Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis after Conservative Treatment for Symptomatic Bile Duct Stones

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) for asymptomatic common bile duct stones (CBDS) has been associated with an increased risk of post-ERCP pancreatitis (PEP). Patients with asymptomatic CBDS at the time of ERCP include those with incidentally discovered CBDS (group A) and previously symptomatic patients with CBDS who became asymptomatic after conservative treatment for symptomatic CBDS, including obstructive jaundice or acute cholangitis (group B). In this study, we aimed to examine PEP risk in group B by comparing PEP risks between groups A, B, and currently symptomatic patients (group C).

Methods

In this multicenter retrospective study, we examined 77 patients in group A, 41 patients in group B, and 1225 patients in group C who had native papillae. PEP incidence rates between asymptomatic patients at the time of ERCP (groups A and B) and symptomatic patients (group C) were compared using one-to-one propensity score matching. Bonferroni's correction analysis was also performed to compare PEP incidence rates among the three groups.

Results

As per our findings, PEP incidence rate in propensity score-matched groups A and B was significantly higher than that of propensity score-matched group C (13.2% [15/114] versus 4.4% [5/114], respectively, P = 0.033). In groups A and B, PEP incidence rates were 11.7% (9/77) and 14.6% (6/41), respectively. PEP risk in group B was similar to that in group A (P = 1.0). PEP incidence in group B was significantly higher than PEP incidence in group C (14.6% (6/41)) vs. 2.9% (35/1225)) (P = 0.005)).

Conclusions

ERCP for previously symptomatic patients with CBDS who became asymptomatic after conservative treatment for symptomatic CBDS may increase the risk of PEP compared with ERCP for currently symptomatic patients. Thus, ERCP should be performed before patients become asymptomatic using conservative treatments if patients can tolerate ERCP procedures.

Our experiences in 1000 case single-centre endoscopic retrograde cholangiopancreatography

Background

Endoscopic retrograde cholangiopancreatography (ERCP) has a very important role in both diagnosis and treatment of pancreaticobiliary pathologies. The aim of this study was to review the indications, technical success complications and results of ERCP procedures performed in our centre.

Materials and Methods

In the study, the data of 1000 patients who were diagnosed with extrahepatic cholestasis, obstructive cholangitis/pancreatitis or bile leakage in clinical, medical and radiological data and who underwent ERCP between May 2019 and November 2021 were evaluated retrospectively.

Results

The age distribution was between 14 and 109 years, and the average age was 57.97 years for women (14-109) and 57.48 for men (19-95). Gender distribution was as follows: 552 (55.2%) women and 448 (44.8%) men. ERCP indications in this study were as follows: choledocholithiasis, malignant bile duct obstruction, odysphincter dysfunction (ODS), post-operative bile leakage, hepatic hydatid cyst rupture into the biliary tract and bile duct stenosis. Eight hundred and seventy-one (87.1%) patients had common bile duct stones, 30 (3%) pancreatic head tumour, 22 (2.2%) common bile duct tumour and 20 (2%) cholestasis due to papilla tumour and/or obstructive icterus. Twenty-two (2.2%) patients were treated for sphincter dysfunction (ODS) of Oddi. ERCP was performed in 12 (1.2%) patients with the diagnosis of bile leakage after liver hydatid surgery, 10 (1%) after gall bladder surgery and 8 (0.8%) with the diagnosis of biliary tract stenosis after gall bladder surgery. ERCP was performed in 5 (0.5%) patients due to biliary tract obstruction as a result of rupture of hydatid liver cyst into the biliary tract. Successful cannulation was achieved in 1000 patients listed. Ninety-seven patients who were included in the ERCP procedure but could not be cannulated were not included in the study. Endoscopic sphincterotomy was performed on all patients in the ERCP procedure. In patients with choledochal stones, stone extraction from the common bile duct and/or plastic stent placement in the common bile duct was added. Plastic stent was placed in the common bile duct in patients with pancreatic head tumour, common bile duct tumour, bile duct leakage and common choledochal stenosis. Endoscopic biopsy was taken from all patients with suspected papillary tumour. The processing time varied between 15 and 90 min. The overall complication rate was 17.4%. After ERCP, 93 patients developed amylasaemia that did not require treatment, while 50 patients were diagnosed with clinical and laboratory acute pancreatitis. Intraoperative bleeding, which did not require blood transfusion and could be controlled with adrenaline injection and/or balloon pressure, developed in 10 patients. In one patient, basket and stone were stuck in the papilla during stone extraction. There was no operative mortality.

