Independent Risk Factors For post-ERCP Pancreatitis Research Articles

Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis After Endoscopic Removal of Common Bile Duct Stones: An Update in Chinese Patients with Choledocholithiasis

Aim: Endoscopic Retrograde Cholangiopancreatography (ERCP) has been widely used in endoscopic surgery for many biliary and pancreatic diseases. Post-ERCP Pancreatitis (PEP) is the most common complication that occurs, even with expert surgeons. However, few reports have addressed the risk of PEP by focusing on the removal of Common Bile Duct Stones (CBDS). Methods: To detect potential risk factors for PEP after endoscopic removal of CBDS, the medical records of CBDS patients who received ERCP procedures at the First Affiliated Hospital of Nanjing Medical University between January 2021 and December 2023 were retrospectively analyzed. Patient- and procedure-related data were collected, and PEP was reevaluated. Single- and multiplevariable analyses were conducted to identify potential risk factors. Results: A total of 1,251 procedures were performed in 1,173 patients and PEP occurred in 84 cases (6.71%). Univariate and multivariate logistic regression analyses showed that female sex (P= 0.049, 95% Confidence Interval [CI]: 1.002-2.521), cerebral infarction (P=0.011, 95% CI: 1.197-3.964), acute pancreatitis history (P=0.001, 95% CI: 2.436-7.249), fatty liver disease (P=0.021, 95% CI: 1.140 -4.843), common bile duct diameter <10 mm (P=0.005, 95% CI: 1.299-4.313), and Endoscopic Papillary Balloon Dilatation (EBD) (P=0.01, 95% CI: 0.321-0.855) were independent risk factors for PEP in CBDS patients. Conclusion: Female sex, a history of Fatty Liver Disease (FLD), previous acute pancreatitis, and common bile duct stenosis are risk factors for PEP, whereas EPBD is a protective factor for PEP in patients with CBDS, which should be considered by clinicians.

Optimal dilation duration of 10 mm diameter balloons after limited endoscopic sphincterotomy for common bile duct stones: a randomized controlled trial

Limited endoscopic sphincterotomy (EST) combined with endoscopic papillary balloon dilation (EPBD) is widely used. However, the optimal duration of small balloon dilation in choledocholithiasis remains controversial. We aimed to determine the optimal duration for 10 mm diameter balloon dilation after limited EST in choledocholithiasis. In this randomized controlled clinical trial, 320 patients were randomly assigned to receive small balloon dilation (10 mm in diameter) for 1 min (n = 160) or 3 min (n = 160) after deep bile duct cannulation. No significant difference in success rate of stone extraction between the two groups was observed. The incidence of post-ERCP pancreatitis (PEP) was higher in the 1 min group (10.6%) than in the 3 min group (4.4%) (P = 0.034). The logistic regression analysis showed that guidewire into the pancreatic duct, cannulation time > 5 min and 1 min balloon dilation were independent risk factors for PEP. There were no significant differences in other post-ERCP adverse events such as acute cholangitis, bleeding, perforation, etc. between the two groups. In conclusion, 3 min in duration was determined to be the optimal dilation condition for the removal of common bile duct stones.

Risk factors of pancreatitis after endoscopic retrograde cholangiopancreatography in patients with biliary tract diseases

