Endoscopic Retrograde Cholangiopancreatography Pancreatitis Research Articles

ThP5.10 - Post ERCP Pancreatitis at a Tertiary Center - A Retrospective Incidence and Causal Analysis

Abstract Background Incidence of Post Endoscopic Retrograde Cholangio-Pancreatography (ERCP) Pancreatitis (PEP) varies between 3.5% and 9.7% as per the 2014 meta-analyses. Our aim was to evaluate the incidence, perform a causal analysis and gauge the financial implications of PEP in our hospital for general surgical patients to help optimise the utilisation of resources. Methods All General Surgical patients who had ERCP between 01/10/2022 and 31/03/2023 were included in the analysis. A successful ERCP was defined as cannulation of the biliary tree. The digital patient records were analysed and collected onto a master datasheet. They were divided into PEP and non-PEP groups. Results A total of 131/155 attempted ERCPs were successful. Of these 131, 13 (9.92%) developed PEP. Females were predominantly affected. Three out of six patients (50%) undergoing ERCP for malignant biliary obstructions developed PEP. Elective ERCPs (15% vs 6.5%) and higher mean bilirubin levels >= 134.92 µmol/L posed a greater risk of developing PEP (p-value=0.021). The mean hospital stay was 3.5 days longer (2-49 days) in the PEP group. The total extra cost to the NHS ranged from £20,475 - £35,763 over 6 months. Conclusion Patients with gallstone disease should receive prompt cholecystectomy in adherence to NICE guidelines to reduce the risk of gallstone-related problems and ERCP need. This in turn would lead to a reduction in PEP and positively affect the financial implications on the NHS. We also recommend a randomised control trial for patients with grossly deranged liver function tests to compare ERCP with laparoscopic cholecystectomy and common bile duct explorations combined.

ThP3.15 - Trends in ERCP in a new city teaching hospital; is there a learning curve for a unit?

Abstract Aims Describe trends in volume, demographics, and complications over time for endoscopic retrograde cholangiopancreatography (ERCP) in a new endoscopy unit. Methods Prospective recording of all ERCPs in a new city teaching hospital commenced when the unit opened in 2015. This registry recorded patient demographics, indications, procedural data and complications. We analysed annual trends over time using linear regression. Results 4504 ERCPs were performed during the study period (1/6/15-31/5/23), with a female predominance of 58%. Median age (70 years, interquartile range 59-80) was unchanged over the study period, however the proportion under 30 years had decreased over time (4%-1%, slope -0.93, p=0.042). Total number of procedures per year has decreased over time (peak 628 in 2016, falling to 438 in 2022). The proportion performed for stone disease has fallen over the study period (80%-71%, slope -0.07, p=<0.001). Though not a statistically significant difference, the rate of ERCP pancreatitis has had a clinically significant decrease over time (5.4%-3.9%, slope -0.033, p=0.32). Conclusion A number of changes in practice have occurred since three units were merged into one unit. We routinely give diclofenac and IV fluids post-procedure. We now preferentially treat younger stone patients with laparoscopic cholecystectomy and common bile duct exploration. This results in an evolving use of contemporary ERCP with an older patient cohort with an increased indication of cancer and other reasons and fewer total numbers. These factors will contribute to a lower incidence of pancreatitis post-procedure but cannot discount a learning curve effect for a new unit.

Nitroglycerin combined with NSAIDs for prevention of post-ERCP pancreatitis: A meta-analysis of prospective, randomized, controlled trials.

Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), with an incidence of approximately 9.7% according to some literature reviews. Recent clinical guidelines propose that glyceryl trinitrate (GTN) can reduce the incidence of post-ERCP pancreatitis (PEP). However, currently, no guidelines provide an exact opinion on GTN and nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent post-ERCP pancreatitis. A meta-analysis was performed of published, full-length, randomized controlled trials (RCTs) evaluating the effects of prophylactic use of GTN, including GTN alone or GTN in combination with NSAIDs, on the prevention of PEP. Literature searches were conducted using PubMed, Embase, Web of Science, and The Cochrane Library. Search terms included "endoscopic retrograde cholangiopancreatography" OR "ERCP," "OR 'PEP' OR 'post-endoscopic retrograde cholangiopancreatography pancreatitis', pancreatitis," "GTN" OR "glyceryl trinitrate" OR "nitroglycerin," "NSAIDs" OR "Nonsteroidal Anti-inflammatory Drugs" and limited to RCT. A total of 10 RCTs comprising 3240 patients undergoing ERCP were included. Meta-analysis revealed that the administration of GTN was associated with a significant reduction in the overall incidence of PEP. Moreover, PEP incidence was significantly lower in the GTN combined with the NSAIDs group than in the GTN alone group. GTN alone or GTN combined with NSAIDs may not reduce the severity of PEP (risk ratio = 0.64; 95% confidence interval: 0.41-0.99; P = .04). The difference in incidence between the 2 groups is 1.01% (6/594) in the GTN with NSAIDs group and 2.36% (14/592) in the placebo group. GTN has a significant benefit in preventing postoperative ERCP pancreatitis (P < .001). And neither GTN nor GTN plus NSAIDs reduces the incidence of non-mild ERCP postoperative pancreatitis. These conclusions need to be confirmed by high-quality randomized controlled studies with multicenter, large samples, and long-term follow-up.

435 Post ERCP Pancreatitis at a Tertiary Centre - a Retrospective Incidence and Causal Analysis

Abstract Background Post Endoscopic Retrograde Cholangio Pancreatography (ERCP) pancreatitis (PEP) is a serious and potentially life-threatening complication of ERCP. The overall incidence of PEP varies between 3.5% and 9.7% as per the recent meta-analyses in 2014. We aim to evaluate the incidence of PEP, conduct a causal analysis and financial implications at our hospital for general surgical patients. Method All General Surgical patients who had ERCP done between 01/10/2022 and 31/03/2023 were included in the analysis. The patient records on TrakCare® were analysed for demographic details, admission records, ERCP details, pre-procedural laboratory values and length of stay. The successful ERCPs defined as cannulation of the common bile duct were divided into the PEP and the non-PEP groups. Results A total of 155 patients had ERCP attempted but only 131 were successful. Of these 131, 13 (9.92%) developed PEP. Females in their 60s were predominantly affected. Three out of six patients undergoing ERCP for malignant biliary obstructions were affected (50%). Patients with grossly deranged Liver Function Tests (mean bilirubin levels &amp;gt;=134.92µmol/L) had a higher risk of developing PEP (p-value=0.021). The mean overall hospital stay was 3.5 days longer (2-49 days) for patients who developed PEP costing an extra £20,475 - £35,763 over 6 months to the NHS. There were no mortalities recorded. Conclusions Patients with gallstone disease should receive prompt cholecystectomy adhering to NICE guidelines to reduce the risk of developing gallstone-related complications. This in turn would lead to a reduction in PEP and positively affect the financial implications for the NHS.

Multistep validation of a post-ERCP pancreatitis prediction system integrating multimodal data: a multicenter study

Background and study aimsThe impact of various categories of information on the prediction of Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis (PEP) remains uncertain. We aimed to comprehensively investigate the risk factors associated with PEP by constructing and validating a model incorporating multi-modal data through multiple steps. Patients and MethodsA total of 1,916 cases underwent ERCP were retrospectively collected from multiple centers for model construction. Through literature research, 49 electronic health record (EHR) features and one image feature related to PEP were identified. The EHR features were categorized into baseline, diagnosis, technique, and prevent strategies, covering pre-ERCP, intra-ERCP, and peri-ERCP phases. We first incrementally constructed models 1-4 incorporating these four feature categories, then added the image feature into models 1-4 and developed models 5-8. All models underwent testing and comparison using both internal and external test sets. Once the optimal model was selected, we conducted comparison among multiple machine learning algorithms. ResultsCompared with model 2 incorporating baseline and diagnosis features, adding technique and prevent strategies (model 4) greatly improved the sensitivity (63.89% vs 83.33%, p<0.05) and specificity (75.00% vs 85.92%, p<0.001). Similar tendency was observed in internal and external tests. In model 4, the top three features ranked by weight were previous pancreatitis, NSAIDS, and difficult cannulation. The image-based feature has the highest weight in model 5-8. Lastly, model 8 employed Random Forest algorithm showed the best performance. ConclusionsWe firstly developed a multi-modal prediction model for identifying PEP with clinical-acceptable performance. The image and technique features are crucial for PEP prediction.

Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis Risk Factors: Is Postsphincterotomy Bleeding Another Risk Factor?

Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis Risk Factors: Is Postsphincterotomy Bleeding Another Risk Factor?

