Update in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis

Of all the possible complications associated with endoscopic retrograde cholangiopancreatography (ERCP), acute pancreatitis undoubtedly represents the heaviest burden for patients and healthcare professionals. The overall incidence, ranging from 3.5% to around 10%, and annual estimated costs exceeding $150 million in the USA should signal caution for everyone carrying out ERCP. In-depth knowledge of the risk factors and the pharmacological and endoscopic treatment options is required to avoid this adverse event. In this review, we evaluate the relevant data published in the literature since the appearance of the latest recommendations of the leading gastroenterological societies. Thus, we intend to provide a comprehensive and up-to-date overview of the factors to consider and possible interventions applicable before and after the intervention to prevent the development of post-ERCP pancreatitis.

Quality of life after endoscopic procedures for chronic pancreatitis: A multicentre study

BACKGROUND

Chronic Pancreatitis (CP) causes morphological changes in the pancreatic tissue, leading to complications and pain, which may require endoscopic interventions.

OBJECTIVE

Our aim was to determine the frequency of endoscopic procedures (EP) in CP patients and to analyse pain and quality of life (QoL) in these patients after their EP.

METHODS

This study included 1327 CP patients from the Scandinavian Baltic Pancreatic Club (SBPC) database including four countries and eight centres. We analysed patients undergoing EPs and gathered information on the EP, pancreatic function, pain, disease and duration. The EORTC C-30 QoL questionnaire was gathered prospectively and multivariable analysis was conducted on independent parameters between the groups. The reference population had no interventions (n = 870).

RESULTS

260 CP patients (22%) underwent EPs, median one year (range 0-39 years) after CP diagnosis. 68% were males. The median age was 59 (20-90) years. Most common aetiological factors were alcohol in 65% and smoking in 71%. Extracorporeal shock wave lithotripsy (ESWL) was used in 6% of the CP population and in 21% of the EP group. Biliary duct stenting was performed on 37% and pancreatic stenting was performed on 56% of the patients. There was no difference in pain patterns between patients who had pancreatic stenting and the reference population. The EP group had slightly better QoL (p = 0.047), functioning and fewer symptoms than the reference population, in the multivariable analysis there was no interaction effect analysis between the groups. The pancreatic stent group had better QoL and the same amount of pain than the reference group. The patients who needed later surgery (23%) had more pain (p = 0.043) and fatigue (p = 0.021).

CONCLUSIONS

One in five of the CP patients underwent EP. These patients scored higher on QoL responses and had better symptom scores. CP patients who had pancreatic stenting performed had the same pain patterns as the reference population. Randomised prospective trials are needed to determine the effect of endoscopy procedures on CP patients.

Case report: Endoscopic retrieval of a proximally migrated pancreatic stent using the basket-through- the-sphincterotome technique

Background

The retrieval of a proximally migrated pancreatic duct (PD) stent via endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging, often requiring surgical intervention. We report a case with proximal migration of a pancreatic stent that was successfully removed by a basket-through-the-sphincterotome technique.

Case presentation

A 46-year-old man with prior history of chronic pancreatitis was admitted to our hospital with 1 month history of epigastric discomfort. 9 months prior he had undergone ERCP with Endoscopic sphincterotomy (EST) and a 5 Fr × 9 cm plastic pancreatic stent placement to relieve pancreatic duct stricture and abdominal pain. Magnetic retrograde cholangiopancreatography (MRCP) done this time revealed PD dilation and a stent-shaped signal inside the PD. The subsequent endoscopic ultrasonography (EUS) verified total pancreatic stent proximal migration with no visible distal end of the stent in the papilla. ERCP was performed again with an attempt to retrieve the stent. General techniques of PD cannulation with a 0.035-in guidewire over the migrated stent and balloon extraction failed. We used a mini-basket (Endoflex Germany) to replace the guidewire, which was inserted into the PD and advanced over the proximal end of the stent through the channel of the sphincterotome. The distal end of the stent was easily caught by manipulating the tip of the sphincterotome, and the stent was then pulled out. A naso-pancreatic drainage tube was placed in the main PD, and the patient was discharged 2 days after tube withdrawal.

Conclusion

This was a successful case of proximally migrated pancreatic stent retrieval using the unique idea of basket-through-the-sphincterotome technique, which has rarely been reported. The basket-through-the-sphincterotome technique provides the endoscopist another way to catch the distal end without difficulty. It can improve the success rate of proximally migrated pancreatic stent retrieval, especially the pig-tail pancreatic stent, of which the sticking of the proximal end into pancreatic duct branches often makes the distal end the only choice to retrieve.