BackgroundTo investigate the risk factors of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in patients with biliary tract diseases.MethodsWe retrospectively analyzed the clinical data of 480 patients who underwent ERCP for biliary tract diseases at the Affiliated Zhongshan Hospital of Dalian University from October 2011 to October 2016. The patients were divided into a study group (n = 75, with PEP) and a control group (n = 405, without PEP) based on whether they developed post-ERCP pancreatitis (PEP), and their clinical baseline data and intraoperative conditions were retrieved and compared. Then, factors associated with PEP were analyzed using logistic regression model, based on which a nomogram prediction model was constructed. The receiver operating characteristic (ROC) curve and calibration curve were used to evaluate the performance of the prediction model.ResultsSignificant differences in age, sex, history of pancreatitis, history of choledocholithiasis, pancreatic duct imaging, pancreatic sphincterotomy, difficult cannulation, multiple cannulation attempts and juxtapapillary duodenal diverticula were observed between the two groups. Multivariate logistic regression analysis showed that age less than 60 years (OR, 0.477; 95% CI, 0.26–0.855), female sex (OR, 2.162; 95% CI, 1.220–3.831), history of pancreatitis (OR, 2.567; 95% CI, 1.218–5.410), history of choledocholithiasis (OR, 2.062; 95% CI, 1.162–3.658), pancreatic sphincterotomy (OR, 2.387; 95% CI, 1.298–4.390), pancreatic duct imaging (OR, 4.429; 95% CI, 1.481–13.242), multiple cannulation attempts (OR, 2.327; 95% CI, 1.205–4.493), difficult cannulation (OR, 2.421; 95% CI, 1.143–5.128), and JPD (OR, 2.002; 95% CI, 1.125–3.564) were independent risk factors for PEP. The nomogram for predicting the occurrence of PEP demonstrated an area under the ROC curve (AUC) of 0.787, and the calibration curves of the model showed good consistency between the predicted and actual probability of PEP.ConclusionOur results showed that age less than 60 years, female sex, history of pancreatitis, history of choledocholithiasis, pancreatic sphincterotomy, pancreatic duct imaging, multiple cannulation attempts, difficult cannulation and juxtapapillary duodenal diverticula were independent risk factors for PEP. In addition, the established nomogram demonstrated promising clinical efficacy in predicting PEP risk in patients who underwent ERCP for biliary tract diseases.

Larger Volume and Higher Fat Content of the Pancreatic Head Are Predictive Factors for Postendoscopic Retrograde Cholangiopancreatography Pancreatitis.

Acute pancreatitis is the most critical complication of endoscopic retrograde cholangiopancreatography (ERCP). In this study, we investigated the association between the volume/fat content of the pancreatic head and the incidence of post-ERCP pancreatitis (PEP). We retrospectively enrolled 157 patients who underwent ERCP. The volume and fat content of the pancreas were calculated by multislice computed tomographic imaging by using a volume analyzer. Multivariate analysis was performed to identify risk factors for PEP. The mean volumes of the whole pancreas and pancreatic head were significantly larger, and the fat content of the pancreatic head was significantly higher in the PEP group (P < 0.01). There were no significant differences in the mean volume and fat content of the pancreatic body and tail in the PEP group. Multivariate analysis revealed that the pancreatic guidewire placement (odds ratio [OR], 12.4; P < 0.01), pancreatic head volume (OR, 5.3; P < 0.01), and the pancreatic head fat content (OR, 4.8; P < 0.01) were independent risk factors for PEP. The pancreatic head volume and fat content were independent predicting factors of PEP. Quantitative assessment of the pancreas may contribute to the prediction of PEP onset.

Nafamostat Mesylate is Not Effective in Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications such as post-ERCP pancreatitis (PEP). Protease inhibitors, including nafamostat mesylate (NM), have been evaluated for prophylaxis against PEP. We describe the first multicenter randomized controlled trial assessing the prophylactic efficacy of NM against PEP. In this multicenter prospective study, we aimed to enroll 800 patients aged ≥ 20years with a planned ERCP between December 2012 and March 2019. The primary outcome was the incidence and severity of PEP in patients who did not receive NM (non-NM) versus those who did (NM; 20mg). Secondary outcomes included the incidence of PEP by NM initiation (pre- and post-ERCP), risk factors for PEP, and NM-related adverse events. Only 441 of the planned 800 patients were enrolled (non-NM: n = 149; NM: n = 292 [pre-ERCP NM: n = 144; post-ERCP NM: n = 148]). Patient characteristics were balanced at baseline with no significant differences between groups. PEP occurred in 40/441 (9%) patients (non-NM: n = 15 [10%]; NM: n = 25 [9%]), including 17 (12%) and eight (8%) in the pre-ERCP and post-ERCP NM groups, respectively. In the NM group, the incidence of PEP was lower in the low-risk group than in the high-risk group. Pancreatic injection and double-guidewire technique were independent risk factors for PEP. NM-related adverse events of hyperkalemia occurred in two (0.7%) patients. We found no evidence for the prophylactic effect of NM against PEP, regardless of the timing of administration; however, further studies are needed.