Endoscopic features of low-phospholipid-associated cholelithiasis syndrome: A retrospective cohort study

Background and objectiveLPAC (low phospholipid-associated cholelithiasis) syndrome is a rare genetic form of cholelithiasis. ERCP (endoscopic retrograde cholangiopancreatography) is often used to remove gallstones in the bile duct. No published data is available on the role of ERCP in LPAC syndrome. Patients and methodsIn this retrospective cohort study, we included patients diagnosed with LPAC syndrome in a single tertiary referral center between 2009 and 2021. Our aim was to assess the frequency, indications, modalities, results, and complications of ERCP, as well as predictive factors for ERCP, in LPAC syndrome. Independent factors associated with ERCP occurrence were identified using a multivariable Cox regression analysis. ResultsERCP was required in 31.2 % of the 269 patients included for analysis. Among patients who required ERCPs, 78.6 % had the procedure before diagnosis (i.e., starting UDCA). Most common indications were choledocholithiasis (53.6 %) and acute cholangitis (29.5 %). Post ERCP pancreatitis, perforation and bleeding rates were 7.2 %, 2.6 %, and 1.3 %, respectively. Age and history of cholelithiasis in first-degree relatives were associated with a higher risk of ERCP (Hazard-ratio [HR]=1.30 [95 %confidence-interval [CI] 1.04–1.62] and HR=1.88 [95 %CI 1.15–3.07] respectively). Female gender and UDCA intake ≥ 1 year were associated with a lower risk of ERCP (HR=0.49 [95 %CI 0.29–0.82] and HR=0.44 [95 %CI 0.22–0.90] respectively). Median follow-up was 10.8 years. ConclusionOne-third of patients with LPAC syndrome undergo sphincterotomy. However, most procedures are performed before diagnosis and UDCA is associated with a lower risk of endoscopic procedure. Earlier diagnosis and treatment with UDCA may further reduce the need for ERCP in patients with LPAC syndrome.

Validity of Predictive Markers for Post ERCP Pancreatitis Patients: A Single Centre Study

Abstract: Endoscopic retrograde cholangiopancreatography (ERCP) is a proprietary procedure, endoscopic modality, and specialized procedure used to diagnose and treat disorders of the pancreatic and biliary systems. The incidence of reported post-ERCP complications varied among several studies including post ERCP pancreatitis (PEP), duodenal perforation, and cholangitis. In this study, the author would like to show certain intra procedural factors related to PEP incidence. This was a retrospective study of secondary data of patients undergoing ERCP procedures from 2017-2022 at Prof. Dr. R. D. Kandou Hospital, Manado. Length of procedure, cannulation on pancreatic duct, pancreatogram, double wire technique, and the use of certain common bile duct (CBD) stone retrieval techniques such as endoscopic papillary balloon dilatation (EPBD) were recorded and analyzed. The results showed that based on the analyzed data, the percentage of pancreas cannulation was 8%, pancreatogram 5%, double-wire technique 3%, and EPBD procedure 10%, Incidence rate of PEP in all ERCP procedures was 19%. Increased amylase/lipase enzymes were found in 13 of 24 patients (54%) who underwent cannulation; 8 of 16 patients (50%) who underwent pancreatogram; 4 of 9 patients (44%) who underwent double wire procedure; and 10 of 30 patients (33%) who underwent EPBD. This PEP could be caused by several risk factors during ERCP including cannulation, pancreatogram, double wire, and EPBD. Number of cannulation attempt could result in trauma to the ampulla. Pancreatogram could result in hydrostatic, chemical, and allergic injury. Any manipulation of the pancreas that caused trauma could trigger the incidence of PEP. Assessment of the occurrence of PEP was based on increases in lipase and amylase enzyme values by four times the normal value and tested 6 hours after procedure. We could reduce the incidence of PEP by providing prophylactic therapy before ERCP. In conclusion, PEP is the most common complication in ERCP procedures and can be risky in patients with high risk factors. In this study, factors that affecting the incidence of PEP are cannulation, pancreatogram, double wire and EPBD. Keywords: endoscopic retrograde cholangiopancreatography; pancreatitis; complications

Weekend endoscopic retrograde cholangiopancreatography has similar outcomes as weekday procedures-a propensity score match analysis of the Hungarian ERCP Registry.