Prophylactic effect of rectal indomethacin plus nitroglycerin administration for preventing pancreatitis after endoscopic retrograde cholangiopancreatography in female patients

BACKGROUND

Prophylactic pancreatic stent placement (PSP) and rectal indomethacin suppository are recommended to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk cases. Clinical trials on the use of nitroglycerin to reduce PEP have reached no definitive conclusion. Our study aimed to determine whether treatment with rectal indomethacin plus nitroglycerin could eliminate the need for PSP in patients.

METHODS

In this randomized clinical trial, patients were allocated into groups using a random number table, with each patient receiving a pre-made envelope containing their intervention prior to ERCP. The three treatment groups were: the placebo group, the indomethacin + nitroglycerin group, and the PSP group. The subjects were assessed for PEP and its severity by a panel of independent and blinded adjudicators.

RESULTS

A total of 526 patients were eligible for inclusion. The placebo group included 176 patients, the indomethacin + nitroglycerin group included 176 patients and the PSP group included 174.A diagnosis of PEP was made in 64 (12.2%) cases. The rate of PEP in the three study groups placebo group, indomethacin + nitroglycerin group and the PSP group was 19.3%, 5.1%, and 12.1%, respectively.

CONCLUSIONS

The risk of post-ERCP pancreatitis in the indomethacin + nitroglycerin group was 7% lower than that in the PSP. Indomethacin + nitroglycerin is superior to PSP in preventing and relieving the severity of post-ERCP pancreatitis in patients with difficult intubation. Indomethacin plus nitroglycerin can avoid the need for PSP in the prevention of post-ERCP pancreatitis.

TRIAL REGISTRATION

Current Controlled Trials ChiCTR2000033944.

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

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

Placement of Palliative Stent With Guidance of a Percutaneous Transhepatic Stent

The incidence of pancreatic cancer has increased and outcomes have been improving with a multidisciplinary treatment approach. Pancreatoduodenectomy is the surgical approach for pancreatic head tumors; however, postoperative cholestasis or cholangitis may require endoscopic or percutaneous intervention. Placement of a percutaneous transhepatic cholangiographic (PTC) drain is a safe approach; however, this requires routine maintenance. This case demonstrates placement of a palliative biliary stent by a rendezvous approach using an in situ PTC drain.

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.

Fully covered self-expanding metal stents for benign refractory pancreatic duct strictures in chronic pancreatitis

Background: Pancreatic duct (PD) stricture is a common adverse event in chronic pancreatitis (CP). Primary treatment for refractory PD strictures is endotherapy (ET), including the insertion of multiple plastic stents. In addition, fully covered self-expandable metal stents (FC-SEMSs) have also been successfully used. More long-term studies are necessary to clarify the complication rate and efficiency, however. Methods: This retrospective study was comprised of 17 patients with symptomatic CP and refractory fibrotic main pancreatic duct (MPD) stricture treated with FC-SEMSs between 2010-2018 at the Helsinki University Hospital. Treated strictures were located in the pancreatic head. Technical success was defined as the accurate positioning of the stent and resolution of the MPD stricture. Clinical success was defined as pain relief at the end of the follow-up. Results: In 12 patients (71%), stricture resolution was accomplished. Clinical success was achieved in 12 patients (71%). The median duration of stenting was 169 days (range 15-804). Ten patients (58.8%) underwent a follow-up of two years or more. Early complications (≤7 days) occurred in two patients (12%): one pancreatitis and one cholestasis. Late complications (≥7 days) included severe abdominal pain (n = 2, 12%), pancreatitis (n = 3, 18%), cholestasis (n = 1, 6%) and stent migration (n = 7, 35%). Significant differences in stricture resolution and pain improvement were evident in patients with stent migration compared to patients without stent migration [1(14.3%) vs. 11(84.6%), p = .004 and 2(28.6%) vs. 11(84.6%), p = .022]. Conclusion: FC-SEMS placement is a safe and potentially effective treatment for this challenging group of patients. However, stent migration appears to affect the clinical and technical outcome.

Successful ERCP for management of traumatic pancreatic disruption in a patient with situs inversus

Endoscopic retrograde cholangio-pancreatography (ERCP) is an important tool for treatment of pancreaticobiliary diseases. However, ERCP may be difficult in patients who have altered gastrointestinal anatomy due to congenital or surgical reasons. A 40-year-old male with HIV infection presented with abdominal pain following abdominal trauma. The patient was diagnosed to have traumatic pancreatic injury and underlying situs inversus. The pancreatic fluid collection was drained using radiology guided pigtail placement done for the symptoms of abdominal pain and vomiting. The resulting external pancreatic fistula was successfully managed with ERCP and stenting. The patient improved with disappearance of ascites and resolution of pigtail output which was then removed. We report the technique used for ERCP in this patient. We also review the literature on pancreatic endotherapy in patients with situs inversus. The published literature suggests that with modifications in the standard ERCP technique like mirror image technique, 180 degree turn technique, left lateral technique etc. these patients can be managed successfully.

