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Abstract

We would like to thank Drs Buxbaum and Yu1Buxbaum J. Yu C.Y. Indomethacin and lactated Ringer’s hydration to prevent post-ERCP pancreatitis: right combination but wrong volume.Gastrointest Endosc. 2017; 86: 925-926Abstract Full Text Full Text PDF Scopus (3) Google Scholar for their contributions to the literature on preventing post-ERCP pancreatitis (PEP) and for their thoughtful assessment of our study.2Mok S.R.S. Ho H.C. Shah P. et al.Lactated Ringer's solution in combination with rectal indomethacin for prevention of post-ERCP pancreatitis and readmission: a prospective randomized, double-blinded, placebo-controlled trial.Gastrointest Endosc. 2017; 85: 1005-1013Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Although we agree with the authors’ pharmacodynamic assessment of lactated Ringer’s solution (LR) in preventing PEP, we believe that it is important to point out several things regarding the timing of volume resuscitation and of other interventions used to prevent PEP. In our randomized, prospective, double-blinded study, we administered either 1 liter of normal saline solution (NS) or LR solution before each patient underwent ERCP in combination with either indomethacin (IND) or placebo.2Mok S.R.S. Ho H.C. Shah P. et al.Lactated Ringer's solution in combination with rectal indomethacin for prevention of post-ERCP pancreatitis and readmission: a prospective randomized, double-blinded, placebo-controlled trial.Gastrointest Endosc. 2017; 85: 1005-1013Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar We found an overall incidence of PEP in 15% of patients: 21% in the NS plus placebo group and 6% in the LR plus IND group. We can extrapolate from the literature on acute pancreatitis that the timing and selection of fluid administration are both vital to reducing the incidence of systemic inflammatory response syndrome.3Wu B.U. Hwang J.Q. Gardner T.H. et al.Lactated Ringer’s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis.Clin Gastroenterol Hepatol. 2011; 9: 710-717Abstract Full Text Full Text PDF PubMed Scopus (322) Google Scholar Also important to note is that weight-based volume resuscitation was not useful for preventing pancreatitis. In evaluating the timing of preventative strategies for PEP, it is important to note that the incidence of PEP was lower in studies in which IND was administered before ERCP (5%) as compared with afterward (8%).4Wan J. Ren Y. Zhu Z. et al.How to select patients and timing for rectal indomethacin to prevent post-ERCP pancreatitis: a systematic review and meta-analysis.BMC Gastroenterol. 2017; 17: 43Crossref PubMed Scopus (20) Google Scholar Given the importance of timing for fluid administration in acute pancreatitis, and for rectal IND, we would argue that 1 liter before ERCP is not the same as 0.66 or 2 to 3 liters given afterward.5Buxbaum J. Yan A. Yeh K. et al.Aggressive hydration with lactated Ringer's solution reduces pancreatitis after endoscopic retrograde cholangiopancreatography.Clin Gastroenterol Hepatol. 2014; 12: 303-307.e1Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar Although perhaps 2 to 3 liters may be superior to 1 liter, the timing of fluid administration makes numeric comparisons less valid between our study and that of Buxbaum et al.1Buxbaum J. Yu C.Y. Indomethacin and lactated Ringer’s hydration to prevent post-ERCP pancreatitis: right combination but wrong volume.Gastrointest Endosc. 2017; 86: 925-926Abstract Full Text Full Text PDF Scopus (3) Google Scholar Again, our goal was to demonstrate that a practical pre-ERCP fluid administration was useful to prevent PEP and that LR was superior to NS in this setting. It is possible that more than 1 liter before ERCP or more than 1 liter after ERCP is more effective than 1 liter alone given before ERCP. However, we believe that comparisons regarding greater volume and the timing of fluid administration need further query before a conclusion can be met. Dr Elfant is a consultant for Boston Scientific. All other authors disclosed no financial relationships relevant to this publication. The authors thank David L. Diehl, MD, FACP, FASGE, and Katie A. Propst, MD, for their thorough review of the manuscript. Indomethacin and lactated Ringer’s hydration to prevent post-ERCP pancreatitis: right combination but wrong volumeGastrointestinal EndoscopyVol. 86Issue 5PreviewWe read with interest the recent study by Mok et al1 describing the role of rectal indomethacin combined with lactated Ringer’s solution (LR) infusion to prevent post-ERCP pancreatitis (PEP). The investigators’ strategy to combat PEP by using 2 potentially synergistic agents with different mechanisms of action draws parallels to the very successful strategy of using multidrug cocktails to treat the human immunodeficiency virus and more recently hepatitis C.2,3 Rectal indomethacin has been proved to prevent pancreatitis in high-risk cases and may have a role for average-risk procedures. Full-Text PDF