Asymptomatic Common Bile Duct Stones Are Associated with Increased Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Introduction: Common bile duct stones (CBDS) are a common disease that can cause biliary complications, including cholangitis, obstructive jaundice, and biliary pancreatitis. Regardless of the presence or absence of symptoms, endoscopic removal of CBDS is generally recommended, but endoscopic retrograde cholangiopancreatography (ERCP) is a high-risk procedure with complications, such as post-ERCP pancreatitis (PEP). As few reports have addressed the risk of PEP by focusing on asymptomatic CBDS, the purpose of this study is to examine the incidence of PEP for asymptomatic CBDS. Methods: This retrospective study included data from 302 patients with naive papilla who underwent therapeutic ERCP for CBDS between January 2012 and December 2019 at our hospital. Univariate and multivariate logistic regression models were used to investigate independent risk factors for PEP. Results: Of the 302 patients, 32 were asymptomatic, and the remaining 270 were symptomatic. Five asymptomatic patients (15.6%) suffered from mild PEP, whereas 10 (3.7%) symptomatic patients suffered from PEP (9 were mild, and 1 was severe). Univariate analysis identified deep cannulation time more than 10 min, endoscopic papillary balloon dilation (EPBD), and asymptomatic CBDS as risk factors for PEP, whereas multivariate analysis revealed deep cannulation time more than 10 min (odds ratio (OR), 6.67; p < 0.001), EPBD (HR, 5.70; p < 0.001), and asymptomatic CBDS (HR, 5.49; p < 0.001) as independent risk factors for PEP. Conclusions: A wait-and-see approach may be an option for the management of asymptomatic CBDS. EPBD may be avoided, especially in case of asymptomatic or if difficult for bile duct cannulation.

Relationship between papilla-related variables and post endoscopic retrograde cholangiopancreatography pancreatitis: A multicenter, prospective study.

Papilla with hooknose or long protruding shape may increase the difficulty of cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, the relationship between papilla anatomy and complications of ERCP has not been fully understood. We aimed to investigate the effect of major duodenal papilla morphology on post-ERCP pancreatitis (PEP) and the procedure of cannulation. Patients with native papilla who underwent ERCP were recruited to this multicenter study. Papilla-related variables were collected, including the length of long axis (L), short axis (S) and opening width (OW), transverse fold, periampullary diverticulum (PAD), papilla location, orientation, swelling, and presence of duodenal stenosis. Demographic data and the procedure of cannulation were also prospectively evaluated. The primary outcome was PEP incidence. Multivariate analysis was used to identify high risk factors for PEP. Six hundred and fifty-eight patients were enrolled. Overall PEP incidence was 4.7% (31/658). The papilla of patients complicated with PEP had higher long to short axis (L/S) ratio (odds ratio [OR] 3.84, 95% confidence interval [CI]: 1.37-10.74, P=0.010), higher long axis to opening width (L/OW) ratio (OR 1.35, 95%CI: 1.06-1.71, P=0.014), more transverse folds (OR 2.53, 95%CI: 1.02-6.26, P=0.044), and less periampullary diverticulum (OR 0.21, 95%CI: 0.06-0.70, P=0.011). Multivariate analysis revealed that the indication of common bile duct stones, normal bilirubin, inadvertent pancreatic duct cannulation >1, L/S ratio ≥1.5, and absence of PAD were independent risk factors for PEP. Besides patient-related and procedure-related factors, papilla-related variables, such as L/S ratio and PAD, can be considered as a third type of factors associated with PEP (Clinicaltrials.gov number: NCT03550768).

