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Okumura M, Koga H, Eguchi H, Sato N, Utsunomiya R, Wakahara Y, Morimoto K, Sugiyama K. Ascending colon perforation by a migrated pancreatic spontaneous dislodgment stent: a case report. Clin J Gastroenterol 2025; 18:383-388. [PMID: 39953361 DOI: 10.1007/s12328-025-02101-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2024] [Accepted: 01/25/2025] [Indexed: 02/17/2025]
Abstract
Here, we report a case of a 74-year-old woman treated for acute cholecystitis. She initially underwent percutaneous transhepatic gallbladder drainage; however, cholecystitis recurred when the drain was clamped. Therefore, endoscopic transpapillary gallbladder drainage (ETGBD) was performed. Endoscopic sphincterotomy was performed, and a transpapillary gallbladder stent was placed. Additionally, a pancreatic spontaneous dislodgment stent (PSDS) was inserted to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. Cholecystitis resolved, and the patient was discharged seven days later. Twenty-five days after ETGBD, she experienced abdominal pain, and computed tomography revealed ascending colon perforation by the migrated PSDS. She underwent laparoscopic surgery, in which the perforation was sutured, and an ileostomy was performed. The postoperative course was uneventful, and colonoscopy performed two months after surgery revealed multiple diverticula in the ascending colon. PSDS-induced gastrointestinal perforations are extremely rare. Previous case reports have suggested that perforation is caused by long-term stent retention in the gastrointestinal tract due to obstructions, such as peritonitis carcinomatosa or postoperative adhesions. We believe that in this case, the PSDS was retained because of multiple colonic diverticula. PSDS should be used with caution in patients with multiple colonic diverticula, peritonitis carcinomatosa, and postoperative adhesions.
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Affiliation(s)
- Mari Okumura
- Department of Gastroenterology and Hepatology, Iseikai International General Hospital, 4-14 Minami-Ogimachi, Kita-Ku, Osaka-Shi, Osaka, 530-0052, Japan
| | - Hideaki Koga
- Department of Gastroenterology and Hepatology, Iseikai International General Hospital, 4-14 Minami-Ogimachi, Kita-Ku, Osaka-Shi, Osaka, 530-0052, Japan.
| | - Hiroki Eguchi
- Department of Gastroenterology and Hepatology, Iseikai International General Hospital, 4-14 Minami-Ogimachi, Kita-Ku, Osaka-Shi, Osaka, 530-0052, Japan
| | - Naoto Sato
- Department of Gastroenterology and Hepatology, Iseikai International General Hospital, 4-14 Minami-Ogimachi, Kita-Ku, Osaka-Shi, Osaka, 530-0052, Japan
| | - Ran Utsunomiya
- Department of Gastroenterology and Hepatology, Iseikai International General Hospital, 4-14 Minami-Ogimachi, Kita-Ku, Osaka-Shi, Osaka, 530-0052, Japan
| | - Yuhei Wakahara
- Department of Gastroenterology and Hepatology, Iseikai International General Hospital, 4-14 Minami-Ogimachi, Kita-Ku, Osaka-Shi, Osaka, 530-0052, Japan
| | - Kazuhiro Morimoto
- Department of Gastroenterology and Hepatology, Iseikai International General Hospital, 4-14 Minami-Ogimachi, Kita-Ku, Osaka-Shi, Osaka, 530-0052, Japan
| | - Kohei Sugiyama
- Department of Gastroenterology and Hepatology, Iseikai International General Hospital, 4-14 Minami-Ogimachi, Kita-Ku, Osaka-Shi, Osaka, 530-0052, Japan
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Michael FA, Feldmann C, Erasmus HP, Kubesch A, Goerguelue E, Knabe M, Abedin N, Heilani M, Hessz D, Graf C, Walter D, Finkelmeier F, Mihm U, Lingwal N, Zeuzem S, Bojunga J, Friedrich-Rust M, Dultz G. A novel ultrasound-based algorithm for the detection of pancreatic stents placed for prophylaxis of post-ERCP pancreatitis: a prospective trial. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2025; 46:177-185. [PMID: 39222928 PMCID: PMC11964603 DOI: 10.1055/a-2407-9651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024]
Abstract
Before removal of retained pancreatic stents placed during endoscopic retrograde cholangiopancreatography to avoid post-ERCP pancreatitis, imaging is recommended. The aim of the present study was to evaluate a new ultrasound-based algorithm.Patients who received a pancreatic stent for PEP prophylaxis were included. Straight 5Fr (0.035inch) 6cm stents with an external flap that were visualized by ultrasound were removed endoscopically with no further imaging. If the ultrasound result reported the stent to be dislodged or was inconclusive, X-ray imaging was performed. The endpoints were positive and negative predictive value, specificity, sensitivity, and contingency coefficient between ultrasound and X-ray and/or endoscopy.88 patients were enrolled in the present study. X-ray was performed in 23 (26%) patients. Accordingly, the ultrasound algorithm saved an X-ray examination in 65 cases, leading to a reduction of 74%. Stents were retained in 67 patients (76%) and visualized correctly by ultrasound in 54 patients with a sensitivity of 81%. The positive predictive value was 83%. The specificity was 48%, because ultrasound described 10/21 dislodged stents correctly. The negative predictive value was 43%, since 10/23 stents were correctly classified by ultrasound as dislodged. In 11 patients (13%), esophagogastroduodenoscopy was performed even though the pancreatic stent was already dislodged.A novel ultrasound-based algorithm reduced the need for X-ray imaging by three quarters. To avoid unnecessary endoscopic examinations, the algorithm should be implemented with a learning phase and procedures should be performed by experienced examiners. An important limitation might be stent length since shorter stents might be more difficult to visualize by ultrasound.
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Affiliation(s)
- Florian Alexander Michael
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Clara Feldmann
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Hans-Peter Erasmus
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Alica Kubesch
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Esra Goerguelue
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Mate Knabe
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
- Centrum Gastroenterology Bethanien, Bethanien-Hospital, Frankfurt am Main, Germany
| | - Nada Abedin
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Myriam Heilani
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Daniel Hessz
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Christiana Graf
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
- Medical Clinic 2, LMU Hospital, Munchen, Germany
| | - Dirk Walter
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Fabian Finkelmeier
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Ulrike Mihm
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Neelam Lingwal
- Institute for Biostatistics and Mathematical Modeling, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Joerg Bojunga
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Mireen Friedrich-Rust
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Georg Dultz
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
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Barakat M, Saumoy M, Forbes N, Elmunzer BJ. Complications of Endoscopic Retrograde Cholangiopancreatography. Gastroenterology 2025:S0016-5085(25)00527-X. [PMID: 40120770 DOI: 10.1053/j.gastro.2025.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2024] [Revised: 03/13/2025] [Accepted: 03/15/2025] [Indexed: 03/25/2025]
Abstract
Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.
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Affiliation(s)
- Monique Barakat
- Divisions of Pediatric and Adult Gastroenterology & Hepatology, Departments of Pediatrics and Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Monica Saumoy
- Center for Digestive Health, Penn Medicine Princeton Health, Princeton, New Jersey
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
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Li L, Li X, Liu K, Wu W, Li M, Liu Y. Mitigating Postoperative Fistula Risks in Laparoscopic Pancreatic Enucleation: A Retrospective Study. Ann Surg Oncol 2025; 32:1887-1895. [PMID: 39710806 PMCID: PMC11811477 DOI: 10.1245/s10434-024-16702-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 11/28/2024] [Indexed: 12/24/2024]
Abstract
BACKGROUND Pancreatic enucleation is a reliable surgical method for treating benign and borderline pancreatic tumors; however, the incidence of postoperative pancreatic fistula (POPF) is high, especially when the tumor is close to the main pancreatic duct. This study aimed to reduce the incidence of pancreatic fistula by preoperative placement of pancreatic stents and to summarize our center's experience with this procedure. METHODS From June 2020 to July 2023, patients diagnosed with benign or borderline pancreatic tumors at Renji Hospital were included. The pancreatic duct stent is placed through endoscopic retrograde cholangiopancreatography on the day of surgery or 1 day before surgery. The effectiveness of preoperative pancreatic stent placement in reducing pancreatic fistula was investigated by comparing the incidence of perioperative and postoperative complications. RESULTS Overall, 63 patients were included in the study, 41 of whom had preoperative pancreatic stents. Multivariate logistic regression showed that tumors located in proximity to the main pancreatic duct (≤ 2 mm) (odds ratio [OR] 5.58, p = 0.020) is an independent risk factor for pancreatic fistula, while preoperative stent placement (OR 0.23, p = 0.021) significantly reduces the occurrence of pancreatic fistula. There was no difference in the incidence of grade Ш-IV complications (p = 0.33) and postoperative pancreatitis (p > 0.99) between groups with or without pancreatic stent. CONCLUSION Preoperative placement of pancreatic stents is associated with a lower incidence of pancreatic fistula, especially in patients with tumors adjacent to the main pancreatic duct. Moreover, preoperative pancreatic stents do not increase the incidence of postoperative pancreatitis or grade Ш-IV complications.
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Affiliation(s)
- Lin Li
- Department of Biliary-Pancreatic Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuechuan Li
- Department of Biliary-Pancreatic Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ke Liu
- Department of Biliary-Pancreatic Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenguang Wu
- Department of Biliary-Pancreatic Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of General Surgery, Jiading Branch, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Systems Regulation and Clinical Translation for Cancer, Shanghai, China
- State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Shanghai, China
| | - Maolan Li
- Department of Biliary-Pancreatic Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of General Surgery, Jiading Branch, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Systems Regulation and Clinical Translation for Cancer, Shanghai, China
- State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Shanghai, China
| | - Yingbin Liu
- Department of Biliary-Pancreatic Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Department of General Surgery, Jiading Branch, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai Key Laboratory of Systems Regulation and Clinical Translation for Cancer, Shanghai, China.
- State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Shanghai, China.
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Tintara S, Buxbaum J. Updates in Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastroenterol Clin North Am 2025; 54:97-112. [PMID: 39880535 DOI: 10.1016/j.gtc.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2025]
Abstract
Although endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be a safe and effective approach in treating these diseases while carrying lower morbidity than traditional surgical treatments, ERCP has associated risks, with post-ERCP pancreatitis (PEP) being the most common serious adverse event and carries significant morbidity and health care cost. PEP results from multifactorial factors involving trauma to the pancreatic duct and papilla, leading to subsequent obstruction and impairment of pancreatic drainage. Important risk factors for PEP include history of prior PEP, suspected sphincter of Oddi dysfunction, difficult cannulation, pancreatic duct contrast injections, and pancreatic sphincterotomy.
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Affiliation(s)
- Supisara Tintara
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Los Angeles, California, USA
| | - James Buxbaum
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Los Angeles, California, USA.
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Sugimoto M, Takagi T, Suzuki T, Shimizu H, Shibukawa G, Nakajima Y, Takeda Y, Noguchi Y, Kobayashi R, Imamura H, Asama H, Konno N, Waragai Y, Akatsuka H, Suzuki R, Hikichi T, Ohira H. A new preprocedural predictive risk model for post-endoscopic retrograde cholangiopancreatography pancreatitis: The SuPER model. eLife 2025; 13:RP101604. [PMID: 39819489 PMCID: PMC11741517 DOI: 10.7554/elife.101604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2025] Open
Abstract
Background Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a severe and deadly adverse event following ERCP. The ideal method for predicting PEP risk before ERCP has yet to be identified. We aimed to establish a simple PEP risk score model (SuPER model: Support for PEP Reduction) that can be applied before ERCP. Methods This multicenter study enrolled 2074 patients who underwent ERCP. Among them, 1037 patients each were randomly assigned to the development and validation cohorts. In the development cohort, the risk score model for predicting PEP was established via logistic regression analysis. In the validation cohort, the performance of the model was assessed. Results In the development cohort, five PEP risk factors that could be identified before ERCP were extracted and assigned weights according to their respective regression coefficients: -2 points for pancreatic calcification, 1 point for female sex, and 2 points for intraductal papillary mucinous neoplasm, a native papilla of Vater, or the pancreatic duct procedures (treated as 'planned pancreatic duct procedures' for calculating the score before ERCP). The PEP occurrence rate was 0% among low-risk patients (≤0 points), 5.5% among moderate-risk patients (1-3 points), and 20.2% among high-risk patients (4-7 points). In the validation cohort, the C statistic of the risk score model was 0.71 (95% CI 0.64-0.78), which was considered acceptable. The PEP risk classification (low, moderate, and high) was a significant predictive factor for PEP that was independent of intraprocedural PEP risk factors (precut sphincterotomy and inadvertent pancreatic duct cannulation) (OR 4.2, 95% CI 2.8-6.3; p<0.01). Conclusions The PEP risk score allows an estimation of the risk of PEP prior to ERCP, regardless of whether the patient has undergone pancreatic duct procedures. This simple risk model, consisting of only five items, may aid in predicting and explaining the risk of PEP before ERCP and in preventing PEP by allowing selection of the appropriate expert endoscopist and useful PEP prophylaxes. Funding No external funding was received for this work.
