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Takada Y, Ishikawa T, Yamao K, Mizutani Y, Iida T, Uetsuki K, Kawashima H. A case of pancreatic fistula with disruption of the inferior branch of the pancreatic duct caused by a pancreatic stent after endoscopic papillectomy. Clin J Gastroenterol 2025; 18:169-175. [PMID: 39576492 DOI: 10.1007/s12328-024-02067-x] [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: 08/21/2024] [Accepted: 11/13/2024] [Indexed: 02/01/2025]
Abstract
A 73-year-old man underwent upper gastrointestinal endoscopy for abdominal pain, which revealed an ampullary adenoma with no obvious extension into the bile or pancreatic ducts. Endoscopic papillectomy (EP) was performed and a 5-Fr 5-cm stent was placed in the pancreatic duct. The patient developed acute pancreatitis on postoperative day (POD) 1 and contrast-enhanced computed tomography performed on POD 2 revealed that the proximal end of the stent had migrated into the retroperitoneum, forming a pancreatic fistula. Stent removal and endoscopic nasopancreatic drainage were performed and the pancreatitis rapidly improved. The tumor was completely resected and after approximately three years of follow-up, no tumor recurrence or acute pancreatitis was observed.Retrospectively, the inferior branch of the pancreatic duct was prominent on pancreatography at the time of EP and the proximal end of the stent had dislocated into the inferior branch. The stent subsequently moved proximally, which could have caused pancreatitis and pancreatic fistula. The morphology of the pancreatic duct should be carefully monitored during stenting. Selecting a stent that matches each patient's specific pancreatic duct morphology may help physicians minimize the risk of adverse outcomes.
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Affiliation(s)
- Yoshihisa Takada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65, Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65, Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan.
| | - Kentaro Yamao
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65, Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65, Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Tadashi Iida
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Kota Uetsuki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65, Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65, Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
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Nagai K, Sofuni A, Tsuchiya T, Ishii K, Tanaka R, Tonozuka R, Mukai S, Yamamoto K, Matsunami Y, Asai Y, Kurosawa T, Kojima H, Minami H, Honma T, Katanuma A, Itoi T. The feasibility of pancreatic duct stenting using a novel 4-Fr plastic stent with a 0.025-in. guidewire. Sci Rep 2021; 11:14285. [PMID: 34253746 PMCID: PMC8275660 DOI: 10.1038/s41598-021-92811-x] [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: 03/05/2021] [Accepted: 07/01/2021] [Indexed: 11/18/2022] Open
Abstract
Pancreatic duct stenting is a well-established method for reducing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, there is no consensus on the optimal type of plastic stent. This study aimed to evaluate the feasibility and safety of a new 4-Fr plastic stent for pancreatic duct stenting. Forty-nine consecutive patients who placed the 4-Fr stent into the pancreatic duct (4Fr group) were compared with 187 consecutive patients who placed a conventional 5-Fr stent (control group). The primary outcome was technical success. Complications rate, including post-ERCP pancreatitis (PEP) were the secondary outcomes. Propensity score matching was introduced to reduce selection bias. The technical success rate was 100% in the 4Fr group and 97.9% in the control group (p = 0.315). Post-ERCP amylase level was significantly lower in the 4-Fr group than the control group before propensity score matching (p = 0.006), though without statistical significance after propensity score matching (p = 0.298). The rate of PEP in the 4Fr group (6.1%) was lower than the control group (15.5%), though without statistical significance before (p = 0.088) and after (p = 1.00) propensity score matching. Pancreatic duct stenting using a novel 4-Fr plastic stent would be at least similar or more feasible and safe compared to the conventional plastic stent.