Endoscopic retrograde cholangiopancreatography (ERCP) is essential for the minimally invasive management of biliary and pancreatic disorders. Under certain indications, performing ERCP without delay during the weekend can be important for improving outcomes. To compare the outcomes of ERCP performed on weekends and holidays with those of regular weekday ERCPs. Propensity score match analysis of the data from the Hungarian ERCP Registry. A total of 116 ERCPs were performed during weekends or holidays, and 3144 during weekday working hours. The analyses were performed on 1:2 propensity-matched groups (116 weekend and 232 weekday cases). Weekend ERCPs were mostly performed for acute cholangitis and acute biliary pancreatitis (70% of cases), whereas in the weekday group, only 32% of cases were performed for these indications. No significant difference was found between weekday and weekend ERCPs in terms of the rates of successful (91.38% vs 93.1%, p = 0.565) and difficult (33.62% vs 36.64%, p = 0.511) biliary cannulations. We found no significant differences in the number of adverse events (bleeding, post-ERCP pancreatitis, and 30-day mortality) in ERCPs performed during weekends or weekdays. Moreover, no significant differences in the aforementioned outcomes were detected between the propensity-matched groups. In this propensity-matched study, no significant differences were found in the outcomes of weekend and weekday ERCPs.

Indications, success, and adverse event rates of pediatric endoscopic retrograde cholangiopancreatography (ERCP): a systematic review and meta-analysis

BackgroundTo improve knowledge on endoscopic retrograde cholangiopancreatography (ERCP) in children, we aimed to study the proportion of indications, success rate and complication of ERCP.MethodsWe performed a systematic search of all articles published up to December 2022 in the following databases: Cochrane Library, PubMed (MEDLINE) and Scopus. The meta-analysis was performed using a random-effects model. Heterogeneity was determined by the I2 statistics and the Cochrane Q test. The included data were analyzed to identify the proportion of indications, success rate and complications of ERCP in children.ResultsBased on data from 52 studies with a total of 5624 participants, the most common indications for ERCP in children were biliary [48% (95% CI: 0.40 - 0.57; I2 = 98.17%, P < 0.001)] and both biliary and pancreatic [41% (95% CI: 0.33 - 0.49; I2 = 98.27%, P < 0.001)]. The success rate of ERCP was 95% (95% CI: 0.94 - 0.96; I2 = 82.53%, P < 0.001) with the overall complication rate of 7% (95% CI: 0.05 - 0.09; I2 = 82.06%, P < 0.001). The pooled estimate for the incidence of post ERCP pancreatitis was 4% (95% CI: 0.03 - 0.06; I2 = 85.46%, P < 0.001) and the bleeding was 0% (95% CI: 0.0 - 0.0; I2 = 28.21%, P = 0.03).ConclusionsERCP appears to be performed safely in children with a similar success rate as in the adult population.

Efficacy and safety of endoscopic retrograde cholangiopancreatography in recurrent pancreatitis of pediatric asparaginase-associated pancreatitis.

Asparaginase (ASP) is an important drug in combined chemotherapy regimens for pediatric acute lymphoblastic leukemia (ALL); ASP-associated pancreatitis (AAP) is the main adverse reaction of ASP. Recurrent pancreatitis is a complication of AAP, for which medication is ineffective. To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in treating recurrent pancreatitis due to AAP. From May 2018 to August 2021, ten children (five males and five females; age range: 4-13 years) with AAP were treated using ERCP due to recurrent pancreatitis. Clinical data of the ten children were collected, including their sex, age, weight, ALL risk grading, clinical symptoms at the onset of pancreatitis, time from the first pancreatitis onset to ERCP, ERCP operation status, and postoperative complications. The symptomatic relief, weight change, and number of pancreatitis onsets before and after ERCP were compared. The preoperative symptoms were abdominal pain, vomiting, inability to eat, weight loss of 2-7 kg, and 2-9 pancreatitis onsets. After the operation, nine of ten patients did not develop pancreatitis, had no abdominal pain, could eat normally; the remaining patient developed three pancreatitis onsets due to the continuous administration of ASP, but eating was not affected. The postoperative weight gain was 1.5-8 kg. There was one case of post ERCP pancreatitis and two cases of postoperative infections; all recovered after medication. ERCP improved clinical symptoms and reduced the incidence of pancreatitis, and was shown to be a safe and effective method for improving the management of recurrent pancreatitis due to AAP.