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Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University, School of MedicineFukushimaJapan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, School of MedicineFukushimaJapan
| | - Tomohiro Suzuki
- Department of Gastroenterology, Fukushima Rosai HospitalIwakiJapan
| | - Hiroshi Shimizu
- Department of Gastroenterology, Fukushima Rosai HospitalIwakiJapan
| | - Goro Shibukawa
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical UniversityAizuJapan
| | - Yuki Nakajima
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical UniversityAizuJapan
| | - Yutaro Takeda
- Department of Gastroenterology, Ohta Nishinouchi HospitalKoriyamaJapan
| | - Yuki Noguchi
- Department of Gastroenterology, Ohta Nishinouchi HospitalKoriyamaJapan
| | - Reiko Kobayashi
- Department of Gastroenterology, Ohta Nishinouchi HospitalKoriyamaJapan
| | - Hidemichi Imamura
- Department of Gastroenterology, Ohta Nishinouchi HospitalKoriyamaJapan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Redcross HospitalFukushimaJapan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Redcross HospitalFukushimaJapan
| | - Yuichi Waragai
- Department of Gastroenterology, Soma General HospitalSomaJapan
| | - Hidenobu Akatsuka
- Department of Gastroenterology, Saiseikai Fukushima General HospitalFukushimaJapan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University, School of MedicineFukushimaJapan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University HospitalFukushimaJapan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, School of MedicineFukushimaJapan
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Lee MH, Lin CH, Wu CH, Tsou YK, Sung KF, Wang SF, Liu NJ. Pancreatic stent improves the success rate of needle-knife papillotomy in patients with difficult biliary cannulation. World J Gastroenterol 2025; 31:97240. [PMID: 39777249 PMCID: PMC11684180 DOI: 10.3748/wjg.v31.i1.97240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 10/25/2024] [Accepted: 11/15/2024] [Indexed: 12/09/2024] Open
Abstract
BACKGROUND Needle-knife precut papillotomy (NKP) is typically performed freehand. However, it remains unclear whether pancreatic stent (PS) placement can improve the outcomes of NKP. AIM To explore whether PS placement improves the success rate of NKP in patients with difficult biliary cannulation. METHODS This single-center retrospective study included 190 patients who underwent NKP between January 2017 and December 2021 after failed conventional biliary cannulation. In cases with incidental pancreatic duct cannulation during conventional biliary cannulation, the decision for pre-NKP PS placement was made at the endoscopist's discretion. The primary outcome was the difference in the NKP success rate between patients with and without PS placement; the secondary outcome was the adverse event rate. RESULTS Among the 190 participants, 82 received pre-NKP PS (PS-NKP group) whereas 108 did not [freehand or freehand NKP (FH-NKP) group]. Post-NKP selective biliary cannulation was successful in 167 (87.9%) patients, and the PS-NKP had a significantly higher success rate than the FH-NKP group (93.9% vs 83.3%, P = 0.027). The overall adverse event rates were 7.3% and 11.1% in the PS-NKP and FH-NKP groups, respectively (P = 0.493). A periampullary diverticulum (PAD) and significant intraoperative bleeding during NKP were independently associated with NKP failure; however, a pre-NKP PS was the only predictor of NKP success. Among the 44 participants with PADs, the PS-NKP group had a non-significantly higher NKP success rate than the FH-NKP group (87.5% and 65%, respectively; P = 0.076). CONCLUSION PS significantly improved the success rate of NKP in patients with difficult biliary cannulation.
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Affiliation(s)
- Mu-Hsien Lee
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
| | - Cheng-Hui Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
| | - Chi-Huan Wu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
| | - Yung-Kuan Tsou
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
- School of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Kai-Feng Sung
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
| | - Sheng-Fu Wang
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
| | - Nai-Jen Liu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
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Shatsnimitkul E, Laopeamthong I, Tansawet A, Techapongsatorn S, Kasetsermwiriya W, Leungon P, Sukhvibul P. High-volume lactated Ringer's solution with human albumin versus standard-volume infusion as a prophylactic treatment for post-endoscopic retrograde cholangiopancreatography pancreatitis: randomized clinical trial. BJS Open 2024; 9:zrae149. [PMID: 39836543 PMCID: PMC11749547 DOI: 10.1093/bjsopen/zrae149] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 10/10/2024] [Accepted: 11/10/2024] [Indexed: 01/23/2025] Open
Abstract
BACKGROUND Adverse events after endoscopic retrograde cholangiopancreatography (ERCP) are rare, and post-ERCP pancreatitis is a serious adverse event. This study aimed to determine the role of aggressive intravenous hydration with lactated Ringer's solution at a specific volume with 20% human albumin before ERCP in reducing the incidence of post-ERCP pancreatitis. METHODS This study was a single-centre randomized clinical trial. The participants were randomly assigned to two groups: those who received aggressive intravenous hydration with 20% human albumin and lactated Ringer's solution (intervention group), and those who received standard-volume intravenous hydration with lactated Ringer's solution (control group). The primary endpoint was post-ERCP pancreatitis. Participants and outcome assessors were blinded to treatment allocation. Comparison was performed using the chi-square, the Fisher's exact, the Student's t, or the Mann-Whitney U tests, where appropriate. RESULTS Of 300 randomized participants, 149 and 144 participants from the intervention and control group were included in the analysis. There was no significant difference in the post-ERCP pancreatitis rate (n = 10; 6.7% versus n = 9; 6.3%, P = 0.873) between the intervention and control groups. High-risk procedures (that is pancreatic duct wiring, pancreatic duct injection, precut sphincterotomy, and balloon dilation of the ampulla) were significantly associated with post-ERCP pancreatitis compared with low-risk procedures (n = 15; 15% versus n = 4; 2.1%, P < 0.001). In the high-risk procedures population, the intervention and control groups had increased post-ERCP pancreatitis rates (P = 0.716). Two participants in each group developed pulmonary congestion. CONCLUSION Aggressive peri-ERCP intravenous hydration with lactated Ringer's solution combined with 50 ml of 20% human albumin did not prevent post-ERCP pancreatitis. None of the subgroups presented with prophylactic effects. TRIAL REGISTRATION Thai Clinical Trials Registry (TCTR20240405003).
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Affiliation(s)
- Ekaphan Shatsnimitkul
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Issaree Laopeamthong
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Amarit Tansawet
- Department of Research and Medical Innovation, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Suphakarn Techapongsatorn
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Wisit Kasetsermwiriya
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Poramet Leungon
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Pakkapol Sukhvibul
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Mirante VG, Lonardo A, Grillo S, Franzoni F, Sassatelli R. Intravenous lactated Ringer’s solution alone and in combination with NSAIDs in prevention of post-ERCP acute pancreatitis: an updated systematic review. EXPLORATION OF MEDICINE 2024. [DOI: 10.37349/emed.2024.00247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 08/02/2024] [Indexed: 01/11/2025] Open
Affiliation(s)
- Vincenzo Giorgio Mirante
- Gastroenterology A, Ospedale Borgo Trento-Azienda Ospedaliera Universitaria Integrata di Verona, 37126 Verona, Italy
| | - Amedeo Lonardo
- Department of Internal Medicine, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, 41126 Modena, Italy
| | - Simone Grillo
- Gastroenterology and Digestive Endoscopy, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Francesca Franzoni
- Clinical Trials Center, Infrastruttura Ricerca e Statistica, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Romano Sassatelli
- Gastroenterology and Digestive Endoscopy, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
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Zhou L, Wang L. Author's reply: Comment on "Feasibility of gallbladder lesion visualization using a novel ultrafine peroral cholangioscopy: A preliminary investigation". Dig Liver Dis 2024; 56:1794. [PMID: 39013711 DOI: 10.1016/j.dld.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 07/01/2024] [Indexed: 07/18/2024]
Affiliation(s)
- Lin Zhou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.
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Xu Y, Dong Z, Huang L, Du H, Yang T, Luo C, Tao X, Wang J, Wu Z, Wu L, Lin R, Yu H. Multistep validation of a post-ERCP pancreatitis prediction system integrating multimodal data: a multicenter study. Gastrointest Endosc 2024; 100:464-472.e17. [PMID: 38583541 DOI: 10.1016/j.gie.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/16/2024] [Accepted: 03/23/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND AND AIMS The impact of various categories of information on the prediction of post-ERCP pancreatitis (PEP) remains uncertain. We comprehensively investigated the risk factors associated with PEP by constructing and validating a model incorporating multimodal data through multiple steps. METHODS Cases (n = 1916) of ERCP were retrospectively collected from multiple centers for model construction. Through literature research, 49 electronic health record (EHR) features and 1 image feature related to PEP were identified. The EHR features were categorized into baseline, diagnosis, technique, and prevention strategies, covering pre-ERCP, intra-ERCP, and peri-ERCP phases. We first incrementally constructed models 1 to 4 incorporating these 4 feature categories and then added the image feature into models 1 to 4 and developed models 5 to 8. All models underwent testing and comparison using both internal and external test sets. Once the optimal model was selected, we conducted comparisons among multiple machine learning algorithms. RESULTS Compared with model 2 that incorporated baseline and diagnosis features, adding technique and prevention strategies (model 4) greatly improved the sensitivity (63.89% vs 83.33%, P < .05) and specificity (75.00% vs 85.92%, P < .001). A similar tendency was observed in the internal and external tests. In model 4, the top 3 features ranked by weight were previous pancreatitis, nonsteroidal anti-inflammatory drug use, and difficult cannulation. The image-based feature has the highest weight in models 5 to 8. Finally, model 8 used a random forest algorithm and showed the best performance. CONCLUSIONS We first developed a multimodal prediction model for identifying PEP with a clinical-acceptable performance. The image and technique features are crucial for PEP prediction.
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Affiliation(s)
- Youming Xu
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zehua Dong
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Li Huang
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hongliu Du
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Ting Yang
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Chaijie Luo
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiao Tao
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Junxiao Wang
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhifeng Wu
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lianlian Wu
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Rong Lin
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Honggang Yu
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
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Suenaga A, Ohno A, Fujimori N. Very rare case of pancreatic stent migration into the biliary stent. Dig Endosc 2024; 36:1054-1055. [PMID: 38989588 DOI: 10.1111/den.14872] [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] [Received: 03/29/2024] [Accepted: 05/28/2024] [Indexed: 07/12/2024]
Abstract
Watch a video of this article.
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Affiliation(s)
- Akihiko Suenaga
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihisa Ohno
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nao Fujimori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Saito H, Kadono Y, Shono T, Kamikawa K, Urata A, Nasu J, Uehara M, Matsushita I, Kakuma T, Hashigo S, Tada S. Synergistic effect of independent risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis: a multicenter retrospective study in Japan. Clin Endosc 2024; 57:508-514. [PMID: 38632965 PMCID: PMC11294859 DOI: 10.5946/ce.2023.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/02/2023] [Accepted: 10/10/2023] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND/AIMS This study aimed to examine the synergistic effect of independent risk factors on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). METHODS This multicenter retrospective study included 1,273 patients with native papillae who underwent ERCP for bile duct stones in Japan. Independent PEP risk factors were identified using univariate and multivariate analyses. Significant risk factors for PEP in the multivariate analysis were included in the final analysis to examine the synergistic effect of independent risk factors for PEP. RESULTS PEP occurred in 45 of 1,273 patients (3.5%). Three factors including difficult cannulation ≥10 minutes, pancreatic injection, and normal serum bilirubin level were included in the final analysis. The incidences of PEP in patients with zero, one, two, and three factors were 0.5% (2/388), 1.9% (9/465), 6.0% (17/285), and 12.6% (17/135), respectively. With increasing risk factors for PEP, the incidence of PEP significantly increased (1 factor vs. 2 factors, p=0.006; 2 factors vs. 3 factors, p=0.033). CONCLUSIONS As the number of risk factors for PEP increases, the risk of PEP may not be additive; however, it may multiply. Thus, aggressive prophylaxis for PEP is strongly recommended in patients with multiple risk factors.