Risk Factors for Post-Endoscopic Retrograde Pancreatography Pancreatitis: A Retrospective Chart Review in a Regional Hospital in Japan

Background: Endoscopic retrograde pancreatography (ERCP) is sometimes complicated by post-ERCP pancreatitis (PEP), which is a severe adverse effect. Objective: The present study was performed to (i) evaluate the risk factors for PEP and (ii) compare the risk of PEP after ERCP performed in the off hours versus regular hours. Methods: This retrospective study included 374 patients who underwent ERCP from January 2013 to December 2017. Among these patients, 38 (10.2%) developed PEP. The potential risk factors for PEP were evaluated by multivariate regression analysis, and the risk of PEP was compared between ERCP performed during regular hours and off hours. Results: The independent risk factors for PEP were a relatively younger age (<75 years; p = 0.024), female sex (p = 0.002), a history of pancreatitis (p = 0.044), and performance of pancreatography (p = 0.010). Use of a diclofenac suppository and performance of pancreatic stenting were not preventive for PEP after ERCP. The complication rate of PEP did not differ between ERCP performed during the off hours versus regular hours. Conclusions: A relatively younger age (<75 years), female sex, a history of pancreatitis, and performance of pancreatography were potential risk factors for PEP, whereas the risk of PEP was not different between ERCP performed during the off hours versus regular hours.

Risk of pancreatitis after pancreatic duct guidewire placement during endoscopic retrograde cholangiopancreatography.

Background & aimsAdvanced techniques have been developed to overcome difficult cannulation cases in endoscopic retrograde cholangiopancreatography (ERCP). Pancreatic duct guidewire placement method (PGW) is performed in difficult cannulation cases; it is possible that it places patients at risk of post-ERCP pancreatitis (PEP). The mechanism of PEP is still unclear, but pancreatic duct pressure and injury of pancreatic duct are known causes of PEP. Therefore, we hypothesized a relationship between pancreatic duct diameter and PEP and predicted that PGW would increase the risk of PEP in patients with non-dilated pancreatic ducts. This study aimed to investigate whether PGW increased the risk of PEP in patients with pancreatic duct diameter ≤ 3 mm.MethodsWe analyzed 332 patients with pancreatic duct ≤ 3 mm who performed first time ERCP session. The primary endpoint was the rate of adverse event of PEP. We evaluated the risk of PEP in patients who had undergone PGW compared to those who had not, using the inverse probability of treatment weighting (IPTW) analysis.ResultsPGW was found to be an independent risk factor for PEP by univariate analysis (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.12–5.38; p = 0.03) after IPTW in patients with pancreatic duct diameter ≤ 3 mm. Adjusted for all covariates, PGW remained an independent risk factor for PEP (OR, 3.12; 95% CI, 1.33–7.33; p = 0.01).ConclusionOur results indicate that PGW in patients with pancreatic duct diameter ≤ 3 mm increases the risk of PEP.

Analysis of risk factors and prevention strategies of post-ERCP pancreatitis.

To analyze the relevant risk factors and preventive measures for post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP) so as to improve the diagnosis and treatment levels of ERCP, thus reducing the prevalence rate of PEP. The clinical data of 278 patients receiving ERCP from January 2014 to December 2016 were retrospectively analyzed. First, the univariate analysis was conducted for the factors such as gender, age, diameter of common bile duct, whether development occurred in the pancreatic duct and other factors. Then, the multivariate logistic regression analysis was performed for factors showing statistical significance in the univariate analysis so as to analyze the independent risk factors for PEP. The success rate of ERCP included in the study was 97.12%. The prevalence rate of PEP was 8.27%. Univariate analysis results showed that the prevalence rate of PEP in the group of patients younger than 60 years old was higher than that in the group of patients older than 60 years old (14.14% vs. 5.03%, p = 0.016); the prevalence rate of PEP in the group of patients with intubation difficulty was higher than that in the group of patients without intubation difficulty (19.61% vs. 5.73%, p = 0.004); the prevalence rate of PEP in the group of patients with operation time more than 60 min was higher than that in the group of patients with operation time less than 60 min (18.60% vs. 6.38%, p = 0.034); the prevalence rate of PEP in the group of patients with the pancreatic duct development was higher than that in the group of patients without the pancreatic duct development (50% vs. 6.72%, p < 0.001); the prevalence rate of PEP in the group of patients placed with nasobiliary drainage catheters was not higher than that in the group of patients not placed with nasobiliary drainage catheters (18.00% vs. 2.81%, p < 0.001). The above five relevant factors were included in the logistic regression equation for the multivariate analysis, which showed that the age less than 60 years old (p = 0.002) and the pancreatic duct development (p = 0.004) were independent risk factors for PEP, and nasobiliary drainage (p = 0.003) was a protective factor for PEP. The occurrence of PEP is associated with the age less than 60 years old, the pancreatic duct development, intubation difficulty and overlong operation time. Among them, the pancreatic duct development and the age less than 60 years old are independent risk factors for PEP. Placing nasobiliary drainage catheters after operation, avoiding the pancreatic duct development, improving the success rate of intubation, reducing ERCP operation time and other methods, can effectively reduce the occurrence of PEP.