Conclusion

ERCP is a complex procedure that uses special equipment and must be performed by experienced specialists. To increase the reliability of the ERCP procedure, it is necessary to determine the risk factors for ERCP complications very well. Unnecessary ERCP should be avoided. ERCP should not be performed, especially in patients with low probability of stone or stricture, patients with normal bilirubin and patients who do not show other signs of biliary disease. The use of non-invasive imaging methods as much as possible instead of diagnostic ERCP will reduce the complications associated with ERCP.

Early and Direct Endoscopic Stone Removal in the Moderate Grade of Acute Cholangitis with Choledocholithiasis Was Safe and Effective: A Prospective Study

BACKGROUND

Evidence supporting the feasibility of single-stage stone removal in patients with a moderate grade of acute cholangitis remains insufficient. The maximal size of a common bile-duct stone suitable for removal during a single-stage ERCP in a moderate grade of acute cholangitis is unknown.

METHODS

We prospectively enrolled 196 endoscopic retrograde cholangiopancreatography (ERCP)-naïve patients diagnosed with acute cholangitis and choledocholithiasis. For eligible patients, single-stage treatment involved stone removal at initial ERCP.

RESULTS

A total of 123 patients were included in the final analysis. The success rate of complete stone extraction was similar between patients with mild and moderate grades of acute cholangitis (89.2% vs. 95.9%; p = 0. 181). Complication rates were comparable between the two groups. In the moderate grade of the cholangitis group, among patients who underwent early single-stage ERCP, the length of hospitalization declined as short as the patients in the mild grade of cholangitis (10.6 ± 6.2 vs. 10.1 ± 5.1 days; p = 0.408). In the multivariate analysis, early ERCP indicated shorter hospitalization times (≤10 days) (odds ratio (OR), 3.981; p = 0.001). A stone size less than 1.5 cm presented a high success rate (98.0%) for complete stone removal.

CONCLUSIONS

Single-stage retrograde endoscopic stone removal in mild and moderate grades of acute cholangitis may be safe and effective, which can obviate the requirement for a second session, thus reducing medical expenses.

CLINICALTRIALS

gov: NCT03754491.

Safety of Nonagenarians Receiving Therapeutic ERCP, Single Center Experience

(1) Background: The complication rates for nonagenarians receiving therapeutic endoscopic retrograde cholangiopancreatography (ERCP) remain poorly understood. We aimed to determine whether nonagenarians were at an increased risk of ERCP-related complications. (2) Methods: We performed a retrospective study on therapeutic ERCP in nonagenarians from 2011 to 2016 at Taichung Veterans General Hospital. A control group comprising patients aged 65 to 89 years was used to compare demographic data and the outcomes of therapeutic ERCP with the nonagenarians. The risk factors for complications were determined by logistic regression model. (3) Results: There were 35 nonagenarians and 111 patients in the control group. Overall, complication rates were not statistically different between the two groups. However, advanced age was an independent predictor of complications in the multivariate analysis (odds ratio [OR] = 1.06; 95% confidence interval [CI] = 1.01-1.12; p = 0.049). End stage renal disease (ESRD) was another independent predictor of complications (OR = 4.87; 95% CI = 1.11-21.36; p = 0.036). Post-ERCP pancreatitis and bleeding were more common in ESRD patients than patients without ESRD. (4) Conclusions: Although nonagenarians receiving ERCP did not have more complications compared to elderly patients younger than 90 years, advanced age and comorbidity still affect the outcome of therapeutic ERCP in the elderly patients.