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Affiliation(s)
- Hirokazu Saito
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City, Japan
| | - Yoshihiro Kadono
- Department of Gastroenterology, Tsuruta Hospital, Kumamoto City, Japan
| | - Takashi Shono
- Department of Gastroenterology, Kumamoto Chuo Hospital, Kumamoto City, Japan
| | - Kentaro Kamikawa
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto City, Japan
| | - Atsushi Urata
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto City, Japan
| | - Jiro Nasu
- Department of Gastroenterological Surgery, Kumamoto Chuo Hospital, Kumamoto City, Japan
| | - Masayoshi Uehara
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto City, Japan
| | - Ikuo Matsushita
- Department of Gastroenterology, Kumamoto Chuo Hospital, Kumamoto City, Japan
| | - Tatsuyuki Kakuma
- Department of Biostatics Center, Medical School, Kurume University, Kurume City, Japan
| | - Shunpei Hashigo
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City, Japan
| | - Shuji Tada
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City, Japan
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Shanti I, Samardali M, Bambhroliya Z, Alhusari L. Post-endoscopic Retrograde Cholangiopancreatography Hemorrhagic Pancreatitis in a Young Female: A Case Report. Cureus 2024; 16:e60929. [PMID: 38910698 PMCID: PMC11193661 DOI: 10.7759/cureus.60929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/25/2024] Open
Abstract
Hemorrhagic pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) is an adverse event that has received limited attention in medical studies. We describe a 28-year-old female who was admitted with symptoms of abdominal pain, nausea, and vomiting, along with tenderness in the right upper quadrant upon physical examination. CT abdomen revealed the presence of a gallstone obstructing the common bile duct. The patient underwent an ERCP procedure, which included a biliary sphincterotomy and the balloon-assisted removal of the obstructing stone. Unfortunately, the procedure was complicated with acute pancreatitis characterized by fluid accumulation in the abdomen, suggestive of hemorrhagic pancreatitis. There was a notable decrease in hemoglobin levels and hypotension, indicating the need for a higher level of care. Patients were managed conservatively with hydration and pain control. Follow-up in the clinic confirmed the resolution of symptoms and stabilization of the hemoglobin. Prompt recognition of post-ERCP hemorrhagic pancreatitis is crucial and warrants a high index of suspicion. Furthermore, the discussion explored the various risk factors and pathological events behind post-ERCP pancreatitis to understand the mechanisms of the disease. Various previously used intervention and prevention strategies were critically discussed for the awareness of future researchers and healthcare practitioners.
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Affiliation(s)
- Ibrahim Shanti
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Malik Samardali
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Zarna Bambhroliya
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Leena Alhusari
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
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15
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Su WC, Wang CC, Hsiao TH, Chen HD, Chen JH. The impact of transpancreatic precut sphincterotomy on the quality of ERCP in a low-volume setting. Gastrointest Endosc 2024; 99:747-755. [PMID: 38042208 DOI: 10.1016/j.gie.2023.11.049] [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] [Received: 06/29/2023] [Revised: 10/27/2023] [Accepted: 11/21/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND AND AIMS Although quality improvement is crucial for ERCP, a low practice volume can pose challenges to achieving high-quality bile duct cannulation. Transpancreatic precut sphincterotomy (TPS) has been proven effective for advanced cannulation. However, existing data mainly come from skilled endoscopists in large medical centers. The impact of TPS on ERCP quality in a lower-volume setting deserves investigation. METHODS Our hospital performs approximately 200 ERCPs annually, with 1 expert endoscopist performing approximately half of them and 3 nonexpert endoscopists sharing the remaining cases. TPS was started and became our predominant advanced cannulation technique in April 2016. We retrospectively reviewed ERCP cases 3 years before and after the introduction of TPS. The primary endpoints of the study were the differences in 2 ERCP quality indicators, the bile duct cannulation rate and the incidence of post-ERCP pancreatitis (PEP). RESULTS A total of 701 ERCP cases with naïve papilla were analyzed, with 350 patients treated before the introduction of TPS and 351 patients treated afterward. The successful cannulation rate was significantly improved (before, 87.4%; after, 92.3%, P = .032), whereas the incidence of PEP decreased, but not significantly (before, 4.0%; after, 2.8%; P = .402). All endoscopists benefited from using TPS, with nonexperts demonstrating a significantly higher improvement in the cannulation rate (before, 85.5%; after, 93.1%; P = .019). CONCLUSIONS TPS can effectively enhance the quality of ERCP irrespective of practice volume.
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Affiliation(s)
- Wei-Chih Su
- Department of Gastroenterology, Buddhist Tzu Chi Medical Foundation, Taipei Tzu-Chi Hospital, New Taipei City, Taiwan
| | - Chia-Chi Wang
- Department of Gastroenterology, Buddhist Tzu Chi Medical Foundation, Taipei Tzu-Chi Hospital, New Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tsung-Hsien Hsiao
- Department of Gastroenterology, Buddhist Tzu Chi Medical Foundation, Taipei Tzu-Chi Hospital, New Taipei City, Taiwan
| | - Hung-Da Chen
- Department of Gastroenterology, Buddhist Tzu Chi Medical Foundation, Taipei Tzu-Chi Hospital, New Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jiann-Hwa Chen
- Department of Gastroenterology, Buddhist Tzu Chi Medical Foundation, Taipei Tzu-Chi Hospital, New Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan.
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Tenner S, Vege SS, Sheth SG, Sauer B, Yang A, Conwell DL, Yadlapati RH, Gardner TB. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol 2024; 119:419-437. [PMID: 38857482 DOI: 10.14309/ajg.0000000000002645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/08/2023] [Indexed: 06/12/2024]
Abstract
Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.
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Affiliation(s)
- Scott Tenner
- State University of New York, Health Sciences Center, Brooklyn, New York, USA
| | | | - Sunil G Sheth
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Bryan Sauer
- University of Virginia, Charlottesville, Virginia, USA
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Elmunzer BJ, Foster LD, Serrano J, Coté GA, Edmundowicz SA, Wani S, Shah R, Bang JY, Varadarajulu S, Singh VK, Khashab M, Kwon RS, Scheiman JM, Willingham FF, Keilin SA, Papachristou GI, Chak A, Slivka A, Mullady D, Kushnir V, Buxbaum J, Keswani R, Gardner TB, Forbes N, Rastogi A, Ross A, Law J, Yachimski P, Chen YI, Barkun A, Smith ZL, Petersen B, Wang AY, Saltzman JR, Spitzer RL, Ordiah C, Spino C, Durkalski-Mauldin V. Indomethacin with or without prophylactic pancreatic stent placement to prevent pancreatitis after ERCP: a randomised non-inferiority trial. Lancet 2024; 403:450-458. [PMID: 38219767 PMCID: PMC10872215 DOI: 10.1016/s0140-6736(23)02356-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND The combination of rectally administered indomethacin and placement of a prophylactic pancreatic stent is recommended to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients. Preliminary evidence suggests that the use of indomethacin might eliminate or substantially reduce the need for stent placement, a technically complex, costly, and potentially harmful intervention. METHODS In this randomised, non-inferiority trial conducted at 20 referral centres in the USA and Canada, patients (aged ≥18 years) at high risk for post-ERCP pancreatitis were randomly assigned (1:1) to receive rectal indomethacin alone or the combination of indomethacin plus a prophylactic pancreatic stent. Patients, treating clinicians, and outcomes assessors were masked to study group assignment. The primary outcome was post-ERCP pancreatitis. To declare non-inferiority, the upper bound of the two-sided 95% CI for the difference in post-ERCP pancreatitis (indomethacin alone minus indomethacin plus stent) would have to be less than 5% (non-inferiority margin) in both the intention-to-treat and per-protocol populations. This trial is registered with ClinicalTrials.gov (NCT02476279), and is complete. FINDINGS Between Sept 17, 2015, and Jan 25, 2023, a total of 1950 patients were randomly assigned. Post-ERCP pancreatitis occurred in 145 (14·9%) of 975 patients in the indomethacin alone group and in 110 (11·3%) of 975 in the indomethacin plus stent group (risk difference 3·6%; 95% CI 0·6-6·6; p=0·18 for non-inferiority). A post-hoc intention-to-treat analysis of the risk difference between groups showed that indomethacin alone was inferior to the combination of indomethacin plus prophylactic stent (p=0·011). The relative benefit of stent placement was generally consistent across study subgroups but appeared more prominent among patients at highest risk for pancreatitis. Safety outcomes (serious adverse events, intensive care unit admission, and hospital length of stay) did not differ between groups. INTERPRETATION For preventing post-ERCP pancreatitis in high-risk patients, a strategy of indomethacin alone was not as effective as a strategy of indomethacin plus prophylactic pancreatic stent placement. These results support prophylactic pancreatic stent placement in addition to rectal indomethacin administration in high-risk patients, in accordance with clinical practice guidelines. FUNDING US National Institutes of Health.
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Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA.
| | - Lydia D Foster
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jose Serrano
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Gregory A Coté
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, Portland, OR, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Raj Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ji Young Bang
- Orlando Health Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Shyam Varadarajulu
- Orlando Health Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mouen Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Richard S Kwon
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - James M Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Field F Willingham
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven A Keilin
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - James Buxbaum
- Division of Gastroenterology, University of Southern California, Los Angeles, CA, USA
| | - Rajesh Keswani
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - Nauzer Forbes
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - Amit Rastogi
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Andrew Ross
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Joanna Law
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yen-I Chen
- Division of Gastroenterology, McGill University, Montreal, QC, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University, Montreal, QC, Canada
| | - Zachary L Smith
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bret Petersen
- Department of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Andrew Y Wang
- Division of Gastroenterology, University of Virginia, Charlottesville, VA, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Rebecca L Spitzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Collins Ordiah
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Cathie Spino
- Department of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Valerie Durkalski-Mauldin
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
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Altunpak B, Aydin H, Cebi F, Seyit H, Kones O, Akarsu C, Kabuli H, Gumusoglu A, Karabulut M. Post-ERCP Pancreatitis Risk Factors: Is Post-Sphincterotomy Bleeding Another Risk Factor? Surg Laparosc Endosc Percutan Tech 2024; 34:69-73. [PMID: 38063573 DOI: 10.1097/sle.0000000000001251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/04/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Despite advancements in technology and expertise, ERCP carries risks of significant complications, such as pancreatitis, bleeding, and perforation. Post-ERCP pancreatitis is the most common and important complication following ERCP. In our study, we aimed to examine the relationship between patient and procedure-related parameters and the development of pancreatitis. METHODS Four hundred patients who underwent ERCP between January 1, 2019 and December 31, 2020, at the General Surgery Clinic of the Bakirköy Dr. Sadi Konuk Health Application and Research Center of the University of Health Sciences Faculty of Medicine were retrospectively evaluated. Patient and procedure-related factors were analyzed statistically through univariate and multivariate analyses. RESULTS Age, urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, pancreatic cannulation, pancreatic stent, and bleeding were statistically significant risk factors for post-ERCP pancreatitis (+). In multivariate analysis, the effects of urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, and pancreatic cannulation on post-ERCP pancreatitis were statistically significant risk factors ( P <0.05). DISCUSSION This study demonstrates that emergency indication, ERCP history, cholangitis, precut sphincterotomy, and pancreatic cannulation are significant risk factors for the development of post- ERCP pancreatitis. One notable contribution of our study to the existing literature is the unique analysis of post-sphincterotomy bleeding as an independent factor.
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Affiliation(s)
- Burak Altunpak
- Department of General Surgery, Gaziantep Nizip State Hospital, Gaziantep
| | - Husnu Aydin
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Fevzi Cebi
- Department of General Surgery, Trabzon of State Hospital, Trabzon
| | - Hakan Seyit
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Osman Kones
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Cevher Akarsu
- Department of General Surgery, Arel University Memorial Hizmet Hospital, Istanbul, Turkey
| | - Hamit Kabuli
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Alpen Gumusoglu
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Mehmet Karabulut
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
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Özcan Ö, Arikan S. Determining the Risk Factors of Complications Due to Endoscopic Retrograde Cholangiopancreatography. Cureus 2024; 16:e51666. [PMID: 38313949 PMCID: PMC10838154 DOI: 10.7759/cureus.51666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/06/2024] Open
Abstract
Background and objective The effective use of endoscopic retrograde cholangiopancreatography (ERCP) has been on the rise in diagnosing and treating benign and malignant pathologies of the common bile duct and pancreas. ERCP, a complex procedure requiring high knowledge, skills, and practice, differs from other endoscopic applications as it involves the use of different techniques and equipment and the occurrence of more complications. The most commonly observed complications of ERCP are pancreatitis, bleeding, perforation, and infections. In this study, we aimed to assess the incidence of post-ERCP complications to identify the associated risk factors and indications. Methodology In this study, 181 ERCP procedures performed on 122 consecutive patients in the endoscopy unit of Istanbul Training Hospital were prospectively evaluated by using an observational method to determine the frequency of and risk factors for post-ERCP complications. The patients were followed up in the course of the ERCP procedure and for 30 days after the procedure; the complications and clinical developments were recorded. Results The mean age of the cohort was 59.7 ± 17.7 (19-97) years; 40.9% were female and 59.1% were male. The cannulation success was achieved in 77.3% of the ERCP procedure performed. Among the ERCP procedures applied, 89% were performed for therapeutic purposes, and choledocholithiasis (60.2%) was the most common indication for ERCP. Major complications were detected in 25.4% of the patients after ERCP. The most common major complication was cholangitis (9.9%), followed by pancreatitis (7.2%), cholecystitis (5.5%), bleeding (3.9%), and perforation (1.1%). It was observed that sphincterotomy was associated with an increase in all complications. The incidence of cholangitis decreased in the presence of dilated bile ducts unrelated to obstruction. The increased incidence of pancreatitis was associated with the female gender, the use of sphincterotomy and basket, inexperienced endoscopists, and inpatient admissions. The incidence of cholecystitis, on the other hand, was found to be linked with sphincterotomy and inexperienced endoscopists. Conclusions ERCP is a complex endoscopic procedure that requires high technical knowledge and skill and can cause serious complications. For endoscopists to perform clinically effective and accurate ERCP, it is important that they correctly determine the indications for the procedure, know its potential complications, and refrain from practices that will create complications and are unnecessary as much as possible.
