Pancreatits after endoscopic retrograde cholangio-pancreatography

Table 1 Studies assessing efficacy of pancreatic stents in prevention of post-ERCP pancreatitis

First author/yr	Study design	Patients	n	Pancreatitis rate without andwith pancreatic stent		P
				Without (%)	With (%)
Smithline 1993[15]	RCT	Pre-cut biliary ES, SOD, small ducts	93	18	14	0.299
Tarnasky 1998[16]	RCT	Biliary ES for SOD	80	26	7	0.03
Elton 1998[17]	Retrospective, case control	Pancreatic ES for all indications	194	12.50	0.70	< 0.003
Fogel 2002[18]	Retrospective, case control	Biliary +/- pancreatic ES for SOD	436	28.20	13.50	< 0.05
Norton 2002[19]	Retrospective, case control	Endosopic ampullectomy	28	11.10	20	> 0.05
Fazel 2003[20]	RCT	Difficult cannulation, biliary ES, SOD	76	28	5	< 0.05
Freeman 2004[21]	Prospective, case control	All attempted major papilla PD stents in high- risk therapeutic ERCP	225	66.70	14.40	0.06
Catalano 2004[22]	Retrospective, case control	Endoscopic ampullectomy	103	16.70	3.30	0.10
Harewood 2005[23]	Prospective, randomized, controlled	Endoscopic ampullectomy	19	33	0	0.02

RCT: randomized controlled trial; ES: endoscopic sphincterotomy; SOD: sphincter of Oddi dysfunction; PD: pancreatic duct.

Table 2 Pharmacalogical prevention of post-ERCP pancreatitis: targeted mechanisms, drug tested, quality of evidence, and overall results¹

Mechanism	Drug	Evidence	Average riskpatients	High riskpatients
Sphincter spasm	Ca++ channel blocker Lidocaine (topical) Nitroglycerine	B B B	Ineffective Ineffective Possibly effective in high dose	No data No data Ineffective
Infection	Antibiotics	B	Possible effective	No data
Contrast	Nonionic contrast	A	Ineffective	Ineffective
Toxicity	Corticosteroids	A	Ineffective	Ineffective
Inflammatory	Allopurinol	B	Ineffective	Ineffective
	PAF inhibitors	A	Ineffective	Ineffective
Cascade	IL-10	B	Ineffective	Ineffective
	Heparin derivatives	A	Ineffective	Ineffective
	NSAID	B	Possibly effective	No data
	Gabexate	A	Ineffective ( ≤ 6 h infusion)	Ineffective
		A	Effective (12-h infusion)	No data
Pancreatic secretions	Octreotide	A	Ineffective	No data
	Somatostatin	A	Ineffective ( ≤ 6-h infusion)	No data
		B	Possibly effective (12-24 h infusion)

PAF: Platelet activating factor; IL-10: interleukin 10; NSAID: non-steroidal anti-inflammatory drug. The level of evidence was graded by using a system adapted from Cook et al 17 as follows: Grade A supported by two or more randomized trials with P values < 0.05, appropriate methodology, and no conflicting results in the trials; Grade B supported by randomized trials with P values > 0.05, and/or inappropriate methodology, and/or inadequate sample sizes, and/or conflicting results among the trials; Grade C supported by non-randomized trials. ¹Adapted from Freeman and Guda[5].

Table 3 Suggested strategies for avoiding post-ERCP pancreatitis

Risk factors	Recommendations
Suspected SOD (sphincter of Oddi manometry is to be performed)	- Usage of an aspirating catheter technique is strongly recommended, particularly for pancreatic manometry. - Stent the pancreas after. - Do in high volume referral centers.
Difficult cannulation	- Once cannulation is begun, traumatic manipulation of the papilla should be kept to a minimum. - Placement of a pancreatic stents to assist biliary cannulation, should be considered.
Pre-cut sphincterotomy	- Should be used for biliary access only if the indication for therapy is relatively clear and the endoscopist is experienced in pre-cut techniques. - Strongly consider placement of temporary pancreatic stent before or after cutting.
During traction biliary and pancreatic sphincterotomy	- Biliary sphincterotomy should be oriented toward the region from 11:00 to 1:00 o’clock on the papilla (i.e., away from the pancreatic orifice). - Consider use of pure-cut current for pancreatic ES.
Balloon dilation of the intact biliary sphincter for stone extraction	- Should be avoided in routine practice, unless the risk of sphincterotomy is unusually high (e.g., patients with severe coagulopathy). - Stent the pancreas after.
Biliary stents	- Generally should not be placed through an intact biliary sphincter in patients with suspected SOD - When placing a plastic biliary stent > 7F for any reason, consider biliary ES first, to help prevent pancreatic orifice occlusion.
Pancreatic brush cytology	- Consider temporary pancreatic stent placement.
Patients with hilar tumors	- Biliary sphincterotomy is recommended before placement of transpapillary biliary stents.
Pancreatic duct injection	- Pancreatic injection should be avoided if the indication for ERCP pertains to the biliary tract alone.
and/or Pancreatic acinarization	- Avoid filling of the body and tail of the pancreas unless clinically needed. - Over injection (acinarization) of the pancreas should be avoided. - Use guidewire to aid view of duct entered (instead of repeat dye injection. - Limit pancreatic filling in obese patients or other settings with suboptimal fluoroscopic viewing.
High risk patients (normal serum bilirubin, female gender, recurrent abdominal pain, absence of biliary dilatation, conditions suggesting possible sphincter of Oddi dysfunction, prior post-ERCP pancreatitis, recurrent pancreatitis or absent chronic pancreatitis)	- Consider non-invasive imaging techniques such as MRCP, EUS, or laparoscopic cholecystectomy with intra-operative cholangiography. - Once a decision for ERCP need is made, the endoscopist should assess the risk profile of the patient and plan maneuvers and modify technique accordingly. - Consider referral to a high volume centers with the capability to reliably place protective small caliber pancreatic stents