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Affiliation(s)
- Kazumasa Nagai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kentaro Ishii
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Yukitoshi Matsunami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Yasutsugu Asai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takashi Kurosawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hiroyuki Kojima
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hirohito Minami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Toshihiro Honma
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Akio Katanuma
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.,Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
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Dubravcsik Z, Hritz I, Keczer B, Novák P, Lovász BD, Madácsy L. Network meta-analysis of prophylactic pancreatic stents and non-steroidal anti-inflammatory drugs in the prevention of moderate-to-severe post-ERCP pancreatitis. Pancreatology 2021; 21:704-713. [PMID: 33926821 DOI: 10.1016/j.pan.2021.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/30/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is an ongoing debate that non-steroidal anti-inflammatory drugs (NSAID) or prophylactic pancreatic stents (PPS) are more beneficial in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). In our present network meta-analysis, we aimed to compare PPSs to rectal NSAIDs in the prevention of moderate and severe PEP in average- and high-risk patients. METHODS We performed a systematic search for randomized controlled trials (RCT) from MEDLINE (via PubMed), Embase and Cochrane Central databases. RCTs using prophylactic rectal NSAIDs or PPSs in patients subjected to ERCP at average- and high-risk population were included. The main outcome was moderate and severe PEP defined by the Cotton criteria. Pairwise Bayesian network meta-analysis was performed, and interventions were ranked based on surface under cumulative ranking (SUCRA) values. RESULTS Seven NSAID RCTs (2593 patients), and 2 PPS RCTs (265 patients) in the average-risk, while 5 NSAID RCTs (1703 patients), and 8 PPS RCTs (974 patients) in the high-risk group were included in the final analysis. Compared to placebo, only PPS placement reduced the risk of moderate and severe PEP in both patient groups (average-risk: RR = 0.07, 95% CI [0.002-0.58], high-risk: RR = 0.20, 95% CI [0.051-0.56]) significantly. Rectal NSAID also reduced the risk, but this effect was not significant (average-risk: RR = 0.58, 95% CI [0.22-1.3], high-risk: RR = 0.58, 95% CI [0.18-2.3]). Based on SUCRA, PPS placement was ranked as the best preventive method. CONCLUSION Prophylactic pancreatic stent placement but not rectal NSAID seems to prevent moderate-to-severe PEP better both, in average- and high-risk patients.
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Affiliation(s)
- Zsolt Dubravcsik
- Department of Gastroenterology, BKM Hospital, Kecskemét, Hungary.
| | - István Hritz
- Center for Therapeutic Endoscopy, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Bánk Keczer
- Center for Therapeutic Endoscopy, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Péter Novák
- Department of Gastroenterology, BKM Hospital, Kecskemét, Hungary
| | | | - László Madácsy
- Department of Gastroenterology, BKM Hospital, Kecskemét, Hungary; Endo-kapszula Private Medical Center, Székesfehérvár, Hungary
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Triaging advanced GI endoscopy procedures during the COVID-19 pandemic: consensus recommendations using the Delphi method. Gastrointest Endosc 2020; 92:535-542. [PMID: 32425235 PMCID: PMC7229945 DOI: 10.1016/j.gie.2020.05.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/10/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS There is a lack of consensus on which GI endoscopic procedures should be performed during the COVID-19 pandemic, and which procedures could be safely deferred without having a significant impact on outcomes. METHODS We selected a panel of 14 expert endoscopists. We identified 41 common indications for advanced endoscopic procedures from the ASGE Appropriate Use of GI Endoscopy guidelines. Using a modified Delphi method, we first achieved consensus on the patient-important outcome for each procedural indication. Panelists prioritized consensus patient-important outcome when categorizing each indication into one of the following 3 procedural time periods: (1) time-sensitive emergent (schedule within 1 week), (2) time-sensitive urgent (schedule within 1 to 8 weeks), and (3) non-time sensitive (defer for >8 weeks and then reassess the timing). Three anonymous rounds of voting were allowed before attempts at consensus were abandoned. RESULTS All 14 invited experts agreed to participate in the study. The prespecified consensus threshold of 51% was achieved for assigning patient-important outcome(s) to each advanced endoscopy indication. The prespecified consensus threshold of 66.7% was achieved for 40 of 41 advanced endoscopy indications in stratifying them into 1 of 3 procedural time periods. For 12 of 41 indications, 100% consensus was achieved; for 20 of 41 indications, 75% to 99% consensus was achieved. CONCLUSIONS By using a Modified Delphi method that prioritized patient-important outcomes, we developed consensus recommendations on procedural timing for common indications for advanced endoscopy. These recommendations and the structured decision framework provided by our study can inform decision making as endoscopy services are reopened.