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Affiliation(s)
- Özhan Özcan
- General Surgery, Istanbul Education Research Hospital, Istanbul, TUR
| | - Soykan Arikan
- Surgical Oncology, Basaksehir Cam and Sakura City Hospital, Istanbul, TUR
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Fukuda R, Hakuta R, Nakai Y, Hamada T, Takaoka S, Tokito Y, Suzuki Y, Oyama H, Kanai S, Noguchi K, Suzuki T, Ishigaki K, Saito K, Saito T, Takahara N, Mizuno S, Ito Y, Kogure H, Fujishiro M. Development and external validation of a nomogram for prediction of post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreatology 2023; 23:789-796. [PMID: 37666733 DOI: 10.1016/j.pan.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 06/04/2023] [Accepted: 08/26/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic retrograde cholangiopancreatography (ERCP) is widely performed for management of pancreatobiliary diseases; however, post-ERCP pancreatitis (PEP) remains as an unsolved problem. Although various risk factors for PEP have been reported, the prediction of PEP remains controversial. This study aimed to develop a predictive model for PEP. METHODS Consecutive patients undergoing ERCP for biliary indications at two centers were retrospectively studied. Using data from a training cohort, we utilized a multivariable model to select five variables to construct a nomogram. The predictive model was internally and externally validated. Based on the nomogram, the patients were categorized into low-, moderate-, and high-risk groups. RESULTS Using the data of 2224 patients in the training cohort, five variables were selected to generate a nomogram: 1) sex, 2) indication for ERCP, 3) difficult cannulation, 4) guidewire insertion into the pancreatic duct, and 5) endoscopic sphincterotomy or sphincteroplasty. The most significant risk factor was endoscopic papillary balloon dilation such as endoscopic sphincterotomy or sphincteroplasty. The bias-corrected concordance index was 0.72 in the training cohort and 0.72 in the validation cohort. Calibration curves for both cohorts demonstrated good agreement between the predicted and observed frequencies of the actual outcome. In the validation cohort, PEP developed in 5.0% and 14% of patients in the moderate- and high-risk groups, respectively. CONCLUSIONS We successfully developed a good predictive model for PEP. The prevention of PEP in high risk patients should be investigated further.
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Affiliation(s)
- Rintaro Fukuda
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan.
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shinya Takaoka
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yurie Tokito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukari Suzuki
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hiroki Oyama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sachiko Kanai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kensaku Noguchi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsunori Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Chemotherapy, The University of Tokyo Hospital, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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21
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Ashat M, Kandula S, Cote GA, Gromski MA, Fogel EL, Sherman S, Lehman GA, Watkins JL, Bick BL, Easler JJ. Utilization pattern of prophylactic measures for prevention of post-ERCP pancreatitis: a National Survey Study. Gastrointest Endosc 2023; 97:1059-1066.e3. [PMID: 36738796 DOI: 10.1016/j.gie.2023.01.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/05/2023] [Accepted: 01/28/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Post-ERCP pancreatitis (PEP) is the most frequent adverse event of ERCP. Various prophylactic measures are endorsed by the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy to both lower the incidence of PEP and to decrease its severity. The extent to which these interventions are practiced throughout the United States is unclear. The aim of this study was to describe the utilization pattern of various PEP measures and determine factors that affect utilization of these measures. METHODS A 27-question electronic survey was distributed using a cloud-based program (Qualtrics). The questions assessed ERCP training, practice setting, experience, practice patterns, and perceptions for PEP prophylaxis interventions. Endoscopists with practices based in the United States listed in the American Society for Gastrointestinal Endoscopy member directory received a survey invitation via e-mail. The invitation outlined the study and contained a link with instructions to complete the voluntary survey if they had an active ERCP practice. Data were de-identified for the purposes of analysis. RESULTS Of survey respondents (N = 319), 46% reported therapeutic endoscopy fellowship training and 37% practiced in teaching programs. Annualized ERCP volume of >100 cases per year were reported by 47%, with pancreatic ERCP comprising ≤5% of procedure volume reported by the majority of respondents (61%). The majority of respondents used prophylactic pancreatic stent (PPS), and 54% reported frequent use during high-risk ERCP. The most common indications for PPS were difficult cannulation, to assist biliary access, and multiple pancreatic duct injections. Most respondents reported frequent use of indomethacin (89%). Of physicians who did not use PPS, use of indomethacin was the most common reason (80%). Variables associated with frequent use of PPS were ERCP fellowship training (P ≤ .001), practice at a teaching program (P ≤ .001), <10 years in practice (P = .005), higher procedure volume (P ≤ .001), and higher proportion of pancreatic cases (P ≤ .001). CONCLUSIONS Physicians with higher annual ERCP volume, who teach at hospital-based ERCP practices, and who regularly perform pancreatic ERCP are more likely to use PPS. Therapeutic ERCP fellowship training and recent entry into practice were also associated with PPS utilization. Indomethacin use seems to be more frequent than PPS. Our findings suggest that indomethacin is supplanting PPS as the preferred method of PEP prophylaxis.
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Affiliation(s)
- Munish Ashat
- Department of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
| | - Sailesh Kandula
- Department of Statistics and Data Science, The University of Texas at Austin, Austin, Texas, USA
| | - Gregory A Cote
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Glen A Lehman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - James L Watkins
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Benjamin L Bick
- Division of Gastroenterology and Hepatology, Rockford Gastroenterology Associates, Rockford, Illinois, USA
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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22
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Hassan AM, Lin TK, Smith MT, Hornung L, Abu-El-Haija M, Nathan JD, Vitale DS. Risk Factors for Post-ERCP Pancreatitis in Pediatric and Young Adult Patients. J Pediatr Gastroenterol Nutr 2023; 76:807-812. [PMID: 36930983 DOI: 10.1097/mpg.0000000000003766] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
OBJECTIVES Post-ERCP pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Limited existing data suggest that prophylactic pancreatic duct (PD) stenting in pediatric patients may increase the risk of PEP. The aim of this study is to identify factors associated with PEP in pediatric patients. METHODS Patients at a single institution who underwent ERCP between 2012 and 2020 were retrospectively reviewed. Patient and procedure-related factors were collected. Data were analyzed using Chi-square or Fisher exact tests as appropriate and Mann-Whitney-Wilcoxon tests. RESULTS Seven hundred thirty-six ERCPs were performed for 402 unique patients. Ninety-four cases were complicated by PEP (12.8%), of which 91 were mild and 3 were moderately severe. Pancreatic indication, native major papilla, PD cannulation and injection, and higher American Society for Gastrointestinal Endoscopy (ASGE) complexity were associated with PEP. A higher proportion of patients who received rectal indomethacin (65% vs 47%, P = 0.002), or who had placement of a prophylactic (31% vs 20%, P = 0.01) or therapeutic PD stent (37% vs 27%, P = 0.04) developed PEP; however, in a subgroup analysis of high-risk patients, this association was not persistent. A smaller proportion of PEP patients had PRSS1 mutation compared to non-PEP patients (22% vs 40%, P = 0.04). CONCLUSIONS This study evaluates factors associated with developing PEP in a large pediatric cohort. A high rate of PEP was observed, likely secondary to higher rates of pancreatic indication and higher ASGE complexity scores compared to previously reported literature. Randomized prospective trials are needed to better define the utility of various interventions.
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Affiliation(s)
- Ahmad M Hassan
- From the Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
| | - Tom K Lin
- the Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH
- the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Milton T Smith
- From the Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
| | - Lindsey Hornung
- the Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Maisam Abu-El-Haija
- the Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH
- the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jaimie D Nathan
- the Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David S Vitale
- the Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH
- the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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23
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Kumar A, Sondhi P. A closer look at universal prophylactic rectal NSAIDs in prevention of post-ERCP pancreatitis. Indian J Gastroenterol 2023; 42:311-314. [PMID: 37314683 DOI: 10.1007/s12664-023-01404-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Ajay Kumar
- BLK Max Institute of Digestive and Liver Diseases, New Delhi, 110 005, India.
| | - Pulkit Sondhi
- BLK Max Institute of Digestive and Liver Diseases, New Delhi, 110 005, India
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Hattori A, Yamada R, Murabayashi T, Sugimoto S, Imai H, Nojiri K, Kuroda N, Tano S, Tanaka H, Matsusaki S, Nishikawa K, Naota H, Moritani I, Kurata K, Fukui T, Tanaka K, Nakagawa H. The safety and efficacy of Ringer's solution loading with rectal diclofenac for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: The RESOLUTION-PEP study. DEN OPEN 2023; 3:e236. [PMID: 37125072 PMCID: PMC10131293 DOI: 10.1002/deo2.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/22/2023] [Accepted: 03/26/2023] [Indexed: 05/02/2023]
Abstract
Objectives We evaluated the safety and efficacy of aggressive hydration with rectal non-steroidal anti-inflammatory drugs for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Methods This prospective, single-arm, multicenter trial was conducted at 12 institutions between October 2020 and August 2021. We enrolled 231 patients who had intact papillae and were scheduled to undergo ERCP. All patients were administered rectal diclofenac before ERCP. They received aggressive hydration with intravenous lactated Ringer's solution in an initial bolus of 5 ml/kg at the start of ERCP, followed by 3 ml/kg/h for 8 h after the procedure. The primary outcome was the occurrence of PEP. Secondary outcomes included PEP severity, hyperamylasemia, and adverse events. Results The mean age of the patients was 68.8 ± 13.7 years, and 81 patients (35.1%) were 75 years or older. Thirteen patients developed PEP (5.6%, 95% confidence interval 3.0%-9.4%). There were 11 cases (4.8%) of mild pancreatitis and two cases (0.9%) of severe pancreatitis. Forty-five patients (19.5%) developed hyperamylasemia and one patient developed non-severe peripheral edema. Conclusions Aggressive hydration combined with rectal diclofenac may be a promising strategy for the prevention of PEP. Furthermore, it is safe even for older individuals.