Pharmacological and Endoscopic Interventions for Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) represents the most common serious complication after endoscopic retrograde cholangiopancreatography (ERCP). Rectal non-steroidal anti-inflammatory drugs (NSAIDs) and pancreatic duct stenting (PDS) are the prophylactic interventions with more evidence and efficacy; however, PEP still represents a significant source of morbidity, mortality, and economic burden. Chronic statin use has been proposed as a prophylactic method that could be cheap and relatively safe. However, the evidence is conflicting. We aimed to evaluate the impact of endoscopic and pharmacological interventions including chronic statin and aspirin use, on the development of PEP. A retrospective cohort study evaluated consecutive patients undergoing ERCP at John H. Stroger, Jr. Hospital of Cook County in Chicago from January 2015 to March 2018. Univariate and multivariate analyses were performed using logistic regression. A total of 681 ERCPs were included in the study. Twelve (1.76%) developed PEP. Univariate, multivariate, and subgroup analyses did not show any association between chronic statin or aspirin use and PEP. PDS and rectal indomethacin were protective in patients undergoing pancreatic duct injection. Pancreatic duct injection, female sex, and younger age were associated with a higher risk. History of papillotomy was associated with lower risk only in the univariate analysis (all P values < 0.05). Chronic use of statins and aspirin appears to add no additional benefit to prevent ERCP pancreatitis. Rectal NSAIDs, and PDS after appropriate patient selection continue to be the main prophylactic measures. The lower incidence at our center compared with the reported data can be explained by the high rates of rectal indomethacin and PDS, the use of noninvasive diagnostic modalities for patient selection, and the expertise of the endoscopists.

Universal prophylactic rectal nonsteroidal anti-inflammatory drugs with a policy of selective pancreatic duct stenting significantly reduce post-endoscopic retrograde cholangiopancreatography pancreatitis.

Although rectal nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be effective for the prevention of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis (PEP) in high-risk patients, the benefit in average-risk patients is unclear. We aimed at assessing the benefit of prophylactic rectal NSAIDs in unselected consecutive patients to prevent PEP. All patients undergoing index ERCP procedures from January 2018 until March 2020 were included. All patients received prophylactic rectal diclofenac. A prophylactic pancreatic duct (PD) stent was placed if there was repeated PD cannulation, at the discretion of the endoscopist. The frequency of PEP was compared with historical controls. Of 769 patients who underwent ERCP, 34 (4.4%) developed PEP (mild in 29 [85.3%], moderate in four [11.8%] and severe in one [2.9%]). Female gender, precut sphincterotomy, inadvertent PD cannulation and procedural time of > 30minutes predicted PEP in univariate analysis. Inadvertent PD cannulation (OR 4.6, 95% CI: 1.8-11.7; p < 0.001) and procedural time of > 30minutes (OR 8.5, 95% CI: 3.7-10.1; p < 0.001) were independent risk factors on multivariate analysis. When compared with historical controls, the odds of PEP with prophylactic use of rectal NSAIDs and selective PD stenting was 0.54 (CI: 0.31-0.93, p = 0.027). The number needed to treat (NNT) was 22 to prevent one PEP with prophylactic rectal NSAIDs. Routine use of prophylactic rectal NSAIDs effectively prevents the occurrence of PEP in unselected consecutive patients in a real-world scenario.

Risk Factors for Post Endoscopic Retrograde Cholangio Pancreatography(ERCP) Pancreatitis (PEP) and Efficacy of Octreotide in its Prevention

Background: Pancreatitis is a potentially fatal complication of ERCP, seen in 5-15% procedures. Factors precipitating its risk and effective pharmacological intervention for its prevention need exploration to improve patient safety. Objective: To identify risk factors for post-ERCP pancreatitis (PEP) and to determine efficacy of intravenous octreotide in preventing PEP. Methodology: A quasi-experimental triple blind placebo-based study included patients undergoing ERCP and randomize them in two groups through simple random sampling. Group A to receive intravenous Octreotide 4μg/kg before attempting cannulation during ERCP and 1cc N/S as placebo for group B. Patients were followed for PEP and data were analyzed using chi square (x2) and logistic regression analysis. Results: Of 203 included patients, 101 (49.3%) received octreotide while 102 (50.7%) were in control group. Post ERCP pancreatitis developed in 32 (15.8%) patients, in 8 (7.9%) patients of octreotide group while in 24 (23.8%) patients of control group (p value 0.002 with odds ratio (OR) for octreotide of 0.33 (95% CI 0.15- 0.71). We identified biliary surgery (p value 0.005), serum bilirubin ≥ 3 mg/dl (p value 0.03), cannulation&#x0D; time &gt; 5 minutes (p value 5 minutes, use of needle knife, PD cannulation and procedure time &gt; 30 minutes are associated with increased risk of PEP. Intravenous octreotide before cannulation reduces risk of post ERCP pancreatitis.