Chemerin: a new biomarker to predict postendoscopic retrograde cholangiopancreatography pancreatitis.

Individuals with increased visceral adiposity are considered to be more sensitive and more prone to severe acute pancreatitis because of the inflammatory microenvironment they have. We hypothesized that insulin resistance, adipokines, and proinflammatory cytokines that markedly affect the course of pancreatitis can contribute toward development of postendoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP) and aimed to investigate the association between PEP risk and preprocedural serum vaspin, chemerin, tumor necrosis factor α, interleukin-6 (IL-6) levels, and homeostasis model assessment of insulin resistance. Eighty-two patients with a diagnosis of choledocholithiasis and 30 controls were enrolled. Preprocedural chemerin, vaspin, IL-6, and well-known PEP risk factors were compared between PEP and non-PEP groups. The mean age of the patients was 56.3±14.4 years; 52 patients were women. Adipocytokine levels, BMIs, and waist circumferences of the patient group were found to be higher than those of the controls. Total cannulation success and the mean procedure time were 82.9% and 28.7±8.8 min, respectively. PEP developed in 12 (14.6%) patients. Chemerin levels in the PEP group were higher than those in the non-PEP group (580.2±172.5 vs. 392.2±168.2 ng/ml, P<0.01). Insulin resistance was higher in the PEP group than the non-PEP group (P=0.001), but there was no significant difference between PEP and non-PEP groups in terms of preprocedural vaspin, tumor necrosis factor α, IL-6, and C-reactive protein levels. According to logistic regression analysis, increased chemerin levels, homeostasis model assessment of insulin resistance 2.5 or greater, and pancreatic duct cannulation were found to be independent risk factors for PEP [odds ratio (OR)=1.006, P=0.006; OR=4.57, P=0.05; OR=6.54, P=0.02]. Elevated serum chemerin levels and insulin resistance are independent risk factors of PEP development.

Pregnancy Is a Risk Factor for Pancreatitis After Endoscopic Retrograde Cholangiopancreatography in a National Cohort Study

There are limited data on the safety of endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy, only data from observational series (approximately 350 cases) have been published. We aimed to evaluate the safety of ERCP in pregnant women by evaluating a large nationwide database. We performed a retrospective matched-cohort study, collecting data from the National Inpatient Sample from 2008 through 2009. We compared data from pregnant women who underwent ERCP (n= 907) with those from nonpregnant women who underwent ERCP (controls, n= 2721). Complications related to ERCP were measured against the matched controls. Obstetric and fetal complications were measured against the national average of all obstetric admissions. ERCP-associated complications of perforation, infection, and bleeding were infrequent in both cohorts (P > .05). Post-ERCP pancreatitis (PEP) occurred in 12% of pregnant women and in 5% of controls (P < .001). There was a significantly lower rate of PEP in teaching hospitals (9.6%) than in nonteaching hospitals (14.6%; P < .001). The adjusted odds ratio for developing PEP among pregnant women vs controls was 2.8 (95% confidence interval [CI], 2.1-3.8). This risk of PEP was higher among nonteaching hospitals (adjusted odds ratio, 3.5; 95% CI, 2.3-5.2) than teaching hospitals (adjusted odds ratio, 2.5; 95% CI, 1.6-3.9). Pregnancy is an independent risk factor for PEP; PEP and PEP among pregnant women are each more prevalent in community hospitals than teaching centers. Proper precautions therefore should be considered for pregnant women undergoing ERCP, including transfer to a tertiary care center if appropriate.