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Affiliation(s)
- Aiji Hattori
- Department of Gastroenterology and HepatologyMie University HospitalMieJapan
- Department of GastroenterologyMatsusaka Municipal HospitalMieJapan
| | - Reiko Yamada
- Department of Gastroenterology and HepatologyMie University HospitalMieJapan
| | | | - Shinya Sugimoto
- Department of GastroenterologyIse Red Cross HospitalMieJapan
| | - Hajime Imai
- Department of GastroenterologyOkanami General HospitalMieJapan
| | - Keiichiro Nojiri
- Department of GastroenterologyKuwana City Medical CenterMieJapan
| | - Naoki Kuroda
- Department of GastroenterologySaiseikai Matsusaka General HospitalMieJapan
| | - Shunsuke Tano
- Department of GastroenterologySuzuka Kaisei HospitalMieJapan
| | - Hiroki Tanaka
- Department of GastroenterologySuzuka General HospitalMieJapan
| | | | | | - Hiroaki Naota
- Department of GastroenterologyMatsusaka Chuo General HospitalMieJapan
| | - Isao Moritani
- Department of GastroenterologyMie Prefectural General Medical CenterMieJapan
| | - Kazunari Kurata
- Department of GastroenterologyMie Chuo Medical CenterMieJapan
| | - Toshitaka Fukui
- Department of GastroenterologyYokkaichi Hazu Medical CenterMieJapan
| | - Kyosuke Tanaka
- Department of Endoscopic MedicineMie University HospitalMieJapan
| | - Hayato Nakagawa
- Department of Gastroenterology and HepatologyMie University HospitalMieJapan
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25
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El Hage Chehade N, Ghoneim S, Shah S, Chahine A, Issak A, Choi AY, Moosvi Z, Chang KJ, Samarasena JB. Combination Topical Epinephrine and Non-steroidal Inflammatory Drugs in the Prevention of Post-ERCP Pancreatitis: A Systematic Review. Dig Dis Sci 2023; 68:957-968. [PMID: 35695971 DOI: 10.1007/s10620-022-07518-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/07/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND The utility of combination rectal NSAID and topical epinephrine (EI) or rectal NSAID and normal saline (SI) sprayed on duodenal papilla in the prevention of post-ERCP pancreatitis (PEP) has been studied but results have been conflicting. AIMS To evaluate the benefit of using combination prophylaxis in preventing PEP. METHODS A literature search was performed using Scopus, PubMed/MEDLINE, and Cochrane databases in May 2021. Randomized controlled trials (RCTs) involving adults patients who underwent ERCP and received EI versus SI were eligible for inclusion. The pooled effect was expressed as odds ratio (OR) to assess the rate of PEP, severity of PEP, and specific adverse events. The results were pooled using Reviewer Manager 5.4 software. RESULTS Six RCTs involving 4016 patients were included in the final analysis. The EI group did not demonstrate any significant benefit over SI group in preventing PEP (OR = 1.00, 95% CI [0.68, 1.45], P = 0.98), irrespective of gender or the epinephrine concentration used. The tests for subgroup differences were not statistically significant with P-values of 0.66 and 0.28, respectively. The addition of topical epinephrine to rectal NSAID did not improve the rate of moderate to severe PEP (OR = 0.94, P = 0.86) or PEP in high-risk patients (OR = 1.14, 95%, P = 0.73). The rates of infection, including cholangitis and sepsis (OR = 0.63, P = 0.07), gastrointestinal bleeding (OR = 1.25, P = 0.56) and procedure-related death (OR = 0.71, P = 0.59) were similar between both groups. CONCLUSION The addition of topical epinephrine did not demonstrate any benefit over rectal NSAID alone in preventing PEP or reducing other procedure-related adverse events.
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Affiliation(s)
- Nabil El Hage Chehade
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Sara Ghoneim
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sagar Shah
- Department of Internal Medicine, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Anastasia Chahine
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, 101 The City Drive S, Orange, CA, 92868, USA
| | - Abdulfatah Issak
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Alyssa Y Choi
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, 101 The City Drive S, Orange, CA, 92868, USA
| | - Zain Moosvi
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth J Chang
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, 101 The City Drive S, Orange, CA, 92868, USA
| | - Jason B Samarasena
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, 101 The City Drive S, Orange, CA, 92868, USA.
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Ikeda Y, Ono M, Ohmori G, Ameda S, Arihara Y, Yamada M, Abe T, Maeda M. Clinical benefit of early precut sphincintroterotomy for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography. Surg Endosc 2023; 37:120-126. [PMID: 35851815 DOI: 10.1007/s00464-022-09426-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 06/29/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVES A precut procedure is sometimes required for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, it is unclear whether the biliary access rate has improved for early precut procedures compared to conventional techniques. This study aimed to identify the benefit of early precut sphincterotomy in cases showing difficult biliary access. METHODS Between April 2017 and August 2021, consecutive patients who underwent precutting for difficult biliary cannulation were retrospectively enrolled. The outcomes of early (≤ 10 min from start of cannulation) and delayed (> 10 min) precut groups were evaluated. All adverse events were defined according to Cotton criteria. RESULTS A total of 70 patients were enrolled in this study. The biliary cannulation rate for a first ERCP was significantly higher in the early compared to delayed precut group (95% vs. 73.3%; P = 0.015). A difference in overall cannulation rate between the two groups was not observed (97.5% vs. 83.3%; P > 0.05). Significantly higher rates of prophylactic pancreatic stents were described in the delayed compared to early precut group (36.7% vs. 12.5%; P = 0.009). Significant differences in the frequency of pancreatitis, bleeding, penetration, and perforation were not noted between the two groups. Overall, the success rate was statistically significant between the experienced and less experienced endoscopists (87.2% vs. 63.9%; P = 0.017). CONCLUSIONS Early precutting within 10 min from the start of cannulation in ERCP is safe and effective in cases with a difficult biliary cannulation, and can improve the biliary cannulation rate.
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Affiliation(s)
- Yuki Ikeda
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan.
| | - Michihiro Ono
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Ginji Ohmori
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Saki Ameda
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Yohei Arihara
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Michiko Yamada
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Tomoyuki Abe
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Masahiro Maeda
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
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27
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An Insight on Pharmacological and Mechanical Preventive Measures of Post-ERCP PANCREATITIS (PEP)—A Review. GASTROENTEROLOGY INSIGHTS 2022. [DOI: 10.3390/gastroent13040038] [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: 12/12/2022] Open
Abstract
Pancreatitis is the most common complication following endoscopic retrograde cholangio-pancreatography (ERCP). With the progress of research in many drugs and technologies, promising efficacy has been achieved in preventing post-ERCP pancreatitis (PEP). Recently, combined prevention has received more attention in order to further reduce the incidence of PEP. However, there is no review about the combined prevention of PEP. This review summarizes the medication and ERCP techniques that are used to prevent PEP and emphasizes that appropriate combination prevention approaches should be based on risk stratification.
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28
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Technical Outcomes in Pediatric Endoscopic Retrograde Cholangiopancreatography: Data from an International Collaborative. J Pediatr Gastroenterol Nutr 2022; 75:755-760. [PMID: 36122368 DOI: 10.1097/mpg.0000000000003612] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Endoscopic retrograde cholangiopancreatography (ERCP) in adults has been extensively studied through multicenter prospective studies. Similar pediatric studies are lacking. The Pediatric ERCP Database Initiative (PEDI) is a multicenter collaborative aiming to evaluate the indications and technical outcomes in pediatric ERCPs. METHODS In this prospective cohort study, data were recorded for pediatric ERCPs performed across 15 centers. A pre-procedure, procedure, 2-week post-procedure follow-up, and adverse event form were completed for each ERCP performed. Univariate and stepwise linear regression was performed to identify factors associated with technically successful procedures and adverse events. RESULTS A total of 1124 ERCPs were performed on 857 patients from May 1, 2014 to May 1, 2018. The median age was 13.5 years [interquartile range (IQR) 9.0-15.7]. Procedures were technically successful in the majority of cases (90.5%) with success more commonly encountered for procedures with biliary indications [odds ratio (OR) 4.2] and less commonly encountered for native papilla anatomy (OR 0.4) and in children <3 years (OR 0.3). Cannulation was more often successful with biliary cannulation (95.9%) compared to pancreatic cannulation via the major papilla (89.6%, P < 0.0001) or minor papilla (71.2%, P < 0.0005). The most commonly identified adverse events included post-ERCP pancreatitis (5%), pain not related to post-ERCP pancreatitis (1.8%), and bleeding (1.2%). Risk factors for the development of each were identified. CONCLUSIONS This large prospective study demonstrates that ERCP is reliable and safe in the pediatric population. It highlights the utility of PEDI in evaluating the technical outcomes of pediatric ERCPs and demonstrates the potential of PEDI for future studies in pediatric ERCPs.
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Saito H, Fujimoto A, Oomoto K, Kadowaki Y, Tada S. Current approaches and questions yet to be resolved for the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastrointest Endosc 2022; 14:657-666. [PMID: 36438884 PMCID: PMC9693687 DOI: 10.4253/wjge.v14.i11.657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/06/2022] [Accepted: 10/26/2022] [Indexed: 11/14/2022] Open
Abstract
Prophylaxis is important for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), which is the most common and serious complication of ERCP. Although the current guidelines include independent patient- and procedure-related risk factors for PEP and available PEP prophylactic measures, the synergistic effect of these risk factors on PEP should also be considered, given that patients often harbor multiple risk factors. Furthermore, a combination of prophylactic measures is often selected in clinical practice. However, established methods estimating the synergistic effect of independent risk factors on PEP incidence are lacking, and evidence on the impact of combining prophylactic measures on PEP should be discussed. Selection of appropriate candidate patients for ERCP is also important to reduce the incidence of PEP associated with unnecessary ERCP. ERCP indications in patients with asymptomatic common bile duct stones (CBDSs) and in those with suspected CBDSs with no imaging-based evidence of stones are controversial. Further studies are warranted to predict the synergistic effect of independent risk factors on PEP, determine the best prophylactic PEP measures, and identify appropriate candidates for ERCP in patients with asymptomatic CBDSs and those with suspected CBDSs.
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Affiliation(s)
- Hirokazu Saito
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
| | - Atsushi Fujimoto
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
| | - Kana Oomoto
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
| | - Yoshitaka Kadowaki
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
| | - Shuji Tada
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
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Frolov PA, Korotkevich AG, May SA, Krasnov KA, Pavlenko VV, Pachgin IV. Evaluation of the effect of double postbulbar blockade (PBB) on the rate of regression of hyperamylasemia in acute biliary pancreatitis. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2022:86-91. [DOI: 10.31146/1682-8658-ecg-201-5-86-91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
Affiliation(s)
- P. A. Frolov
- Kuzbass Clinical Hospital of Emergency Medical Care named after M. A. Podgorbunsky
| | - A. G. Korotkevich
- Novokuznetsk State Institute of Advanced Training of Doctors; Novokuznetsk City Clinical Hospital № 29
| | - S. A. May
- Novokuznetsk City Clinical Hospital № 29
| | - K. A. Krasnov
- Kuzbass Clinical Hospital of Emergency Medical Care named after M. A. Podgorbunsky; Kemerovo State Medical University
| | - V. V. Pavlenko
- Kuzbass Clinical Hospital of Emergency Medical Care named after M. A. Podgorbunsky; Kemerovo State Medical University
| | - I. V. Pachgin
- Kuzbass Clinical Hospital of Emergency Medical Care named after M. A. Podgorbunsky
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Ryu J, Paik KH, Kwon CI, Koh DH, Song TJ, Jeong S, Park WS. The Safety and Efficacy of an Unflanged 4F Pancreatic Stent in Transpancreatic Precut Sphincterotomy for Patients with Difficult Biliary Cannulation: A Prospective Cohort Study. J Clin Med 2022; 11:jcm11195692. [PMID: 36233560 PMCID: PMC9573508 DOI: 10.3390/jcm11195692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Prophylactic pancreatic stenting effectively reduces the rate and severity of post-ERCP pancreatitis (PEP) in the precut technique; however, studies on the optimal type and duration of the stent are still lacking. This prospective study evaluated the incidence and severity of PEP and the rate of spontaneous stent dislodgement in patients undergoing transpancreatic precut sphincterotomy (TPS) accompanied by prophylactic pancreatic stenting with an unflanged plastic stent (4F × 5 cm) for difficult biliary cannulation. A total of 247 patients with naïve papilla were enrolled in this study, and data were collected prospectively. In the final analysis, 170 and 61 patients were included in the standard cannulation technique and TPS groups, respectively. The incidence of PEP in the standard cannulation technique and TPS groups was 3.5% and 1.6% (p = 0.679), respectively. The technical success rate of selective biliary cannulation in the TPS group was 91.8%. The spontaneous dislodgement rate of the prophylactic plastic stent was 98.4%. In conclusion, an unflanged pancreatic stent (4F × 5 cm) placement in TPS for patients with failed standard cannulation technique is a safe and effective measure due to low adverse events and few additional endoscopic procedures for removing the pancreatic duct (PD) stent.