A 25 mg rectal dose of diclofenac for prevention of post-ERCP pancreatitis in elderly patients

A 50-100 mg rectal dose of diclofenac or indomethacin is recommended for prophylaxis of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP); however, limited data are available regarding the appropriate dose to prevent PEP in elderly patients. We aimed to evaluate the efficacy and safety of 25 mg diclofenac in preventing PEP in elderly patients. Material and methods: Overall, 276 patients with naive papilla, aged over 75 years, were included in the present study between April 2013 and March 2020. We retrospectively evaluated the risk of PEP in patients over 75 years, administered with or without 25 mg diclofenac 30 min before ERCP using inverse probability of treatment weighting (IPTW) analysis. Results: Patients were categorized into the diclofenac group (83 patients) or non-diclofenac group (193 patients). The incidence rate of PEP in the diclofenac group was significantly lower than that in the non-diclofenac group (4% vs. 14%, p = .01). Multivariate analysis revealed that 25 mg diclofenac was an independent protective factor against PEP in elderly patients aged over 75 years (odds ratio [OR] = 0.17; 95% confidence interval [CI] = 0.04-0.67; p = 0.01). This protective effect of diclofenac against PEP remained robust after IPTW analysis (OR = 0.11; 95% CI = 0.03-0.40; p = .001). No adverse events related to diclofenac were observed. Conclusion: Diclofenac (25 mg) was considered effective and safe for preventing PEP in elderly patients. Our results may provide a new strategy for preventing PEP in elderly patients.

Role of SCO-792, A Novel Enteropeptidase Inhibitor, In the Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Acute pancreatitis is the most common iatrogenic dilemma of endoscopic retrograde cholangiopancreatography, and it is associated with significant morbidity and mortality. Several factors have been implicated in the pathogenesis of post-endoscopic retrograde cholangiopancreatography pancreatitis, and preventive measures were practiced accordingly. This study aims to refine the potential mechanisms that trigger post-endoscopic retrograde cholangiopancreatography pancreatitis and define the role of enteropeptidase in the pathogenesis of post-endoscopic retrograde cholangiopancreatography pancreatitis. Furthermore, address the role of a new novel medication known as SCO-792, a potent enteropeptidase inhibitor, in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

Post-endoscopic retrograde cholangiopancreatography pancreatitis is caused by premature activation of the pancreatic enzymes within the pancreatic parenchyma. This activation is either an autoactivation due to direct provocation of intra-acinar enzymes as a result of the procedure or due to activation by enterpeptidase, a rate-limiting enzyme. Endoscopic retrograde cholangiopancreatography interjects duodenal juice that is rich in enterokinase into the pancreatic-biliary tract, which in turn leads to intra-ductal activation of trypsinogen and subsequent enzymes. Given the vital role of enterokinase in initiating the pathogenesis of pancreatitis, enteropeptidase inhibition may prevent and reduce the severity of post-endoscopic retrograde cholangiopancreatography pancreatitis.

SCO-792, a novel enteropeptidase inhibitor, is developed by SCOHIA Pharma, and pre-clinical trials confirmed its efficacy in inhibiting enteropeptidase. Studies are needed to confirm the efficacy of enteropeptidase inhibitors in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis.

Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis by Endoscopic Pancreatic Stenting after Insertion of Self-Expandable Metal Stent for Malignant Distal Biliary Stricture

The insertion of a self-expandable metal stent (SEMS) for nonpancreatic cancer is a factor predicting the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). We evaluated the efficacy of endo-scopic pancreatic stenting (EPS) to prevent PEP after SEMS insertion in patients with malignant distal biliary stricture and without main pancreatic duct (MPD) obstruction. We performed a single-center, retrospective, historically controlled investigation to assess the outcomes of 33 consecutive patients who underwent SEMS insertion. From March 2013 to June 2015, 13 patients did not undergo EPS (Non-EPS group). The other 20 patients underwent EPS (EPS group) between July 2015 and August 2018. The background data demonstrated no significant differences. Except for one patient in the Non-EPS group, all patients underwent biliary sphinc-terotomy. The EPS group's PEP incidence was significantly lower (n = 1, 5%) than that of the Non-EPS group (n = 4, 31%) (p = 0.04). The median serum amylase and lipase levels after the procedure were significantly lower in the EPS group than in the Non-EPS group (amylase: 104 vs. 262 U/L; p < 0.01, lipase: 102 vs. 666 U/L; p = 0.01). The use of EPS decreased the incidence of PEP after SEMS insertion in individuals with malignant distal biliary stricture and without MPD obstruction.

Incidence and risk factors for post-ERCP pancreatitis in pancreas divisum patients without chronic pancreatitis

Aims: The studies on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in pancreas divisum (PD) patients without chronic pancreatitis (CP) are rare. In this study, we aimed to evaluate the incidence of PEP in PD patients without CP and the risk and protective factors for PEP.Methods: Consecutive patients with symptomatic PD that underwent ERCP from January 2005 to December 2017 were retrospectively analyzed. The patients were divided into PD without CP group and CP group. The basic information and medical records of patients were collected. The risk and protective factors for PEP in PD patients without CP were analyzed by univariate logistic analysis.Results: A total of 89 ERCP procedures were performed in 51 PD patients without CP, and 249 procedures in 136 patients with CP. The incidence of PEP was significantly higher in PD patients without CP than those with CP (15.7% vs. 5.6%, p = .005). Female gender were independent risk factors for PEP, while dorsal duct stent placement was a protective factor.Conclusion: CP may be a protective factor against PEP in PD patients. Female was a risk factor for PEP in PD patients and dorsal duct stent placement was a preventive factor that reduced the incidence of PEP in PD patients without CP.

Assessing spontaneous passage of prophylactic pancreatic duct stents by X-ray: is a radiology report adequate?

Background:

Pancreatic duct stents are frequently placed for prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis. Because of concern for possible secondary ductal changes from a retained stent, these stents need to be monitored and removed if retained. Usually an abdominal X-ray is performed to assess retained stent, and if present, an esophagogastroduodenoscopy is performed to remove the stent. Limited data is published on false-negative radiology reports for spontaneous passage of stents.

Methods:

Using an Institutional Review Board–approved stent log, a retrospective chart review of all pancreatic duct stents placed at our institution from 2008 to 2014 was performed.

Results:

A total of 856 pancreatic duct stents were placed during the study period. Of these, 435 (50.8%) were prophylactic stents and 421 (49.2%) were therapeutic. Complete follow-up data were available in 426 (97.9%) patients with prophylactic stents. Six patients (1.4%) were lost to follow up and three (0.7%) expired prior to removal. In all, 283 (66%) had follow-up imaging, with 167 (39.2%) having the official radiology read with no retained pancreatic duct stent in place. Eight of these cases were “false-negative” radiology interpretation (4.8% of cases read as “no stent,” NNH = 20). The stent was found either by review of image by an endoscopist or incidental stent discovery during a follow-up procedure.

Conclusion:

Radiologist interpretation of abdominal X-rays to assess spontaneous passage of prophylactic pancreatic ducts stents resulted in a false-negative interpretation in approximately 5% of cases. Independent review of the images by the endoscopist may be beneficial given unfamiliarity of these stents by radiologists.