Predictive factors for post-ERCP pancreatitis: a large-scale single expertized endoscopist study.

Pancreatitis remains the most common and feared complication of therapeutic endoscopic cholangiopancreatography (ERCP) associated with substantial morbidity. The patient-related and procedure-related independent risk factors for post-ERCP pancreatitis (PEP) in a large case volume by a single experienced endoscopist have been investigated only by few studies. The aim of the study was to investigate patient-related and procedure-related risk factors for PEP collected by a defined protocol on patients who underwent therapeutic ERCP in a single endoscopic unit during the last 8 years. Our retrospective cohort study included a total of 2688 therapeutic ERCPs enrolled in the final analysis. The impact of the risk factors on PEP development was investigated by univariate and multivariate analysis. PEP was diagnosed and its severity was graded according to the consensus criteria. With the exception of history of pancreatitis, there was no other statistically significant difference of patients' characteristics between patients with and without PEP. Female sex, age, difficult cannulation, suspected sphincter of Oddi dysfunction, metal stent placement, opacification of main pancreatic duct, and suprapapillary fistulotomy were not found to be risk factors for PEP by univariate and multivariate analysis. Both univariate and multivariate analysis showed history of acute pancreatitis, needle-knife papillotomy, transpancreatic sphincterotomy, opacification of first-class and second-class pancreatic ductules, and acinarization as independent risk factors for PEP. History of acute pancreatitis, needle-knife papillotomy, transpancreatic sphincterotomy, opacification of first-class and second-class pancreatic ductules, and acinarization were all identified as independent risk factors for PEP.

Analysis of risk factors for post-ERCP pancreatitis

Objective To investigate the risk factors of post-ERCP pancreatitis( PEP). Methods Data of 4,234 patients who underwent ERCP in Nanjing Drum Tower Hospital were retrospectively analysed. Information of patients and operations,including age,gender,operation history,major disease history,labora-tory examination before operation,abdominal ultrasound,CT,MRCP,detailed ERCP operation process,com-plications and treatment were carefully recorded. Then Chi-square test was used for univariate analysis,and stepwise multivariate Logistic regression for variate analysis. Linear correlations between risk factors were de-tected. Results There were totally 226 PEPs,with 5. 3% incidence rate. Univariate analysis showed that the female(χ2 =9. 715,P=0. 002),young( <60 years)(χ2 =6. 108,P=0. 013),chronic pancreatitis(χ2 =14. 703,P=0. 001),initial ERCP(χ2 =14. 899,P=0. 000),hypertension(χ2 =4. 489,P=0. 034),nor-mal bilirubin levels before operation(χ2 =19. 159,P =0. 000 ),difficult cannulation(χ2 =45. 824,P =0. 000),pancreatic guide wire(χ2 =30. 223,P=0. 000),papillary pre cut(χ2 =45. 928,P=0. 000),pan-creatography(χ2 =20. 170,P=0. 000)may be risk factors for PEP. Non conditional Logistic regression analy-sis showed that female(OR=1. 449,P=0. 011),initial ERCP(OR=1. 745,P=0. 003),normal bilirubin levels before operation(OR=1. 917,P=0. 000),difficult cannulation(OR=3. 317,P=0. 000)and pancre-atography(OR=1. 823,P=0. 004)were independent risk factors for PEP. Linear correlation analysis sugges-ted that pancreatic duct guide wire and papillary precut were related to the difficult cannulation,and the corre-lation coefficients were -0. 788 and -0. 699. Conclusion Female,young(<60 years),chronic pancreati-tis,initial ERCP,hypertension,normal bilirubin levels,difficult cannulation,pancreatic duct guide wire,pa-pillary precut,pancreatography may induce PEP. Female,normal bilirubin levels before operation,initial ER-CP,difficult cannulation and pancreatography are independent risk factors for PEP,while pancreatic duct guide wire,papillary precut are not,as they were linear correlated to difficult cannulation. Key words: Cholangiopancreatography,endoscopic retrograde ; Pancreatitis ; Risk factor ; Uni-variate analysis ; Independent risk factor ;

Post-endoscopic retrograde cholangiopancreaticography complications in liver transplanted patients, a single-center experience.