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Affiliation(s)
- Jieun Ryu
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea
| | - Kyu-Hyun Paik
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea
| | - Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13497, Korea
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
| | - Dong Hee Koh
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea
| | - Tae Jun Song
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Division of Gastroenterology, Department of Internal Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Seok Jeong
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon 22332, Korea
| | - Won Suk Park
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Correspondence: ; Tel.: +82-42-220-9339
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Azuma S, Kurita A, Yoshimura K, Matsumori T, Kobayashi Y, Yane K, Inatomi O, Sawada K, Harada R, Yazumi S. Effect of ice water injection toward the duodenal papilla for preventing post-ERCP pancreatitis: study protocol for a multicenter, single-blinded, randomized controlled trial (EUTOPIA study). BMC Gastroenterol 2022; 22:382. [PMID: 35962311 PMCID: PMC9373460 DOI: 10.1186/s12876-022-02462-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/02/2022] [Indexed: 12/07/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure in the diagnosis and treatment of biliopancreatic diseases. The most common adverse event of ERCP is post-ERCP pancreatitis (PEP), which can sometimes be severe. Our previous study suggested that injecting ice water at the end of ERCP suppressed PEP, and we decided to investigate this effect in a multicenter randomized controlled trial. Methods This study is being conducted at eight hospitals in Japan starting in April 2022. Patients undergoing ERCP will be randomized to ice water group and control group. In the ice water group, 250 ml of ice water is injected toward the papilla at the end of ERCP. The next morning, a physical examination and blood tests are performed to evaluate for the development of pancreatitis. The goal is to have 440 cases in each group. Discussion The main cause of PEP is thought to be papilla edema. Cooling the papilla, as everyone naturally does at the time of a burn, is expected to prevent its inflammation and edema. Various methods to suppress PEP have been reported, but so far none of them are reliable. The method we have devised is very simple, easy, and safe. We hope that our study will change the world's ERCP common practice. Trial registration:UMIN000047528. Registered 20 April 2022, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000053209
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Affiliation(s)
- Shunjiro Azuma
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan
| | - Akira Kurita
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan. .,Department of Gastroenterology and Hepatology, Rakuwakai Otowa Hospital, 2 Otowachinjicho Yamashina-ku, Kyoto, 607-8062, Japan.
| | - Kenichi Yoshimura
- Medical Center for Translational and Clinical Research, Hiroshima University Hospital, 1-2-3 Kasumi Minami-ku, Hiroshima, 734-8551, Japan
| | - Tomoaki Matsumori
- Department of Gastroenterology and Hepatology, Kyoto University Hospital, 54 Shogoin Kawaharacho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yosuke Kobayashi
- Department of Gastroenterology, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu-shi, Shizuoka, 430-8558, Japan
| | - Kei Yane
- Department of Gastroenterology and Hepatology, Tonan Hospital, 3-8, 7-3, Kita 4-jo Nishi, Chuo-ku, Sapporo-shi, Hokkaido, 060-0004, Japan
| | - Osamu Inatomi
- Department of Gastroenterology, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu city, Shiga, 520-2192, Japan
| | - Kenji Sawada
- Department of Gastroenterology and Hepatology, Japanese Red Cross Osaka Hospital, 5-30 Fudegasaki-cho, Tennoji-ku, Osaka, 543-8555, Japan
| | - Ryo Harada
- Department of Gastroenterology and Hepatology, Japanese Red Cross Okayama Hospital, 2-1-1 Aoe, Kita-ku, Okayama City, Okayama, 700-8607, Japan
| | - Shujiro Yazumi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan
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Rao B H, Vincent PK, Nair P, Koshy AK, Venu RP. The preventive effect of tacrolimus on patients with post-endoscopic retrograde cholangiopancreatography pancreatitis. Clin Endosc 2022; 55:665-673. [PMID: 35915049 PMCID: PMC9539296 DOI: 10.5946/ce.2021.265] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/04/2022] [Indexed: 11/29/2022] Open
Abstract
Background/Aims In patients undergoing endoscopic retrograde cholangiopancreatography (ERCP), calcineurin activates zymogen, which results in pancreatitis. In this study, we aimed to determine the efficacy of tacrolimus, a calcineurin inhibitor, in preventing post-ERCP pancreatitis (PEP).
Methods This was a prospective pilot study in which patients who underwent ERCP received tacrolimus (4 mg in two divided doses); this was the Tac group. A contemporaneous cohort of patients was included as a control group. All patients were followed-up for PEP. PEP was characterized by worsening abdominal pain with an acute onset, elevated pancreatic enzymes, and a duration of hospital stay of more than 48 hours. Serum tacrolimus levels were measured immediately before the procedure in the Tac group.
Results There were no differences in the baseline characteristics between the Tac group (n=48) and the control group (n=51). Only four out of 48 patients (8.3%) had PEP in the Tac group compared to eight out of 51 patients (15.7%) who had PEP in the control group. The mean trough tacrolimus level in patients who developed PEP was significantly lower (p<0.05).
Conclusions Oral tacrolimus at a cumulative dose of 4 mg safely prevents PEP. Further randomized controlled studies are warranted to establish the role of tacrolimus in this context.
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Affiliation(s)
- Harshavardhan Rao B
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - Paul K Vincent
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - Priya Nair
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - Anoop K Koshy
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - Rama P Venu
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
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Koshitani T, Konaka Y, Ohishi T, Yasuda T, Morinushi T, Mita M, Masuda M, Nakano K, Fuki S, Nakagawa S. Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Using Temporary Pancreatic Stents Versus Rectal Nonsteroidal Anti-inflammatory Drugs: A Randomized Controlled Trial. Pancreas 2022; 51:663-670. [PMID: 36099496 DOI: 10.1097/mpa.0000000000002090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Both pancreatic stenting and rectal nonsteroidal anti-inflammatory drugs (NSAIDs) prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. The aim of the study was to compare post-ERCP pancreatitis (PEP) prophylaxis using pancreatic stents and/or rectal NSAIDs prospectively. METHODS A total of 321 patients undergoing ERCP were studied. Each patient was randomly allocated to receive pancreatic stent placement (PS), 50 mg of rectal diclofenac (NSAID), or both (PS + NSAID) for PEP prophylaxis. The primary outcome was the occurrence rate of PEP, and secondary outcomes included the severity of PEP and serum pancreatic amylase and lipase levels on the day after ERCP. RESULTS Five patients (PS: 2/101, NSAID: 1/106, PS + NSAID: 2/102) developed PEP, and the overall occurrence rate of PEP was 1.6% (5/309). The occurrence rates of PEP in the PS, NSAID, and PS + NSAID groups were statistically equivalent with an equivalent margin of 10%. The severity of PEP was mild in all 5 patients. Median serum pancreatic amylase and lipase levels in the NSAID group were significantly lower than those in the PS and PS + NSAID groups. CONCLUSIONS Rectal administration of 50 mg of diclofenac may become a first-line therapy for PEP prophylaxis in our country.
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Affiliation(s)
- Tatsuya Koshitani
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Yoshitomo Konaka
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Takashi Ohishi
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Tomoyo Yasuda
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Tatsuo Morinushi
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Masaki Mita
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Masataka Masuda
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Keimei Nakano
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Shuichi Fuki
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
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Obeidat AE, Mahfouz R, Monti G, Kozai L, Darweesh M, Mansour MM, Alqam A, Hernandez D. Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: What We Already Know. Cureus 2022; 14:e21773. [PMID: 35251843 PMCID: PMC8890589 DOI: 10.7759/cureus.21773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 11/05/2022] Open
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Suzuki A, Uno K, Nakase K, Mandai K, Endoh B, Chikugo K, Kawakami T, Suzuki T, Nakai Y, Kusumoto K, Itokawa Y, Inatomi O, Bamba S, Mizumoto Y, Tanaka K. Post-endoscopic retrograde cholangiopancreatography pancreatitis assessed using criteria for acute pancreatitis. JGH Open 2021; 5:1391-1397. [PMID: 34950783 PMCID: PMC8674548 DOI: 10.1002/jgh3.12687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/10/2022]
Abstract
Background and Aim International consensus on the definition and classification of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has been reached. However, the diagnosis and severity of PEP are often assessed according to the diagnostic criteria and classification for acute pancreatitis (AP). This study determined the incidence, severity, and risk factors of PEP diagnosed according to the diagnostic criteria and classification for AP in a large cohort. Methods This prospective, multicenter, observational cohort study conducted at five high-volume centers included 1932 patients who underwent ERCP-related procedures. The incidence, severity, and risk factors for PEP were evaluated. Results PEP occurred in 142 patients (7.3%); it was mild in 117 patients (6.0%) and severe in 25 patients (1.3%). According to the Cotton criteria, PEP occurred in 87 patients (4.5%); it was mild in 54 patients (2.8%), moderate in 20 patients (1.0%), and severe in 13 patients (0.7%). In the multivariate analysis, female sex (odds ratio [OR] 2.239; 95% confidence interval [CI] 1.546-3.243), naïve papilla (OR 3.047; 95% CI 1.803-5.150), surgically-altered gastrointestinal anatomy (OR 2.538; 95% CI 1.342-4.802), procedure time after reaching the papilla (OR 1.009; 95% CI 1.001-1.017), pancreatic duct injection (OR 2.396; 95% CI 1.565-3.669), and intraductal ultrasonography (OR 1.641; 95% CI 1.024-2.629) were independent risk factors. Conclusion According to the diagnostic criteria and classification for AP, the incidence of PEP was higher than that according to the Cotton criteria and the severity of PEP tended to be severe.
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Affiliation(s)
- Azumi Suzuki
- Department of Gastroenterology Kyoto Second Red Cross Hospital Kyoto Japan.,Present address: Department of Gastroenterology Hamamatsu Medical Center Shizuoka Japan
| | - Koji Uno
- Department of Gastroenterology Kyoto Second Red Cross Hospital Kyoto Japan
| | - Kojiro Nakase
- Department of Gastroenterology Kyoto Second Red Cross Hospital Kyoto Japan.,Present address: Department of Gastroenterology Kyoto Okamoto Memorial Hospital Kyoto Japan
| | - Koichiro Mandai
- Department of Gastroenterology Kyoto Second Red Cross Hospital Kyoto Japan
| | - Bunji Endoh
- Department of Gastroenterology National Hospital Organization Kyoto Medical Center Kyoto Japan
| | - Koki Chikugo
- Department of Gastroenterology National Hospital Organization Kyoto Medical Center Kyoto Japan.,Present address: Center for Gastroenterology Teine Keijinkai Hospital Sapporo Japan
| | - Takumi Kawakami
- Department of Gastroenterology Japanese Red Cross Kyoto Daiichi Hospital Kyoto Japan.,Present address: Department of Gastroenterology Municipal Tsuruga Hospital Fukui Japan
| | - Takahiro Suzuki
- Department of Gastroenterology Japanese Red Cross Kyoto Daiichi Hospital Kyoto Japan.,Present address: Suzuki Naika Iin Kyoto Japan
| | - Yoshitaka Nakai
- Digestive Disease Center, Department of Gastroenterology and Hepatology Kyoto Katsura Hospital Kyoto Japan
| | - Kiyonori Kusumoto
- Digestive Disease Center, Department of Gastroenterology and Hepatology Kyoto Katsura Hospital Kyoto Japan
| | - Yoshio Itokawa
- Digestive Disease Center, Department of Gastroenterology and Hepatology Kyoto Katsura Hospital Kyoto Japan
| | - Osamu Inatomi
- Division of Gastroenterology, Department of Medicine Shiga University of Medical Science Otsu Japan
| | - Shigeki Bamba
- Division of Gastroenterology, Department of Medicine Shiga University of Medical Science Otsu Japan
| | - Yoshinori Mizumoto
- Department of Gastroenterology National Hospital Organization Kyoto Medical Center Kyoto Japan
| | - Kiyohito Tanaka
- Department of Gastroenterology Kyoto Second Red Cross Hospital Kyoto Japan
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Sanders DJ, Bomman S, Krishnamoorthi R, Kozarek RA. Endoscopic retrograde cholangiopancreatography: Current practice and future research. World J Gastrointest Endosc 2021; 13:260-274. [PMID: 34512875 PMCID: PMC8394185 DOI: 10.4253/wjge.v13.i8.260] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/18/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.
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Affiliation(s)
- David J Sanders
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Shivanand Bomman
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Rajesh Krishnamoorthi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
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Wang X, Luo H, Luo B, Ren G, Liang S, Wang X, Tao Q, Zhang L, Kang X, Guo X, Pan Y. Combination prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients undergoing double-guidewire assisted biliary cannulation: A case-control study with propensity score matching. J Gastroenterol Hepatol 2021; 36:1905-1912. [PMID: 33444486 DOI: 10.1111/jgh.15402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/27/2020] [Accepted: 01/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Rectal indomethacin and pancreatic duct stenting (PDS) are recommended for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). However, the effects of the combination of the two methods on preventing PEP are controversial. We hypothesized that some group of difficult patients might benefit from the combination of indomethacin plus PDS (IP) compared with indomethacin alone (IN). METHODS Patients with native papilla who underwent endoscopic retrograde cholangiopancreatography in eight tertiary hospitals were screened. They were enrolled if the cannulation proved difficult and post-procedure indomethacin was administered. Propensity score matching (PSM) was used to balance the baseline characteristics between IP and IN groups. The primary outcome was PEP. RESULTS Among 4456 patients with available cannulation-related data, 1889 (42.4%) patients had difficult cannulation and received indomethacin. After PSM, both IP and IN groups included 332 patients. PEP was comparable between the two groups (12.7% vs 10.2%, P = 0.329). By subgroup analysis, the PEP rate was found to be lower in the IP group than in the IN group (7.3% vs 18.2%, P = 0.026) in patients undergoing double-guidewire technique (DGT). The results of an additional analysis using PSM in DGT patients were consistent with the subgroup analysis results (7.8% vs 19.4%, P = 0.036). CONCLUSIONS The current study indicated that the combined prevention of PEP with indomethacin plus PDS was useful in PEP prevention in patients undergoing DGT. Other groups of patients with difficult cannulation may not benefit from the combination strategy.