Indomethacin down-regulating HMGB1 and TNF-α to prevent pancreatitis after endoscopic retrograde cholangiopancreatography

Background and aims: Several articles demonstrated that non-steroidal anti-inflammation drugs (NSAIDs) were effective in reducing the incidence of pancreatitis after endoscopic retrograde cholangiopancreatography (PEP). However, studies revealed inconsistent results. The mechanism of NSAIDs in preventing PEP is still little known. Therefore, the aim of our study was to evaluate the efficacy of NSAIDs for PEP prophylaxis and further to explore the mechanism of NSAIDs for prevention of PEP. Methods: Patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) were randomly assigned to receive 100 mg rectal indomethacin or glycerin suppository 15-20 min before ERCP. The primary outcome was the rate of PEP. And the levels of serum HMGB1 and TNF-α were also measured before ERCP and 3 and 24 h after ERCP. Univariate analysis and multivariate analysis were carried out to estimate the independent risk factors for PEP. Results: Totally, 100 patients were enrolled, 50 received indomethacin and 50 with placebo (glycerin suppository). PEP developed in six patients in indomethacin group and 16 in the control group, the difference was significant (p = .016). The levels of HMGB1 and TNF-α were significantly decreased in indomethacin group at 3 (p < .0001) and 24 h (p < .0001) after ERCP, compared to the control group. Multivariate analysis revealed that duration of ERCP (OR, 0.221; 95% CI, 0.072-0.680; p = .008) and usage of NSAIDs (OR, 0.278; 95% CI, 0.090-0.861; p = .026) were independent predictors of PEP. Conclusions: Rectal indomethacin could significantly reduce the risk of PEP by down-regulating the levels of HMGB1 and TNF-α.

Modified prophylactic 5-fr pancreatic duct stent enhances the rate of spontaneous dislodgement: A multicenter randomized controlled trial

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.

Pancreatic function following post-endoscopic retrograde cholangiopancreatography pancreatitis: A controlled cohort study with long-term follow-up

Background

Acute pancreatitis is one of the most common causes of gastrointestinal-related hospitalization and the incidence is increasing. Endo- and exocrine pancreatic function can be compromised after acute pancreatitis.

Objective

The purpose of this study was to explore the long-term consequences of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) on pancreatic function.

Methods

A follow-up study was carried out with prospective assessment of endo- and exocrine pancreatic function among cases with previous PEP and matched controls from a Danish cohort consisting of 772 patients undergoing first-time ERCP. Pancreatic function was evaluated by faecal-elastase-1 test, blood levels of haemoglobin A1c, C-peptide, vitamin B12, vitamin D and indirectly by changes in body weight.

Results

Twenty-nine cases and 49 controls participated in the study. Mean follow-up time (standard deviation) was 58 (21) months. Twelve (41%), eight (28%) and nine (31%) patients had mild, moderate and severe PEP, respectively. There was no difference between cases and controls with regard to pancreatic function parameters and PEP severity was not associated with pancreatic function. Factors associated with pancreatic function impairment included body mass index, alcohol consumption, age and smoking.

Conclusion

This study suggests that long-term pancreatic function following PEP is similar to the pancreatic function of other patients with comparable gallstone-related morbidity.

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.

A comparison of 4-Fr with 5-Fr endoscopic nasopancreatic drainage catheters: A randomized, controlled trial

BACKGROUND AND AIM

Although endoscopic nasopancreatic drainage (ENPD) is useful for collecting samples for pancreatic juice cytology and for treating leakage of pancreatic juice and occlusive pancreatitis, placement of the ENPD catheter is associated with complications such as post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). We investigated whether an ENPD catheter with a smaller diameter could reduce the incidence of complications.

METHODS

Patients requiring placement of an ENPD catheter (n = 254) were enrolled and randomly assigned to one of two catheter-size groups: the 4-Fr group or the 5-Fr group. The incidence of PEP, cholangitis, and spontaneous catheter displacement and the suitability of pancreatic juice cytology samples were compared between groups. In addition, univariate and multivariate analyses were conducted on factors associated with PEP.

