S0079 Prophylactic Rectal Indomethacin and Prophylactic Pancreatic Duct Stents (PPS) for Prevention of Post-ERCP Pancreatitis Are Underutilized in Average and High-Risk Patients Undergoing ERCP

Abstract

INTRODUCTION: Incidence of Post-ERCP pancreatitis (PEP) ranges from 1% to 10% in unselected patients and as high as 25% to 30% in high-risk patients. Rectal indomethacin (RI) administered before or immediately after an ERCP is associated with a 35% to 65% reduction in the incidence of PEP. Prophylactic pancreatic duct stent (PPS) placement in high risk patients is also regarded as the most effective mechanical prophylactic approach to reduce the incidence and severity of PEP. We sought to investigate utilization rate of prophylactic RI and PPS in average and high-risk patients undergoing ERCP between 2014 and 2019. METHODS: We performed a retrospective analysis in the IBM Explorys database, a pooled, national, de-identified clinical database of over 72 million unique patients from 26 health care networks and 300 hospitals across the United States. We examined demographics, high-risk features [history of acute pancreatitis at least 30 days before ERCP, sphincter of Oddi dysfunction (SOD), sphincterotomy] and incidence of PEP in patients with cumulative risk factors. The subjects were risk-stratified as either average-risk (absence of any of the studied risk factors) or high risk (presence of at least one risk factor). PEP was defined by the presence of SNOMED CT diagnosis of acute pancreatitis and an inpatient admission within 5 days of an ERCP procedure. RESULTS: Out of 31,050 adults who had undergone ERCP from 2014 to 2019, only 10,500 individuals (33.8%) had a PEP prophylaxis. RI and PPS accounted for 82.4% and 12.9% respectively. About 4.8% of patients had both RI and PPS within a day of ERCP procedure. Young individuals (< 40 years) had significantly higher RI use (32.1% vs 26.8%, P < 0.0001) than older individuals but lower PPS placement than older individuals (2.6% vs 4.7%, P < 0.0001). Women had higher RI use compared to men (29.2% vs 25.8%, P < 0.0001) but lower PPS placement (4.6% vs 5.2%, P = 0.016) than men. Individuals with three risk factors had the highest PEP rates: female + young + SOD: 20%; female + AP + sphincterotomy: 11.8%, followed by individuals with two risk factors: female + SOD: 11.1% and young + sphincterotomy: 10.7%. CONCLUSION: Only a third of all patients undergoing ERCP received prophylaxis in the form of RI and PPS in this large population-based data. Increased implementation of prophylactic use is needed in patients undergoing ERCP as supported by current guidelines.