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Affiliation(s)
- Xu Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hui Luo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Bing Luo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Gui Ren
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shuhui Liang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiangping Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qin Tao
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Linhui Zhang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiaoyu Kang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xuegang Guo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
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Ishizaki Y, Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Okubo Y, Nakamura J, Takasumi M, Hashimoto M, Kato T, Kobashi R, Hikichi T, Ohira H. Spontaneous disappearance of common bile duct stones following the insertion of a new dumbbell-shaped, covered self-expandable metallic stent in a patient with benign biliary stricture. Clin Case Rep 2021; 9:e04093. [PMID: 34026137 PMCID: PMC8122123 DOI: 10.1002/ccr3.4093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/04/2021] [Accepted: 03/13/2021] [Indexed: 11/11/2022] Open
Abstract
The new dumbbell-shaped, covered self-expanding metallic stent can efficiently remove the choledocholiths in cases with common bile duct (CBD) strictures; moreover, it may potentially prevent a positional displacement and contribute to the better improvement of the CBD stricture.
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Affiliation(s)
- Yuto Ishizaki
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Mitsuru Sugimoto
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Tadayuki Takagi
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Rei Suzuki
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Naoki Konno
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Hiroyuki Asama
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Yuki Sato
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Hiroki Irie
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Yoshinori Okubo
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
- Department of EndoscopyFukushima Medical University HospitalFukushimaJapan
| | - Jun Nakamura
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
- Department of EndoscopyFukushima Medical University HospitalFukushimaJapan
| | - Mika Takasumi
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Minami Hashimoto
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
- Department of EndoscopyFukushima Medical University HospitalFukushimaJapan
| | - Tsunetaka Kato
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
- Department of EndoscopyFukushima Medical University HospitalFukushimaJapan
| | - Ryoichiro Kobashi
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
| | - Takuto Hikichi
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
- Department of EndoscopyFukushima Medical University HospitalFukushimaJapan
| | - Hiromasa Ohira
- Department of Gastroenterology, School of MedicineFukushima Medical UniversityFukushimaJapan
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Michael FA, Gerber L, Weiler N, Hunyady PM, Abedin N, de la Vera ALL, Stoffers P, Filmann N, Zeuzem S, Bojunga J, Friedrich-Rust M, Dultz G. Transabdominal ultrasonography to reduce the burden of X-ray imaging in prophylactic pancreatic stent localization after ERCP-A prospective trial. United European Gastroenterol J 2021; 9:469-477. [PMID: 33887119 PMCID: PMC8259253 DOI: 10.1002/ueg2.12063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/13/2021] [Accepted: 02/07/2021] [Indexed: 11/25/2022] Open
Abstract
Background Before performing endoscopy to remove prophylactic pancreatic stents placed in patients with high risk of post‐endoscopic retrograde cholangiopancreatography pancreatitis (PEP), X‐ray imaging is recommended to confirm the stents position in the pancreatic duct. Objectives The aim of the present study was to investigate the feasibility of prophylactic pancreatic stent detection by transabdominal ultrasonography, to reduce the burden of X‐ray imaging, which is currently the golden standard. Methods All patients who received a pancreatic stent for PEP prophylaxis were included in the present prospective trial. First, stent position was determined by transabdominal ultrasonography. Afterwards, it was verified by X‐ray imaging. Retained stents were removed by esophagogastroduodenoscopy. Dislocated stents needed no further intervention. Results Fourty‐one patients were enrolled in this study. All prophylactic pancreatic stents were straight 6 cm long 5 Fr stents with external flap. All stents were removed between day 1 and 10 (median: 3 days) in all cases. In 34 of 41 cases (83.0%), the pancreatic stent was still in place on the day of examination. Twenty‐nine of 34 (85.3%) stents were detected correctly by transabdominal ultrasonography. Overlying gas prevented visualization of the pancreas in 3/41 (7.3%) cases. Sensitivity of sonographic detection of the stent was 93.5% (29/31). Six of seven stents were determined correctly as dislocated by ultrasonography. Here, specificity was 85.7%. A positive predictive value of 96.7% (29/30) was examined. The negative predictive value was 75.0% (6/8). Conclusion Transabdominal ultrasonography detects the majority of prophylactic pancreatic stents. Thereby, it helps to identify patients with an indication for endoscopy sufficiently. X‐ray imaging could subsequently be omitted in about 70% of examinations, reducing the radiation exposure for the patient and the endoscopy staff.
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Affiliation(s)
| | - Ludmilla Gerber
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Nina Weiler
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Peter Marton Hunyady
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Nada Abedin
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Philipp Stoffers
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Frankfurt, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Jörg Bojunga
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Georg Dultz
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
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Lee JM, Moon SH, Park SW, Paik WH, Paik CN, Son BK, Song TJ, Ahn DW, Lee ES, Lee YN, Lee YS, Jeon TJ, Chon HK, Lee DW, Park CH, Cho KB. A National Survey on the Environment and Basic Techniques of Endoscopic Retrograde Cholangiopancreatography in Korea. Gut Liver 2021; 15:904-911. [PMID: 33790058 PMCID: PMC8593499 DOI: 10.5009/gnl20329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/23/2020] [Accepted: 01/11/2021] [Indexed: 11/04/2022] Open
Abstract
Background/Aims The work environment in which endoscopic retrograde cholangiopancreatography (ERCP) is conducted has influence on its efficacy and safety. We aimed to assess the current status of ERCP work environments and to investigate the trends associated with the basic techniques of ERCP in Korea. Methods The work environment and information on the basic techniques of ERCP were acquired by the Korean Pancreatobiliary Association (KPBA) through a national survey in 2019. The survey was performed at the KPBA conference in 2019. The contents of survey comprised of the current environment of ERCP, preparation before ERCP, and the preferred basic techniques used in ERCP. Results Completed questionnaires were returned from 84 KPBA members. The mean ERCP volume per year was approximately 500. About 60% (50/84) reported that they worked with a dedicated ERCP team with experienced nurses. Two-thirds (57/84, 68%) answered that they had a fluoroscopy room used solely for ERCP procedures. All respondents intravenously hydrated the patient to prevent post-ERCP pancreatitis (84/84, 100%). The preferred procedural sedations were balanced propofol sedation (50%) and midazolam-only sedation (47%). Wire-guided cannulation was most commonly used for selective cannulation (81%). Endoscopic retrograde biliary drainage was preferred over endoscopic nasobiliary drainage (60% vs 22%). The initial method of ampullary intervention was endoscopic sphincterotomy in 60%. Conclusions Data from the survey involving a large number of Korean ERCP doctors revealed considerable variabilities with regard to the work environment and basic techniques of ERCP in Korea. The study provides information regarding the current trends of ERCP that can be used to establish ERCP standards in Korea.
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Affiliation(s)
- Jae Min Lee
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sung Hoon Moon
- Department of Internal Medicine, Hallym University College of Medicine, Anyang, Korea
| | - Sang Wook Park
- Department of Internal Medicine, Kwangju Christian Hospital, Gwangju, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Nyol Paik
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byoung Kwan Son
- Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea
| | - Tae Jun Song
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Won Ahn
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Eaum Seok Lee
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Yun Nah Lee
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Yoon Suk Lee
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Tae Joo Jeon
- Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Hyung Ku Chon
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Korea
| | - Dong Wook Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Chang Hwan Park
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Kwang Bum Cho
- Department of Internal Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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Vanbiervliet G, Strijker M, Arvanitakis M, Aelvoet A, Arnelo U, Beyna T, Busch O, Deprez PH, Kunovsky L, Larghi A, Manes G, Moss A, Napoleon B, Nayar M, Pérez-Cuadrado-Robles E, Seewald S, Barthet M, van Hooft JE. Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:429-448. [PMID: 33728632 DOI: 10.1055/a-1397-3198] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
1: ESGE recommends against diagnostic/therapeutic papillectomy when adenoma is not proven.Strong recommendation, low quality evidence. 2: ESGE recommends endoscopic ultrasound and abdominal magnetic resonance cholangiopancreatography (MRCP) for staging of ampullary tumors.Strong recommendation, low quality evidence. 3: ESGE recommends endoscopic papillectomy in patients with ampullary adenoma without intraductal extension, because of good results regarding outcome (technical and clinical success, morbidity, and recurrence).Strong recommendation, moderate quality evidence. 4: ESGE recommends en bloc resection of ampullary adenomas up to 20-30 mm in diameter to achieve R0 resection, for optimizing the complete resection rate, providing optimal histopathology, and reduction of the recurrence rate after endoscopic papillectomy.Strong recommendation, low quality evidence. 5: ESGE suggests considering surgical treatment of ampullary adenomas when endoscopic resection is not feasible for technical reasons (e. g. diverticulum, size > 4 cm), and in the case of intraductal involvement (of > 20 mm). Surveillance thereafter is still mandatory.Weak recommendation, low quality evidence. 6: ESGE recommends direct snare resection without submucosal injection for endoscopic papillectomy.Strong recommendation, moderate quality evidence. 7: ESGE recommends prophylactic pancreatic duct stenting to reduce the risk of pancreatitis after endoscopic papillectomy.Strong recommendation, moderate quality evidence. 8: ESGE recommends long-term monitoring of patients after endoscopic papillectomy or surgical ampullectomy, based on duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and thereafter yearly for at least 5 years.Strong recommendation, low quality evidence.
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Affiliation(s)
- Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Marin Strijker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arthur Aelvoet
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Urban Arnelo
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Torsten Beyna
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - Olivier Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pierre H Deprez
- Gastroenterology and Hepatology Department, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Lumir Kunovsky
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianpiero Manes
- Aziende Socio Sanitaria Territoriale Rhodense, Gastroenterology, Garbagnate Milanese, Italy
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Australia.,Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Bertrand Napoleon
- Service de Gastroentérologie, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Manu Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Enrique Pérez-Cuadrado-Robles
- Department of Gastroenterology, Georges-Pompidou European Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Stefan Seewald
- Gastroenterology Center, Klinik Hirslanden, Zurich, Switzerland
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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Guyot A, Lequeu JB, Dransart-Rayé O, Chevallier O, Nguyen M, Charles PE, Mouillot T, Manfredi S, Degand T. [Management of acute pancreatitis. A literature review]. Rev Med Interne 2021; 42:625-632. [PMID: 33676780 DOI: 10.1016/j.revmed.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/02/2020] [Accepted: 01/09/2021] [Indexed: 12/07/2022]
Abstract
The management of acute pancreatitis is now fairly codified, with specific recommendations developed by expert groups. These recommendations deal in particular with the minimum initial assessment, recognized severity scores, initial medical management with hyperhydration, preventive anticoagulation, early refeeding, delays in imaging and management of complications. In this work, we have tried to bring together the various recommendations, articles and studies dealing with this subject, based more particularly on European recommendations, in order to guide the management of acute pancreatitis in current practice.
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Affiliation(s)
- A Guyot
- Service d'hépato-gastro-entérologie, CHU de Dijon F.-Mitterrand Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| | - J B Lequeu
- Chirurgie viscérale, digestive et endocrinienne, CHU de Dijon, Dijon, France.
| | - O Dransart-Rayé
- Département d'anesthésie réanimation, CHU de Dijon, Dijon, France.
| | - O Chevallier
- Département de radiologie diagnostique et thérapeutique, CHU de Dijon, Dijon, France.
| | - M Nguyen
- Département d'anesthésie réanimation, CHU de Dijon, Dijon, France.
| | - P E Charles
- Médecine intensive réanimation, CHU de Dijon, Dijon, France.
| | - T Mouillot
- Service d'hépato-gastro-entérologie, CHU de Dijon F.-Mitterrand Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| | - S Manfredi
- Service d'hépato-gastro-entérologie, CHU de Dijon F.-Mitterrand Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| | - T Degand
- Service d'hépato-gastro-entérologie, CHU de Dijon F.-Mitterrand Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
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Shintani S, Inatomi O, Takeda Y, Matsumoto H, Fujimoto T, Tsuji Y, Kutsumi H, Andoh A. Utility and safety of a new uneven double-lumen sphincterotome in cases of difficult biliary cannulation. BMC Gastroenterol 2021; 21:102. [PMID: 33663397 PMCID: PMC7934518 DOI: 10.1186/s12876-021-01689-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/24/2021] [Indexed: 11/30/2022] Open
Abstract
Background We investigated the utility and safety of a new uneven double-lumen sphincterotome in biliary cannulation in comparison with the conventional pancreatic guidewire (PGW) method.