Trans-papillary bilio-pancreatic stenting: When how and which stent

Nowadays, stenting malignant biliary stenosis (extrahepatic or hilar), benign biliary stenosis, and pancreatic duct stenosis in chronic pancreatitis as well as stenting for prophylaxis of post- endoscopic retrograde cholangiopancreatography pancreatitis and for failed extraction of biliary stones or endoscopic papillectomy are the many common challenges for a bilio-pancreatic endoscopist. The purpose of this review is to provide a practical approach to bilio-pancreatic stenting indications and techniques. Having a thorough understanding of stenting indications and techniques, for a bilio-pancreatic endoscopist means being able to develop a tailored approach for each clinical scenario depending on the type of stent used. Biliary stents, in fact, vary in diameter, length, and composition, making it possible to give each patient personalized treatment.

Evaluation of direct epinephrine injection into the major papilla in the prevention of post ERCP pancreatitis

Giriş ve Amaç: Akut pankreatit, endoskopik retrograd kolanjiyopankreatografinin en yaygın komplikasyonudur. Dikkate değer morbidite ve mortalite oranlarına sahiptir. Bu çalışmanın amacı, tek başına lokal epinefrin uygulamasının endoskopik retrograd kolanjiyopankreatografi sonrası pankreatit sıklığını ve şiddetini azaltmadaki etkisini araştırmaktır. Gereç ve Yöntem: Endoskopik retrograd kolanjiyopankreatografi yapılan 979 hastanın verileri retrospektif olarak değerlendirildi. Yaş, cinsiyet, endoskopik retrograd kolanjiyopankreatografi endikasyonları, tekniği, endoskopik retrograd kolanjiyopankreatografi sonrası pankreatit riskini artıran durumlar, endoskopik retrograd kolanjiyopankreatografi sonrası pankreatit varlığı ve şiddeti, serum amilaz, lökosit ve C-reaktif protein seviyeleri (öncesi ve sonrası) kaydedildi. Veriler sadece lokal epinefrin profilaksisi alan 473 hasta ve almayan 506 hasta olmak üzere iki grup arasında karşılaştırıldı. Bulgular: Tüm hastalar arasında endoskopik retrograd kolanjiyopankreatografi sonrası pankreatit oranı %6.8, yüksek riskli hasta grubunda ise %13.6 olarak saptandı. Lokal epinefrin profilaksisi alan grupta, almayan gruba göre endoskopik retrograd kolanjiyopankreatografi sonrası pankreatit daha az görüldü (%9.1’e karşı %4.4; p = 0.004). Epinefrin grubunda endoskopik retrograd kolanjiyopankreatografi sonrası amilaz, lökosit ve C-reaktif protein düzeyleri epinefrin almayan gruba göre anlamlı olarak düşük saptandı (p = 0.001, p = 0.004, p = 0.001). Epinefrin grubunda daha az sıklıkla şiddetli ve orta derecede şiddetli pankreatit görüldü (p = 0.003). Yüksek riskli hasta grubunda lokal epinefrin irrigasyonunun endoskopik retrograd kolanjiyopankreatografi sonrası pankreatit oranını düşürdüğü gözlendi (%18.9’a karşı %7.9; p = 0.002). Sonuç: Majör papillaya direkt püskürtme yöntemi ile epinefrin irrigasyonu endoskopik retrograd kolanjiyopankreatografi sonrası pankreatitin önlenmesinde uygulaması kolay, güvenli ve ümit verici bir yöntemdir. Etkinliğini araştırmak için geniş popülasyonlarla daha fazla çalışmaya ihtiyaç vardır.