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Phillip V, Pukitis A, Epstein A, Hapfelmeier A, Haf D, Schwab M, Demir IE, Rosendahl J, Hoffmeister A, Schmid RM, Weber A, Algül H. Pancreatic stenting to prevent post-ERCP pancreatitis: a randomized multicenter trial. Endosc Int Open 2019; 7:E860-E868. [PMID: 31281872 PMCID: PMC6609234 DOI: 10.1055/a-0886-6384] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/29/2019] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Acute pancreatitis (AP) is one of the most common gastrointestinal disorders leading to hospitalization and the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Besides pharmaco-prophylaxis, pancreatic stenting has been demonstrated to protect from post-ERCP pancreatitis (PEP). However, it remains unclear which patients benefit from pancreatic stenting. We therefore hypothesized that in an unselected population, inadvertent cannulation of the pancreatic duct during first-time ERCP increases risk of PEP and that this risk can be significantly reduced by pancreatic stenting. Patients and methods This study was a multicenter, prospective, randomized controlled trial conducted at four European centers. A total of 167 patients undergoing first-time ERCP were enrolled in this trial. In the case of inadvertent cannulation of the pancreatic duct, patients were randomly assigned to receive either a 5 French plastic pancreatic stent of various length or no routine prophylactic intervention for PEP. Results A total of 167 patients were included in the final analysis. Prophylactic stent insertion significantly reduced the rate of PEP during first-time ERCP (odds ratio 0.43; 95% confidence interval 0.19 - 0.98; P = 0.04). The number needed to treat to prevent one case of PEP by prophylactic stent insertion after inadvertent cannulation of the pancreatic duct was 8.1 for the intention-to-treat population. Conclusion In an unselected patient population, inadvertent cannulation of the pancreatic duct during first-time ERCP is associated with a high risk for PEP. This risk can be significantly reduced by prophylactic pancreatic stenting, which is a safe and feasible procedure.
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Affiliation(s)
- Veit Phillip
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Aldis Pukitis
- Pauls Stradins Clinical University Hospital, Center of Gastroenterology, Hepatology and Nutrition, Riga, Latvia
| | - Alexey Epstein
- First Clinical Hospital named after E.E. Volosevich, Arkhangelsk, Russia
| | - Alexander Hapfelmeier
- Institut für Medizinische Informatik, Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - David Haf
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Miriam Schwab
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Ihsan Ekin Demir
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Jonas Rosendahl
- Klinik für Gastroenterologie und Rheumatologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik für Gastroenterologie und Rheumatologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Roland M. Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Andreas Weber
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Hana Algül
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany,Corresponding author Prof. Dr. Hana Algül, MPH Klinikum rechts der Isar, Technische Universität MünchenKlinik und Poliklinik für Innere Medizin IIIsmaningerstr. 22, 81675 MünchenGermany+49089-4140-4115
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Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Watanabe K, Nakamura J, Kikuchi H, Takasumi M, Hashimoto M, Hikichi T, Ohira H. Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis using pancreatic stents: A review of efficacy, diameter and length. World J Meta-Anal 2019; 7:259-268. [DOI: 10.13105/wjma.v7.i6.259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/02/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023] Open
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Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Watanabe K, Nakamura J, Kikuchi H, Takasumi M, Hashimoto M, Hikichi T, Ohira H. Pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis. World J Meta-Anal 2019; 7:249-258. [DOI: 10.13105/wjma.v7.i5.249] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/07/2019] [Accepted: 05/11/2019] [Indexed: 02/06/2023] Open
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Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Watanabe K, Nakamura J, Kikuchi H, Waragai Y, Takasumi M, Hikichi T, Ohira H. Pancreatic stents for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis should be inserted up to the pancreatic body or tail. World J Gastroenterol 2018; 24:2392-2399. [PMID: 29904246 PMCID: PMC6000294 DOI: 10.3748/wjg.v24.i22.2392] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 03/29/2018] [Accepted: 05/05/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the location to which a pancreatic stent should be inserted to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). METHODS Over a ten-year period at our hospital, 296 patients underwent their first ERCP procedure and had a pancreatic stent inserted; this study included 147 patients who had ERCP performed primarily for biliary investigation and had a pancreatic stent inserted to prevent PEP. We divided these patients into two groups: 131 patients with a stent inserted into the pancreatic head (head group) and 16 patients with a stent inserted up to the pancreatic body or tail (body/tail group). Patient characteristics and ERCP factors were compared between the groups. RESULTS Pancreatic amylase isoenzyme (p-AMY) levels in the head group were significantly higher than those in the body/tail group [138.5 (7.0-2086) vs 78.5 (5.0-1266.5), P = 0.03] [median (range)]. No cases of PEP were detected in the body/tail group [head group, 12 (9.2%)]. Of the risk factors for post-ERCP hyperamylasemia (≥ p-AMY median, 131 IU/L), procedure time ≥ 60 min [odds ratio (OR) 2.65, 95%CI: 1.17-6.02, P = 0.02) and stent insertion into the pancreatic head (OR 3.80, 95%CI: 1.12-12.9, P = 0.03) were identified as independent risk factors by multivariate analysis. CONCLUSION Stent insertion up to the pancreatic body or tail reduces the risk of post-ERCP hyperamylasemia and may reduce the risk of PEP.