RESULTS

The incidence of PEP was significantly lower in the 4-Fr group compared with the 5-Fr group (4.1% vs 12.4%, respectively; P = 0.021). The rate of cholangitis and spontaneous catheter displacement and the suitability of pancreatic juice cytology samples did not differ between groups. Multivariate analysis revealed that the risk of PEP was 3.7 times higher when using a 5-Fr catheter than when using a 4-Fr catheter (P = 0.019). In addition, the risk of PEP was 4.1 times higher in patients with an intraductal papillary mucinous neoplasm than in those without (P = 0.0049) and 4.6 times higher in patients aged <65 than in those aged ≥65 (P = 0.0033).

CONCLUSIONS

A 4-Fr catheter is as useful as a 5-Fr catheter and is associated with a significantly lower incidence of PEP.

Effectiveness and tolerability of NSAIDs in the prophylaxis of pancreatitis after endoscopic retrograde cholangiopancreatography: A systematic review and meta-analysis

BACKGROUND

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). The beneficial effects of pharmaco-logic treatment of acute pancreatitis are unclear. Although the prophylactic use of NSAIDs for the reduction of the risk for pancreatic injury after ERCP has been assessed, the beneficial effects of NSAIDs on pancreatic injury are still being debated.

OBJECTIVE

The aim of this study was to determine the effectiveness and tolerability of NSAIDs in the prophylaxis of post-ERCP pancreatitis (PEP).

METHODS

MEDLINE (January 1966-January 2009), EMBASE (January 1966-January 2009), and the Cochrane Central Register of Controlled Trials (Issue 1, 2009) were searched using the key terms: pancreatitis, post-ERCP pancreatitis, nonsteroidal anti-inflammatory drugs, indomethacin, and diclofenac. The methods recommended by the Cochrane Collaboration and the Quality of Reporting Meta-Analyses guideline were used to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) of NSAIDs in the prevention of PEP.

RESULTS

Four multinational RCTs were included in the meta-analysis (969 patients). The pooled odds ratio for NSAIDs for mild PEP was 0.69 (95% CI, 0.40-1.17; P = NS); moderate to severe PEP, 0.22 (95% CI, 0.05-1.01; P = 0.05); PEP (pooled), 0.44 (95% CI, 0.21-0.93; P = 0.03); in high-risk patients, 0.49 (95% CI, 0.17-1.39; P = NS); and in low-risk patients, 0.29 (95% CI, 0.12-0.71; P = 0.006). No evidence of publication bias was found.

CONCLUSION

Based on the findings from the present systematic review of 4 RCTs, NSAIDs were effective and well tolerated in the prevention of PEP, especially in low-risk patients.

Somatostatin administration prior to ERCP is effective in reducing the risk of post-ERCP pancreatitis in high-risk patients

Somatostatin has been extensively studied for the prophylaxis of pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). However, the results remain controversial. The present retrospective cohort study aimed to investigate the efficacy of pre- and post-ERCP somatostatin administration in the prevention of post-ERCP pancreatitis (PEP). All ERCP procedures performed at one hospital between January 2009 and December 2012 were reviewed. They were divided into three groups based on somatostatin administration: pre-ERCP som group (somatostatin administration: 0.25 mg/h for 24 h, starting 1 h prior to ERCP), post-ERCP som group (somatostatin administration: 0.25 mg/h for 24 h, starting immediately following ERCP), and control group (no somatostatin administration). Out of a total of 304 cases, 81 received pre-ERCP somatostatin; 126 received post-ERCP somatostatin and 97 were not administered somatostatin. Pre-ERCP somatostatin was effective in reducing the incidence of PEP compared with that in the control group (4.9 vs. 16.5%; P=0.017). This benefit was significant in high-risk patients (8.9 vs. 26.0%; P=0.035), but not in low-risk patients (0 vs. 6.4%; P=0.254). Post-ERCP somatostatin was not effective in preventing PEP in high- or low-risk patients. In conclusion, pre-ERCP somatostatin may be effective in reducing the risk of PEP in high-risk patients, but not in low-risk patients. Post-ERCP somatostatin did not reveal a benefit in high- or low-risk patients. However, large randomized controlled trials are required to further confirm these findings.