Methods We retrospectively evaluated 119 patients who required PGW placement because of difficult biliary cannulation. Endoscopic retrograde cholangiopancreatography (ERCP) was performed using a conventional ERCP catheter or a new uneven double-lumen sphincterotome. The success rate of bile duct cannulation, the operation time of bile duct cannulation, and the incidence of post-ERCP pancreatitis (PEP) were evaluated. Results Forty-four patients were treated with a new double-lumen sphincterotome (the new sphincterotome group) and 75 patients underwent conventional PGW placement (the conventional group). The success rate of bile duct cannulation was 39/44 (88.6%) in the new sphincterotome group and 63/75 (84.0%) in the conventional group (not significant). The total biliary cannulation time (from the reach to the papilla to the finish of biliary cannulation) was 16.0 (6.5–78) min in the new sphincterotome group and 26.0 (5–80) min in the conventional group (P < 0.01). The time from PGW placement to bile duct cannulation was 3.5 (0.3–57) min in the magictome group and 12.0 (1–65) min in the conventional group (P < 0.01). Hyperamylasemia was observed in 13/44 (29.5%) and 17/75 (22.7%), respectively (not significant). Five of 44 (11.3%) of the new sphincterotome group and 14/75 (18.7%) of the conventional group were diagnosed with PEP (not significant). Conclusion A new double-lumen sphincterotome allows selective bile duct cannulation to be performed in a shorter time than the conventional PGW method.
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Affiliation(s)
- Shuhei Shintani
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Osamu Inatomi
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan.
| | - Yoshiya Takeda
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Hiroshi Matsumoto
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Takehide Fujimoto
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Yoshihisa Tsuji
- Department of General Medicine, Sapporo Medical University, Sapporo, Japan
| | - Hiromu Kutsumi
- Center for Clinical Research and Advanced Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Akira Andoh
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
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Maharshi S, Sharma SS. Early precut versus primary precut sphincterotomy to reduce post-ERCP pancreatitis: randomized controlled trial (with videos). Gastrointest Endosc 2021; 93:586-593. [PMID: 32615179 DOI: 10.1016/j.gie.2020.06.064] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/21/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Precut sphincterotomy, usually performed after prolonged and failed cannulation, is considered a risk factor for post-ERCP pancreatitis (PEP). There are limited studies on primary needle-knife precut for the prevention of PEP. The aim of this study was to assess the safety and efficacy of primary precut. METHODS A randomized controlled trial was conducted in a tertiary care setting on patients who underwent ERCP. Patients were randomized to very early precut (group A, precut after 2 failed attempts of wire-guided sphincterotome cannulation) and primary precut (group B, direct needle-knife precut). All procedures were done by an experienced endoscopist. The primary outcome of the study was to compare the incidence of PEP between the 2 groups. RESULTS Three hundred three patients were randomized to group A (n = 152, age 48.2 ± 15.4 years, 61 men) and group B (n = 151, age 46.7 ± 13.8 years, 65 men). There was no significant difference in baseline characteristics and indications for ERCP between the 2 groups. Development of PEP (5.2% vs .67%; P = .04) and asymptomatic hyperamylasemia (12.5% vs 2.6%; P = .01) were lower in group B compared with group A. The bile duct cannulation time (13.8 ± 2.2 vs 7.2 ± 1.7 minutes; P = .001) was lower in group B, whereas the overall cannulation success rate (98% vs 98.6%; P = 1.0) was similar in both the groups. CONCLUSIONS Primary precut by an experienced endoscopist results in low risk of PEP. (Clinical trial registration number: CTRI/2017/08/009510.).
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Affiliation(s)
- Sudhir Maharshi
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Shyam Sunder Sharma
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
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Han S, Attwell AR, Tatman P, Edmundowicz SA, Hammad HT, Wagh MS, Wani S, Shah RJ. Adverse Events Associated With Therapeutic Endoscopic Retrograde Pancreatography. Pancreas 2021; 50:378-385. [PMID: 33835969 PMCID: PMC8041157 DOI: 10.1097/mpa.0000000000001769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Data regarding the safety of endoscopic retrograde pancreatography (ERP) are limited compared with biliary endoscopic retrograde cholangiopancreatography. The aim of this study was to determine adverse events (AEs) associated with therapeutic ERP. METHODS This single-center retrospective study examined consecutive therapeutic ERPs with the primary intention of cannulating the pancreatic duct. Multivariate logistic regression was performed to identify risk factors for AEs. RESULTS A total of 3023 ERPs were performed in 1288 patients (mean age, 50.3 years; 57.8% female) from January 2000 to January 2017. Overall AE rate was 18.9% with abdominal pain requiring admission (9.8%) and post-ERP pancreatitis (5.7%) being most common. On multivariate analysis, female sex (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.9-2.9), acute recurrent pancreatitis (aOR, 5.0; 95% CI, 1.7-15.3), chronic pancreatitis (aOR, 1.8; 95% CI, 1.3-2.6), and pancreatic sphincter of Oddi dysfunction (aOR, 2.1; 95% CI, 1.4-3.3) were associated with an increased risk of overall AEs. Pancreatic sphincterotomy (aOR, 1.9; 95% CI, 1.5-2.4) and therapeutic stenting (aOR, 1.6; 95% CI, 1.2-2.2) also increased the risk of AEs. CONCLUSIONS Nearly 1 in 5 patients who undergo therapeutic ERP will experience an AE; however, the rates of major AEs, including post-ERP pancreatitis, bleeding, and perforation, are low.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Augustin R. Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Philip Tatman
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Steven A. Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Hazem T. Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Mihir S. Wagh
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Raj J. Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
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Bhatt H. Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: An Updated Review of Current Preventive Strategies. Clin Exp Gastroenterol 2021; 14:27-32. [PMID: 33564256 PMCID: PMC7866941 DOI: 10.2147/ceg.s276361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Harshil Bhatt
- Goshen Hospital, Goshen, IN, USA
- Indiana University School of Medicine, South Bend, IN, USA
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Pan G, Yang K, Gong B, Deng Z. Analysis of the Efficacy and Safety of Endoscopic Retrograde Cholangiopancreatography in Children With Symptomatic Pancreas Divisum. Front Pediatr 2021; 9:761331. [PMID: 34796156 PMCID: PMC8592933 DOI: 10.3389/fped.2021.761331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/12/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Endoscopic retrograde cholangiopancreatography (ERCP) has been increasingly performed in children with symptomatic pancreas divisum (PD). Aim: To investigate the safety and efficacy of ERCP in the treatment of children with symptomatic PD. Methods: We performed a retrospective analysis on children with PD who were treated with ERCP at Shanghai Children's Medical Center between June 2015 and May 2020. Pertinent patient, clinical and procedural data were collected to assess the therapeutic effects and identify the risk factors for post-ERCP pancreatitis (PEP). Results: Overall, 114 ERCPs were performed in 46 children with PD. With a median follow-up of 28.5 months (12-71 months), 40 (87.0%) children achieved clinical remission, the median number of acute pancreatitis episodes decreased from four times per year pre-operatively to once per year post-operatively (P < 0.001), and the nutritional score improved post-operatively (P = 0.004). The incidence of PEP was 7.9%, and female sex, stone extraction, and gene mutations were identified as possible risk factors for PEP on univariate analysis. However, there was no statistical significance on multivariate analysis (P > 0.05). Conclusion: Therapeutic ERCP is an effective and safe intervention for children with symptomatic PD.
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Affiliation(s)
- Guixian Pan
- Department of Gastroenterology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kaihua Yang
- Department of Gastroenterology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Biao Gong
- Department of Gastroenterology, Shanghai Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhaohui Deng
- Department of Gastroenterology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Wang X, Ren G, Xi Y, Luo H, Liang S, Wang B, Tao Q, Luo B, Qin Q, Farrell JJ, Guo X, Wu K, Pan Y. Learning curve of double-guidewire technique by trainees during hands-on endoscopic retrograde cholangiopancreatography training. J Gastroenterol Hepatol 2020; 35:2176-2183. [PMID: 32473040 DOI: 10.1111/jgh.15120] [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] [Received: 03/24/2020] [Revised: 05/22/2020] [Accepted: 05/25/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Double-guidewire technique (DWT) has been successfully performed by experts in difficult biliary cannulation as an advanced technique. This study aimed to define the learning curve and safety of DWT by trainees during hands-on endoscopic retrograde cholangiopancreatography (ERCP) training. METHODS Patients were eligible for inclusion in the study if the biliary cannulation was difficult and the pancreatic duct was inadvertently cannulated. DWT was performed by two trainees randomly under trainers' guidance. The primary outcome was the success rate of DWT biliary cannulation of trainees. Cumulative sum analysis was used to generate visual learning curves. RESULTS A total of 60 patients with difficult cannulation were enrolled. The main indications for ERCP were common bile duct stones (65%) and biliary stricture (31.7%). The learning curve analysis showed that to achieve a 70% rate of successful DWT, 12 procedures were needed for trainee A and 15 for trainee B. Higher targeted success rate of DWT could be achieved if the number of DWT procedures increased. Compared with the early stage of learning DWT (case 1 to 15 for each trainee), trainees had significantly higher DWT success rate in the late stage (36.7% [11/30] vs 80% [24/30], P = 0.001). The final success rate of cannulation was 98.3% (59/60). The overall rate of post-ERCP pancreatitis and adverse events was 6.7% (4/60) and 8.3% (5/60), respectively. CONCLUSIONS Double-guidewire technique was safely performed by two novel trainees during hands-on ERCP training. Fifteen procedures may be enough for trainees to achieve the competency of performing DWT. (Clinicaltrials.gov number: NCT03707613).
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Affiliation(s)
- Xiangping Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Gui Ren
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yibin Xi
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Hui Luo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Shuhui Liang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Biaoluo Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qin Tao
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bing Luo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qian Qin
- Department of General Surgery, First Affiliated Hospital of Xian Jiaotong University, Xi'an, China
| | - James J Farrell
- Department of Digestive Disease and Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Xuegang Guo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Wang X, Zhao J, Wang L, Ning B, Zeng W, Tao Q, Ren G, Liang S, Luo H, Wang B, Farrell JJ, Pan Y, Guo X, Wu K. Relationship between papilla-related variables and post endoscopic retrograde cholangiopancreatography pancreatitis: A multicenter, prospective study. J Gastroenterol Hepatol 2020; 35:2184-2191. [PMID: 32511794 DOI: 10.1111/jgh.15135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/23/2020] [Accepted: 06/06/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIM Papilla with hooknose or long protruding shape may increase the difficulty of cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, the relationship between papilla anatomy and complications of ERCP has not been fully understood. We aimed to investigate the effect of major duodenal papilla morphology on post-ERCP pancreatitis (PEP) and the procedure of cannulation. METHODS Patients with native papilla who underwent ERCP were recruited to this multicenter study. Papilla-related variables were collected, including the length of long axis (L), short axis (S) and opening width (OW), transverse fold, periampullary diverticulum (PAD), papilla location, orientation, swelling, and presence of duodenal stenosis. Demographic data and the procedure of cannulation were also prospectively evaluated. The primary outcome was PEP incidence. Multivariate analysis was used to identify high risk factors for PEP. RESULTS Six hundred and fifty-eight patients were enrolled. Overall PEP incidence was 4.7% (31/658). The papilla of patients complicated with PEP had higher long to short axis (L/S) ratio (odds ratio [OR] 3.84, 95% confidence interval [CI]: 1.37-10.74, P = 0.010), higher long axis to opening width (L/OW) ratio (OR 1.35, 95%CI: 1.06-1.71, P = 0.014), more transverse folds (OR 2.53, 95%CI: 1.02-6.26, P = 0.044), and less periampullary diverticulum (OR 0.21, 95%CI: 0.06-0.70, P = 0.011). Multivariate analysis revealed that the indication of common bile duct stones, normal bilirubin, inadvertent pancreatic duct cannulation > 1, L/S ratio ≥ 1.5, and absence of PAD were independent risk factors for PEP. CONCLUSION Besides patient-related and procedure-related factors, papilla-related variables, such as L/S ratio and PAD, can be considered as a third type of factors associated with PEP (Clinicaltrials.gov number: NCT03550768).
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Affiliation(s)
- Xiangping Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jianghai Zhao
- Department of Gastroenterology, Huaihe Hospital of Henan University, Kaifeng, China
| | - Limei Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.,Shaanxi Second People's Hospital, Xi'an, China
| | - Bo Ning
- Department of Gastroenterology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Zeng
- Department of Gastroenterology, Successful Hospital of Xiamen university, Xiamen, China
| | - Qin Tao
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Gui Ren
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Shuhui Liang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hui Luo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Biaoluo Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - James J Farrell
- Department of Digestive Disease and Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Yanglin Pan
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xuegang Guo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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