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Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Rei Suzuki
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Naoki Konno
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Yuki Sato
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Hiroki Irie
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Ko Watanabe
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Jun Nakamura
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Hitomi Kikuchi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Yuichi Waragai
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Mika Takasumi
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima 960-1247, Japan
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Zagalsky D, Guidi MA, Curvale C, Lasa J, de Maria J, Ianniccillo H, Hwang HJ, Matano R. Early precut is as efficient as pancreatic stent in preventing post-ERCP pancreatitis in high-risk subjects - A randomized study. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:258-562. [PMID: 27604474 DOI: 10.17235/reed.2016.4348/2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The most common adverse event of endoscopic retrograde cholangiopancreatography is pancreatitis. Precut sphincterotomy has been regarded as a risk factor. Some authors have stated that early precut may actually reduce post-ERCP pancreatitis risk. However, early precut as a preventive measure has not been compared to other preventive measures, such as pancreatic duct stent placement. AIM To compare the efficacy of early precut sphincterotomy versus pancreatic duct stent placement in high-risk subjects undergoing endoscopic retrograde cholangiopancreatography for the prevention of post-endoscopic cholangiopancreatography. MATERIALS AND METHODS This was a single-blinded, randomized trial that took place in two tertiary referral centers in Buenos Aires, from November 2011 to December 2013. ERCP subjects presented at least one of the following risk factors: female sex, age less than 40 years, clinical suspicion of sphincter of Oddi dysfunction, previous pancreatitis, and/or common bile duct diameter of less than 8 mm. Only those who presented a difficult biliary cannulation were randomized into two groups: those who received early precut sphincterotomy and those in whom persistency of biliary cannulation was intended, with subsequent pancreatic duct stent placement after cholangiography was achieved. The incidence of post-ERCP pancreatitis, as well as other adverse events incidence, was compared. RESULTS Overall, 101 patients were enrolled, 51 in the pancreatic duct stent group and 50 in the early precut group. Pancreatitis rate was similar in both groups (3.92% vs 4%, p NS). In all cases, pancreatitis was classified as mild. There were no deaths registered. CONCLUSION Early precut was associated with an incidence of adverse events similar to pancreatic duct stent placement.
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Talukdar R. Complications of ERCP. Best Pract Res Clin Gastroenterol 2016; 30:793-805. [PMID: 27931637 DOI: 10.1016/j.bpg.2016.10.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 10/11/2016] [Accepted: 10/21/2016] [Indexed: 01/31/2023]
Abstract
Even though considered safe, endoscopic retrograde cholangiopancreatography (ERCP) is among the endoscopic procedures associated with the highest rate of complications. Post ERCP pancreatitis (PEP) is the most common complication of ERCP. Several independent risk factors have been associated with PEP. Prophylactic PD stenting has been shown to be highly effective in preventing PEP. More recent studies have suggested that NSAIDs, especially rectal indomethacin, could by itself be effective in preventing PEP. However, head to head RCTs comparing PD stents with NSAIDs would be required to confirm this. Other complications include ERCP induced bleeding, perforation, and cholangitis. Bleeding is related to morphological, procedural, and patient related factors. Early identification and correction of the risk factors are of paramount importance in preventing bleeding. Risk of infection is particularly high during ERCP. It is important to ensure complete drainage of obstructed biliary system in order to reduce the risk of post-ERCP cholangitis.