Gabexate mesylate in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis update

BACKGROUND

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP), and the benefit of pharmacologic treatment of the condition is unclear. Although prophylactic use of gabexate mesylate (GM) for the reduction of pancreatic injury after ERCP has been evaluated, uncertainty remains regarding the effectiveness of GM treatment in post-ERCP pancreatitis (PEP).

OBJECTIVE

The aim of this study was to determine through systematic review and meta-analysis the effectiveness and tolerability of GM in the prophylaxis of PEP.

METHODS

MEDLINE (January 1966-July 2007), EMBASE (January 1966- July 2007), the Cochrane Controlled Trials Register on The Cochrane Library (Issue 2, 2007), and the China Biological Medicine Database (January 1978-July 2007) were searched. We used the method recommended by The Cochrane Collaboration to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) of GM in the prevention of PEP.

RESULTS

Of the 38 studies identified, 31 were excluded for the following reasons: they were reviews or editorials (9 articles); were meta-analyses (4); had differences in cointerventions (4); were nonrandomized controlled trials or had incorrect randomization (4); were repeat publications (2); lacked a placebo group (1); or other (7). Seven RCTs, totaling 2883 patients, conducted in a variety of languages were included in the meta-analysis. When the RCTs were analyzed, odds ratios for GM were 0.65 (95% CI, 0.36-1.18; P 0.16) for PER 1.90 (95% CI, 0.54-6.65; P 0.32) for severe PEP, 0.55 (95% CI, 0.17-1.77; P 0.32) for the case-fatality ratio of PEP, 0.88 (95% CI, 0.74-1.05; P 0.16) for post-ERCP hyperamylasemia, and 0.78 (95% CI, 0.49 1.25; P 0.30) for post-ERCP abdominal pain. No evidence of publication bias was found.

CONCLUSIONS

No beneficial effects of GM on acute pancreatitis, the PEP mortality rate, or post-ERCP abdominal pain or hyperamylasemia were found; therefore, GM cannot be recommended for the prophylaxis of PEP.

Comparative study of 4 Fr versus 6 Fr nasobiliary drainage catheters: a randomized, controlled trial

BACKGROUND AND AIM

Despite the benefits of endoscopic nasobiliary drainage (NBD) in endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP pancreatitis (PEP) and nose/throat discomfort can result. We aimed to determine whether the use of a smaller catheter alleviates these complications.

METHOD

A randomized, controlled trial at a tertiary care center compared 4 Fr and 6 Fr NBD catheters; 165 ERCP patients with naïve papillae were randomly assigned to a catheter-size group.

RESULTS

The prevalence of PEP was significantly lower in the 4 Fr group (3.7%; 3/82) than in the 6 Fr group (15.7%; 13/83; P = 0.019). No spontaneous catheter displacement occurred within 24 h. Discomfort visual analog scores were 2.6 and 4.3 in the 4 Fr and 6 Fr groups, respectively (P = 0.0048) on procedure day; on the following day, the scores were 2.3 and 3.6 (P = 0.028). Bile output was 16.3 mL/h and 21.4 mL/h in the 4 Fr and 6 Fr groups (P = 0.051). On obstructive jaundice subgroup analysis, bile drainage was 19.2 mL/h and 22.1 mL/h in the 4 Fr and 6 Fr groups (P = 0.40). The 4 Fr group required 5.6 days to reduce bilirubin levels versus 6.1 days in the 6 Fr group (P = 0.51).

CONCLUSIONS

In patients with naïve papillae, lower rates of PEP and less nose/throat discomfort are associated with the use of 4 Fr NBD catheters. In patients with obstructive jaundice, 4 Fr and 6 Fr catheters are comparable with regard to bile output and bilirubin level reduction.