Modified transprepancreatic septotomy reduces postoperative complications after intractable biliary access

This study aimed to assess the clinical value of transprepancreatic septotomy indwelling guide wire or pancreatic duct stent in intractable endoscopic retrograde cholangiopancreatography (ERCP) for bile duct cannulation.Of the 2107 patients treated by ERCP, a total of 81 cases with difficult bile duct cannulation underwent transprebiliopancreatic septotomy (referred to as the septotomy group, 37 cases) and transprepancreatic septotomy with pancreatic duct stent (modified septotomy group, 44 cases). Success rates of cannulation and postoperative complications for both methods were compared.Among them, 77 cases were successfully administered bile duct cannulation. The success rates of the septotomy and modified septotomy groups were 91.89% and 97.73%, respectively, with no significant difference (P = .489). Of the 77 patients, 12 cases had complications. The septotomy group included 7 acute pancreatitis, 1 bleeding, and 1 biliary tract infection cases; while in the modified septotomy group, there were 1 acute pancreatitis, 1 bleeding, and 1 biliary tract infection cases. The occurrence rate of acute pancreatitis in the modified septotomy group was lower than that of the septotomy group (2.33% vs 20.59%) with a significant difference (P = .026).These findings indicate that transprepancreatic septotomy with pancreatic duct stent seems to be a safe and feasible operation with reducing complication rates.

Risk factors of post- endoscopic retrograde cholangiopancreatography pancreatitis in biliary type sphincter of Oddi dysfunction in Japanese patients

OBJECTIVE

Suspected sphincter of Oddi dysfunction (SOD) is a well-known risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The indication of ERCP for suspected SOD patients was very low in Japan compared to other countries. Therefore, the risk of PEP may be different in Japanese SOD patients. The objective of this study was to evaluate the risk of PEP in suspected biliary type SOD in Japan.

METHODS

From December 1996 to January 2017, 72 patients were suspected as having biliary type SOD, by questionnaire, liver function tests, hepatobiliary scintigraphy, abdominal ultrasonography, upper gastrointestinal endoscopy, endoscopic ultrasonography and magnetic resonance cholangiopancreatography. Finally, 60 patients who underwent ERCP were included in this study, and the factors associated with PEP were evaluated.

RESULTS

The overall PEP rate was 23.3% (n = 14). Diagnostic ERCP alone for SOD did not increase the risk of PEP. The correlation of PEP incidence with pancreatic duct guidewire (PGW) technique and endoscopic sphincterotomy (EST) was indicated in univariate and multivariate analysis. Pancreatic stent placement was a risk in univariate analysis but not in multivariate analysis.

CONCLUSIONS

PGW technique and EST for biliary type SOD were important risk factors for PEP. Pancreatic stenting was ineffective for prevention of PEP.

Endoscopic wire-guided papillectomy versus conventional papillectomy for ampullary tumors: A prospective comparative pilot study

BACKGROUND AND AIM

A major concern about endoscopic snare papillectomy (ESP) is the risk of procedure-related pancreatitis. To maintain pancreatic duct access for stent placement after ESP, wire-guided ESP (WP) was introduced. The aim of the study was to compare post-procedure pancreatitis rates, the success rate of pancreatic stent insertion, and complete resection rates between WP and conventional ESP (CP) procedures.

METHODS

This was a multi-center, prospective, randomized pilot study. Forty-five patients with ampullary tumors were randomly assigned to a WP group (n = 22) or a CP group (n = 23). In the WP group, a guidewire was placed in the pancreatic duct prior to ESP. A 5-Fr pancreatic stent was passed over the guidewire and placed across the pancreatic duct orifice.

RESULTS

Complete resection was achieved in 20 patients (91%) in the WP group and 18 patients (78%) in the CP group (P = 0.414). A pancreatic stent was placed successfully in all patients in the WP group but in only 15 patients (65%) in the CP group (P = 0.004). Post-papillectomy pancreatitis occurred in four (18%) patients in the WP and three (13%) patients in the CP groups (P = 0.960). In the CP group, three of eight (37.5%) patients without stents developed pancreatitis compared with zero of 15 patients with stents (P = 0.032).

