ERCP-Associated Pancreatitis: Systematic Evaluation of 99,483 ERCP Procedures with Qualitative Meta-Analysis

Abstract

Purpose: ERCP-associated pancreatitis (EAP) is a serious complication of ERCP. Contradictory data exist regarding prevention of ERCP. We did a systematic eval of 99,483 ERCP procedures with qualitative meta- analysis (Meta-ethnography). Methods: PubMed Search for ERCP with no language barrier (1995–2006) was done. Also PubMed Search for”PostERCPpancreatitis”was done. More papers on EAP were added manually. Depending on the quality, trials were classifiedLevel1–4. Meta-ethnography by Qualitative research methods was performed (Eval Rev 9:627–643, 1985:The Lancet 358:483–488, 2001) Results: From 1995 to 2006, there were 6140 citations for ERCP;5193(85%) were in English. There were 203 citations for EAP;29 more papers on EAP were added manually. Detailed eval of 232 papers was done:Summary shheets were created. The total no. of ERCP procedures was 99,483; EAP occurred in 4535 (4.5%, range 0.2–33%; Median 6.2%) cases. Gender info was available in 34,951;20,062 (57%) were women. Mean age was 55.6 yrs. Pharmacologic interventions to prevent EAP included somatostatin, Octreotide, gabexate, ionic vs non-ionic contrast media, prednisone, allopurinol, hydrocortisone, glucagon, calcitonin, atropine, n-acetylcysteine, nifedipine, glyceryl trinitrate, 5FU, Lidocaine or epinephrine spray, botulinum toxin, ulinastatin, aprotinin, beta-carotene, S.Q. heparin, diclofenac, indocin (Rect Supp), secretin, prophylactic antibiotics, interleukin-10 antag, monoleukast Na, H-2 receptor antag, CCK antag, lexipanphate (PAF inhibitor) & oral tetracycline. In general pharmacologic methods were ineffective:somatostatin, gabexate, Ulinastatin showed promise. Osmolality of Contrast media had no effect on EAP. Endoscopic methods included suprapapillary needle puncture, transpapillary septotomy, biliary sphincterotomy, prophylactic pancreatic stent (PPS). The PPS seems effective in preventing EAP: however a failure to put an attempted SSP more likely will result in SEVERE EAP. The risk factors for EAP are:female gender, young age, precut sphinct, balloon dilation of papilla, SOD, difficult cannulation, pancreatic injection, normal bilirubin, previous h/o EAP. Conclusion: The frequency of EAP is 4.5%; range 0.25 to 33%; median 6.5% Pharmacologic methods to prevent EAP unsatisfactory. PPS is effective but has important caveat. Risk factors for EAP should be recognized.