S61 Opiate Use Is Associated With Increased Risk of Post ERCP Pancreatitis: A National Cohort Study

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) has evolved as a valuable tool in therapeutic management of pancreatobiliary disorders but is associated with a range of significant complications, the most common being post-ERCP pancreatitis (PEP). The aim of this study was to elucidate the impact of opiate use on the development and severity of post-endoscopic retrograde cholangiopancreatography. Pancreatitis (PEP). Methods: We retrospectively analyzed patients who were hospitalized in 2017 using the national inpatient sample (NIS) database who underwent endoscopic retrograde cholangiopancreatography (ERCP) (via ICD-10 procedure codes). Our study group consisted of patients who had a secondary diagnosis of opiate use, and our control group consisted of patients who did not have a secondary diagnosis of opiate use. Our primary end point was to elucidate if the presence of opiate use increased the risk of developing post-ercp pancreatitis. Additionally, we assessed if opiate use worsened outcomes in patients who underwent ERCP. We accomplished this by extracting variables such as length of hospital stay (LOS), total hospital charges and in hospital mortality rates. Categorical variables were compared using the chi-square test, and continuous variables were compared using t-test. Multivariate regressions models and all statistical analysis were performed using STATA 16 software. Results: A total of 172,255 patients who underwent ERCP were identified, of which 2,120 were opiate users. Opiate users were hospitalized at a younger age when compared to opiate non-users (53.7 years vs 60.5 years; p-value: < 0.01), had a longer length of hospital stay (8.3 days vs 6.0 days; p-value: < 0.01), total hospital charges ($102,469 vs $82,191; p-value: < 0.01) and higher incidence of PEP (4% vs 2.7%; p-value: < 0.01). Conclusion: Opiate use is associated with younger age of presentation, increased LOS, total hospital charges, and increased frequency of PEP amongst patients undergoing ERCP. Further investigation is needed to assess the extent to which chronic opiate use may be a risk factor for post-ERCP pancreatitis and worse outcomes. If so, discontinuation of opiates before ERCP may be reasonable when possible. (Table) Table 1. - Hospital outcomes in opiate users vs non-users undergoing ERCP Opiate Use (N=2,120) No Opiate Use (N=170,135) P-value Age of presentation 53.7 60.5 < 0.01 LOS (days) 8.3 6.0 < 0.01 Total charges (USD) $102,469 $82,191 0.087 Died 35 (1.6%) 2,520 (1.4%) 0.525 PEP 85 (4%) 4,740 (2.7%) < 0.01 LOS: Length of hospital stay; USD: United States Dollar; PEP: Post-ERCP Pancreatitis.