CONCLUSIONS

The WP method is a useful technique used to insert a pancreatic stent after ESP, compared with CP. However, there was no significant difference in the post-procedure pancreatitis or complete resection rates between the two methods.

A modern approach to ERCP: maintaining efficacy while optimising safety

BACKGROUND AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging and complications such as post-ERCP pancreatitis (PEP) remain a concern. Modern ERCP techniques aim to maintain efficacy and improve safety. There are limited data regarding efficacy and safety of ERCP carried out by a newly qualified practitioner using modern techniques. The aim of the present study was to conduct an ERCP practice audit and compare it with an Australian national survey in order to review the evidence base underlying modern ERCP practice.

METHODS

All ERCP carried out by a newly qualified practitioner, using prospectively collected data, from September 2011 to May 2015, were audited. Outcomes were compared to an Australia-wide survey of ERCP practice. A literature review was carried out regarding recent developments in ERCP practice.

RESULTS

Audit results correlated well with national data. All 478 ERCP were therapeutic and had pre-procedure imaging. Wire-guided biliary cannulation was used. Success rate was 97%. Overall adverse-event rate was 0.8%. Choledocholithiasis was the predominant indication (72%). Biliary cannulation was successful in 338 of 348 naiive papillae. Of these, there were 53 (16%) difficult cannulations but the needle-knife sphincterotomy (NKS) rate was low compared to national data (13% vs 33%). Rate of dual-wire cannulation technique was higher (87% vs 30%). Pancreatic duct stenting (done in 32 cases [70% of dual-wire cannulation cases]) and rectal indomethacin (25%) were used to reduce PEP risk.

CONCLUSIONS

A newly qualified ERCP proceduralist achieved high success rates with minimal adverse events using modern techniques. Practice was consistent with national data, although dual-wire cannulation technique was preferred to NKS. Evidence base for modern ERCP techniques was reviewed. ERCP efficacy and safety should be monitored by practice audit.

Unusual foreign body in the sigmoid colon, chronic alcohol abuse, and Fournier gangrene: a case report

Fournier gangrene (FG) is an infectious condition with fulminant evolution and is sometimes life-threatening. Here, we present the case of an immunocompromised 59-year-old male with surgical history of a pancreatic pseudocyst stented endoscopically. After unrecognized stent migration in the sigmoid without colonic perforation, he developed severe necrosis of the scrotum and perineum, which spontaneously perforated, presenting a smell suggesting moist gangrene. FG that has spread to the male genital organs presents therapeutic challenges. The purpose of our study is to present this case, typical for FG, with an educational aim both for the internal and surgical specialties, and the goal of further multidisciplinary collaboration for the optimal management of the patient with personalized treatment.

Risk of pancreatitis after endoscopic retrograde cholangiopancreatography and endoscopic biliary drainage

BACKGROUND

Pancreatitis is the most common and serious complication to occur after endoscopic retrograde cholangiopancreatography (ERCP). It is often associated with additional diagnostic modalities and/or treatment of obstructive jaundice. The aim of this study was to determine the risk of post-ERCP pancreatitis associated with pancreaticobiliary examination and endoscopic biliary drainage (EBD).

METHODS

A total of 740 consecutive ERCP procedures performed in 477 patients were analysed for the occurrence of pancreatitis. These included 470 EBD procedures and 167 procedures to further evaluate the pancreaticobiliary tract using brush cytology and/or biopsy, intraductal ultrasound and/or peroral cholangioscopy or peroral pancreatoscopy. The occurrence of post-ERCP pancreatitis was analysed retrospectively.

RESULTS

The overall incidence of post-ERCP pancreatitis was 3.9% (29 of 740 procedures). The risk factors for post-ERCP pancreatitis were: being female (6.5%; odds ratio [OR] 2.5, P= 0.02); first EBD procedure without endoscopic sphincterotomy (ES) (6.9%; OR 3.0, P= 0.003), and performing additional diagnostic procedures on the pancreatobiliary duct (9.6%; OR 4.6, P < 0.0001). Pancreatitis after subsequent draining procedures was rare (0.4%; OR for first-time drainage 16.6, P= 0.0003). Furthermore, pancreatitis was not recognized in 59 patients who underwent ES. Seven patients with post-EBD pancreatitis were treated with additional ES.

CONCLUSIONS

Invasive diagnostic examinations of the pancreaticobiliary duct and first-time perampullary biliary drainage without ES were high-risk factors for post-ERCP pancreatitis. Endoscopic sphincterotomy may be of use to prevent post-EBD pancreatitis.