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Affiliation(s)
- Rupjyoti Talukdar
- Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad, 500082, Telangana, India; Asian Healthcare Foundation, 6-3-661 Somajiguda, Hyderabad, 500082, Telangana, India.
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11
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Olsson G, Lübbe J, Arnelo U, Jonas E, Törnqvist B, Lundell L, Enochsson L. The impact of prophylactic pancreatic stenting on post-ERCP pancreatitis: A nationwide, register-based study. United European Gastroenterol J 2016; 5:111-118. [PMID: 28405329 DOI: 10.1177/2050640616645434] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/23/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The role of prophylactic pancreatic stenting (PS) in preventing post-endoscopic retrograde cholangio-pancreatography (ERCP) pancreatitis (PEP) has yet to be determined. Most previous studies show beneficial effects in reducing PEP when prophylactic pancreatic stents are used, especially in high-risk ERCP procedures. The present study aimed to address the use of PS in a nationwide register-based study in which the primary outcome was the prophylactic effect of PS in reducing PEP. METHODS All ERCP-procedures registered in the nationwide Swedish Registry for Gallstone Surgery and ERCP (GallRiks) between 2006 and 2014 were studied. The primary outcome was PEP but we also studied other peri- and postoperative complication rates. RESULTS Data from 43,595 ERCP procedures were analyzed. In the subgroup of patients who received PS with a total diameter ≤ 5 Fr, the risk of PEP increased nearly four times compared to those who received PS with a total diameter of >5 Fr (OR 3.58; 95% CI 1.40-11.07). Furthermore, patients who received PS of >5 Fr and >5 cm had a significantly lower pancreatitis frequency compared to those with shorter stents of the same diameter (1.39% vs 15.79%; p = 0.0033). CONCLUSIONS PS with a diameter of >5 Fr and a length of >5 cm seems to have a better protective effect against PEP, compared to shorter and thinner stents. However, in the present version of GallRiks it is not possible to differentiate the exact type of pancreatic stent (apart from material, length and diameter) that has been introduced, so our conclusion must be interpreted with caution.
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Affiliation(s)
- Greger Olsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Highland Hospital, Eksjö, Sweden
| | - Jeanne Lübbe
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Division of Surgery, Tygerberg Hospital and Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Eduard Jonas
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Björn Törnqvist
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Lars Lundell
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Enochsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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Prophylactic Efficacy of 3- or 5-cm Pancreatic Stents for Preventing Post-ERCP Pancreatitis: A Prospective, Randomized Trial. J Clin Gastroenterol 2016; 50:e30-4. [PMID: 26280707 DOI: 10.1097/mcg.0000000000000397] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND STUDY AIMS Prophylactic pancreatic stent placement is effective for preventing postendoscopic retrograde cholangiopancreatography pancreatitis (PEP). The most effective type of stent, however, remains unclear. Therefore, we prospectively compared the prophylactic efficacy for PEP prevention between short (3 cm) and long (5 cm) pancreatic stent. PATIENTS AND METHODS Between July 2012 and June 2014, 240 consecutive patients requiring therapeutic endoscopic retrograde cholangiopancreatography to remove a choledocholith or for bile drainage for obstructive jaundice were prospectively enrolled and randomized to undergo prophylactic insertion with unflanged, 5 Fr, 3 or 5-cm pancreatic stent. An efficacy of each stent for preventing PEP was evaluated as a primary endpoint. The period until stent dislodgement and the total adverse event rate were also evaluated as a secondary endpoint. RESULTS Per-protocol analysis revealed that the PEP rate was significantly lower with the short stent than with the long stent (2.0% vs. 8.8%, P=0.035), although they were not significantly different in intention-to-treat analysis. The adverse event rate excluding PEP did not differ significantly between groups (3.0% vs. 0.9%, P=0.293). The median period until dislodgement of the short stent was significantly shorter than that of the long stent (2 vs. 4 d, P<0.001). CONCLUSIONS The present study revealed a superiority of 3-cm stents compared with 5-cm stents for prophylactic pancreatic stent. On the basis of the past reports and the result of the present study, we recommend using a 5 Fr, 3-cm unflanged stent.This study was registered on the UMIN Clinical Trial Registry (UMIN000008290).
