of 305 high-risk patients in the universal group and 35 (12%) of 281 high-risk patients in the risk-stratified group (p=0·0057). Post-ERCP pancreatitis was also less frequent in average-risk patients in the universal group (3% [29/992]), in which they received indometacin, than in the risk-stratified group (6% [65/1022]), in which they did not receive the drug (p=0·0003). Other than pancreatitis, adverse events occurred in 41 (3%; two severe) patients in the universal indometacin group and 48 (4%; one severe) patients in the risk-stratified group. The most common adverse events were biliary infection (22 [2%] patients vs 33 [3%] patients) and gastrointestinal bleeding (13 [1%] vs ten [1%]). INTERPRETATION Compared with a risk-stratified, post-procedural strategy, pre-procedural administration of rectal indometacin in unselected patients reduced the overall occurrence of post-ERCP pancreatitis without increasing risk of bleeding. Our results favour the routine use of rectal indometacin in patients without contraindications before ERCP. FUNDING National Key Technology R&D Program, National Natural Science Foundation of China.
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Affiliation(s)
- Hui Luo
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Lina Zhao
- Department of Radiotherapy, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Joseph Leung
- Gastroenterology, Sacramento VA Medical Center, VANCHCS, Mather, and UC Davis Medical Center, Sacramento, CA, USA
| | - Rongchun Zhang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhiguo Liu
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiangping Wang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Biaoluo Wang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanguo Nie
- Department of Gastroenterology, Urumqi General Hospital of Lanzhou Military Region, Urumqi, China
| | - Ting Lei
- Department of Gastroenterology, Urumqi General Hospital of Lanzhou Military Region, Urumqi, China
| | - Xun Li
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Wence Zhou
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Lingen Zhang
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Qi Wang
- Department of Hepatobiliary Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Ming Li
- Department of Hepatobiliary Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yi Zhou
- Department of Gastroenterology, No 451 Military Hospital, Xi'an, China
| | - Qian Liu
- Department of Gastroenterology, No 451 Military Hospital, Xi'an, China
| | - Hao Sun
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shuhui Liang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaoyang Guo
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qin Tao
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
| | - Xuegang Guo
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
| | - Daiming Fan
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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15
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Zou XP, Leung JW, Li YH, Yao YL, Pei QS, Wu YL, He QB, Cao J, Ding XW. Comparison of sequential pancreatic duct guidewire placement technique and needle knife precut sphincterotomy for difficult biliary cannulation. J Dig Dis 2015; 16:741-6. [PMID: 26562073 DOI: 10.1111/1751-2980.12300] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/28/2015] [Accepted: 11/08/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Pancreatic duct guidewire placement (PDGP) includes double guidewire technique (DGT) and transpancreatic sphincterotomy (TPS). DGT can be switched to TPS with ease due to the existing guidewire in the pancreatic duct. In this study, we aimed to combine DGT and TPS as a single technique, named sequential PDGP, and to compare its performance with needle knife precut sphincterotomy (NKPS) in treating difficult biliary cannulation (BC). METHODS A total of 83 patients with difficult BC were enrolled in this study. Of these, 63 underwent sequential PDGP and 20 underwent NKPS. Cannulation success rate, cannulation time and endoscopic retrograde cholangiopancreatography (ERCP)-related complications were prospectively recorded and compared between the two groups. RESULTS Successful BC was achieved in 88.9% (56/63) of the patients in the sequential PDGP group compared with 70.0% (14/20) in the NKPS group (P = 0.095). Cannulation time was 7.49 ± 5.03 min in the sequential PDGP group and 10.60 ± 7.24 min in the NKPS group (P = 0.086). Post-ERCP pancreatitis occurred in 12.7% of patients in the sequential PDGP group and 10.0% in the NKPS group (P = 1.000). There was no significant difference in the rates of other complications (bleeding, perforation and cholangitis) between the two groups. CONCLUSIONS Sequential PDGP is a safe and effective alternative method to NKPS in cases of difficult BC. In those with failed standard cannulation, sequential PDGP can be considered when the guidewire is inadvertently inserted into the pancreatic duct or can be placed in the pancreatic duct without difficulty.
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Affiliation(s)
- Xiao Ping Zou
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
| | - Joseph W Leung
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province, China.,Division of Gastroenterology, Sacramento VA Medical Center, Mather, CA, USA
| | - Yun Hong Li
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
| | - Yu Ling Yao
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
| | - Qing Shan Pei
- Division of Gastroenterology, UC Davis Medical Center, Sacramento, CA, USA
| | - Yu Lin Wu
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
| | - Qi Bin He
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
| | - Jun Cao
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
| | - Xi Wei Ding
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
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