S1146 Impact of Frailty on ERCP Outcomes

Introduction: Frailty has been recognized as an important risk factor and predictor of mortality and adverse events in the inpatient setting. It has not been studied as a tool to assess risk among patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP). We aim to determine the association between frailty and risk of adverse events in hospitalized patients undergoing ERCP. Methods: We conducted a cohort study using the 2017 Nation Inpatient Sample database, using International Classification of Diseases (ICD) diagnostic codes to identify adult patients who underwent ERCP and the Hospital Frailty Risk Score (HFRS) to classify patients as Frail or non- Frail. HFRS is a validated algorithm of ICD-10 codes. Multivariable analysis logistic regression was performed for outcomes of frail patients compare to non frail patients Results: 216,775 hospitalizations met inclusion criteria, of which 31.7% (68,555) were identified as frail and 68.3% (148,220) as non-frail. Baseline characteristics of both groups are compared in Table. Frail patients had worse post procedure complications including post ERCP pancreatitis (7.3% vs 3.4%, p < .001), perforation (1.2% vs 0.4%, p < .001), bleeding (0.8% vs 0.3%, p < .001) and peritonitis (1.2% vs 0.3%, p < .001). Frail patients had more cardiovascular (22.2% vs 5.5%, P < .001), pulmonary (22.1% vs 4.7%, P < .001), GI (25.9% vs 19.8%, P < .001) and infectious (39.2% vs 4.6%) adverse events compared with non-frail patients. Frail patients also had higher ICU admission (8.5% vs 0.5%, p < .001), increased length of stay (9.3 days vs 4.3 days, p < .001), more total charges (118,875$ vs 62,386$, p< .001) and higher all-cause inpatient mortality rates (4.2 % vs 0%, P < 0.001 as compared to non-frail. When adjusted for age, gender, race, hospital location, teaching status, insurance, median household income and Charlson co-morbidity index frail patients were had a higher risk of cardiac[OR 2.29 (95% CI 2.12-2.46), p< 0.001], pulmonary[OR 4.9 (95% CI 4.52-5.31), p< 0.001], infectious[OR 12.83 (95% CI 11.85-13.88), p< 0.001], GI [OR 1.68 (95% CI1.58-1.77), p< 0.001] adverse events as well as inpatient mortality[OR 9.93 (95% CI 7.3-13.3), p< 0.001] as compared to non-frail. Conclusion: In hospitalized patients undergoing ERCP, frailty status is associated with increased adverse events including all-cause mortality. The use of frailty assessments can further guide clinical decision-making when considering ERCP and the risk of adverse events in adult patients. Table 1. - Baseline characteristics and outcomes of the frail and non-frail groups undergoing ERCP Variable ERCP + Not Frail n=148,220 ERCP + Frail * n= 68,555 p-value Female, % 59.69 52.61 < 0.001 Age (years), mean ± SD 55.87 ± 18.93 69.37 ± 15.35 < 0.001 Age >=65 years, % 37.20 67.85 < 0.001 Race, % < 0.001 White 65.18 70.06 Black 9.21 10.58 Hispanic 17.38 11.67 Other 8.24 7.70 Charlson co-morbidity index, mean ± SD 1.33 ± 1.98 3.11 ± 2.59 < 0.001 Hospital Frailty Risk Score, mean ± SD 1.71 ± 1.55 8.56 ± 3.14 < 0.001 In-hospital all-cause mortality, % 0.25 4.20 < 0.001 Length of Stay (Days), mean ± SD 4.37 ± 3.80 9.39 ± 10.32 < 0.001 Total Charges ($), mean ± SD 62,386.77 ± 50,903.26 118,875.9 ± 175,602 < 0.001 Post Procedure complications, % Post-ERCP pancreatitis 3.44 7.38 < 0.001 Perforation 0.43 1.28 < 0.001 Bleeding 0.31 0.81 < 0.001 Peritonitis 0.29 1.25 < 0.001 Cardiac complications, % 5.50 22.19 < 0.001 Pulmonary complications, % 4.75 22.11 < 0.001 GI complications, % 19.82 25.95 < 0.001 ID complications, % 4.59 39.23 < 0.001 Anesthesia and drug-related complications, % 0.02 0.08 0.001 Required Intensive Care Unit, % 0.53 8.56 < 0.001 Multivariate Regression for the Outcomes # Outcome Adjusted Odds Ratio (FrailERCP vs NonFrailERCP) 95% CI p-value In-hospital mortality 9.93 [7.38 – 13.35] < 0.001 Length of Stay (Days) 4.53 & [4.28 – 4.77] < 0.001 Total Charges ($) 54,659.9$ & [50,176.52$ – 59,143.28$] < 0.001 Cardiac complications 2.29 [2.12 – 2.46] < 0.001 Pulmonary complications 4.90 [4.52 – 5.31] < 0.001 GI complications 1.68 [1.58 – 1.77] < 0.001 ID complications 12.83 [11.85 – 13.88] < 0.001 Anesthesia and drug-related complications 3.68 [2.13 – 15.13] 0.001 Required Intensive Care Unit 17.19 [13.99 – 21.13] < 0.001 *Frail =Hospital Frailty Risk Score (HFRS)≥5.#Analysis adjusted for age, gender, race, hospital location and teaching status, insurance, median household income and Charlosn co-morbidity index.&Adjusted co-efficient representing the average difference in this outcome between FrailERCP and NonFrailERCP.

Knowledge, attitude, and the practices in prevention of post endoscopic retrograde cholangiopancreatography pancreatitis (PEP) among advanced endoscopists.

Knowledge, attitude, and the practices in prevention of post endoscopic retrograde cholangiopancreatography pancreatitis (PEP) among advanced endoscopists.

Serum Amylase as a Biomarker for Proof-of-Concept Studies in Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis Prevention

Considerable effort and resources have been expended in the last 3 decades on the study of pharmacoprevention for post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), with limited success, in part because of inadequate sample sizes in randomized controlled trials (RCTs). For reference, an adequately powered RCT aiming to detect a 50% reduction in PEP from 10% to 5% requires approximately 950 subjects. 1 Elmunzer B.J. et al. N Engl J Med. 2012; 366: 1414-1422 Crossref PubMed Scopus (460) Google Scholar ,2 Fogel E.L. et al. Lancet Gastroenterol Hepatol. 2020; 5: 132-141 Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Because sample sizes of this magnitude for every potentially effective medication are impractical, a cogent framework for proof-of-concept (POC) studies to screen candidate agents is critical for drug development and repurposing.