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Abstract
This article reviews the diagnosis and management of sphincter of Oddi dysfunction (SOD), including the various factors to consider before embarking on endoscopic therapy for SOD. Selection starts with patient education to include possible patient misconceptions related to symptoms caused by the pancreaticobiliary sphincter as well as reinforcing the risks associated with the diagnosis and therapy. The likelihood of relief of recurrent abdominal pain attributed to SOD is related to the classification of SOD type and a crucial consideration before considering endoscopic therapy in light of recent evidence.
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Endoscopic retrieval technique of proximally migrated pancreatic stents: a retrospective study in a tertiary centre. Gastroenterol Res Pract 2015; 2015:485980. [PMID: 25918523 PMCID: PMC4397053 DOI: 10.1155/2015/485980] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/23/2015] [Accepted: 03/24/2015] [Indexed: 12/29/2022] Open
Abstract
Background. There were scarce trials concerning the treatments and outcomes of proximal pancreatic stent migration. Herein, we did a retrospective study to discuss this problem from an endoscopist's point of view. Patients and Methods. From January 2009 to June 2014, patients with proximally migrated pancreatic duct stents were identified. Their clinical information was viewed. Retrieval techniques, success rates, and adverse events were analyzed. Results. A total of 36 procedures were performed in 34 patients; the median age of the patients was 53 years, with 17 males and 17 females. Eight patients' pancreatic duct stents could still be seen in the major or minor papilla and were pulled out with a snare forceps or a grasping forceps; in the remaining 28 procedures, the management was somewhat thorny; the retrieval called for several devices. Final success was achieved in 31 patients. No adverse event was observed in the process of ERCP procedures, 5 patients developed post-ERCP pancreatitis (PEP), 1 patient got infection, and 1 patient had haemorrhage. Conclusions. Endoscopic retrieval of migrated pancreatic stent is safe and less invasive; nonetheless, attention should be paid so as to reduce the incidence and degree of related adverse events, especially PEP.
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is widely used in the diagnosis and treatment of cholangiopancreatic diseases, and pancreatitis remains the most common and severe complication. It is therefore important to minimize the incidence and severity of pancreatitis. This paper discusses the recent progress in the prevention and treatment of post-ERCP pancreatitis.
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is performed commonly for therapy. Its role in pancreaticobiliary diagnostic imaging has significantly decreased over time. Despite advances in our knowledge of the risk factors, complications, (especially post-ERCP pancreatitis), remain a significant problem. This review highlights the risk factors as related to the patient, procedure and the endoscopist, and the possible means to prevent complications. The best way to avoid any complication is "to avoid any procedure where the indication is not strong" and especially to refrain from doing diagnostic ERCP when alternate noninvasive imaging such as magnetic resonance cholangiopancreatography is available.
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Affiliation(s)
- Nalini M Guda
- St. Luke's Medical Center and University of Wisconsin School of Medicine and Public Health, Milwaukee, USA
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Abstract
Pancreatitis is one of the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). A variety of patient-related and procedure-related factors have been identified to risk-stratify patients. Several measures can be undertaken in order to decrease the risk of post-ERCP pancreatitis in high-risk groups. These measures include pancreatic duct stenting and rectal indomethacin, amongst others.
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Affiliation(s)
- Jennifer Maranki
- Temple University School of Medicine, 3401 N. Broad St., Suite 830 Parkinson Pavilion, Philadelphia, PA, 19140, USA,
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Chennat J. Indications for endoscopic retrograde cholangiopancreatography. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2012. [DOI: 10.1016/j.tgie.2012.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Letter in response to the recently published study: prophylactic pancreatic stents: does size matter? A comparison of 4-Fr and 5-Fr stents in reference to post-ERCP pancreatitis and migration rate. Dig Dis Sci 2012; 57:1105; author reply 1105-6. [PMID: 22302245 DOI: 10.1007/s10620-012-2063-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 01/14/2012] [Indexed: 12/09/2022]
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