Complications in the biliary tract occur in 5%-30% after liver transplantation and the main part of the complications is successfully managed with endoscopic retrograde cholangiopancreaticography (ERCP). The incidence and risk factors for post-ERCP complications in liver transplantation patients are not well described. Our objective was to define the frequency of post-ERCP complications in liver transplantation patients at the Abdominal Center, Rigshospitalet, the only Liver Transplantation Center in Denmark. Retrospective study of all ERCPs performed in liver transplantation patients during a 9-year period. A total of 292 ERCPs were included. Overall post-ERCP complications occurred in 24 procedures (8.2%): pancreatitis in 8 (2.7%), bleeding in 5 (1.7%), and cholangitis in 13 (4.5%) procedures. Simultaneous pancreatitis and cholangitis, and simultaneous bleeding and cholangitis occurred after two procedures, respectively. Multivariate analysis concerning overall complications identified biliary sphincterotomy (p = 0.006) and time since liver transplantation within 90 days postoperatively (p = 0.044) as risk factors for post-ERCP complications. Specifically concerning post-ERCP pancreatitis (PEP), it was found that pre-ERCP cholangitis was another independent risk factor for PEP (p = 0.026). Stent in the biliary tract prior to ERCP seemed to be protective (p = 0.041). Complications were of surprisingly mild degree. The rates of post-ERCP complications in our study were in line with previous studies with liver transplantation patients. Cholangitis prior to ERCP may be another risk factor for post-ERCP pancreatitis.

Needle Knife Sphincterotomy Does Not Increase the Risk of Pancreatitis in Patients With Difficult Biliary Cannulation

Biliary cannulation is unsuccessful during 5%-10% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. Needle knife sphincterotomy (NKS) can improve success of cannulation but is often used as a last resort and is associated with post-ERCP pancreatitis (PEP). We evaluated the safety and efficacy of performing NKS during early stages of difficult cannulation and the relationship between difficult cannulation and the risk of PEP. We performed a prospective trial of consecutive patients with an intact papilla who were undergoing ERCP at tertiary referral center; 73 patients were defined as having difficult biliary cannulation according to predefined cannulation parameters. These patients were randomly assigned to groups that received either NKS or continued standard cannulation. Main outcome measures were PEP and successful biliary cannulation. Of 464 patients with an intact papilla undergoing ERCP, 73 met the criteria for difficult cannulation. Cannulation success in difficult cannulation cases was 86%, with a PEP rate of 19%. There was no difference in eventual cannulation success between the groups. However, 65% of the patients assigned to the standard cannulation group required crossover to NKS. There was no significant difference in development of PEP among patients in the early NKS group (20.5%) vs standard cannulation (17.6%). Pancreatic duct stents were inserted in 23 of the patients in the early NKS arm and in 15 in the standard cannulation arm. The number of cannulation attempts (more than 7) increased the risk of PEP (P < .01). On the basis of multivariate analysis, independent risk factors for PEP were failure of early cannulation and failure of biliary cannulation. Early application of NKS during difficult cannulation does not increase the risk of PEP. The risk of PEP increases greatly after 7-8 attempts at or failure of cannulation. Further studies are required to assess whether early implementation of NKS during difficult cannulation reduces the development of PEP. Australia and New Zealand Clinical Trials registry: ANZTRN 12,612,000,060,842.

Complications of ERCP

Complications of ERCP

Combination of diclofenac plus somatostatin in the prevention of post-ERCP pancreatitis: a randomized, double-blind, placebo-controlled trial

Pancreatitis is the most common complication of therapeutic endoscopic retrograde cholangiopancreatography (ERCP), and many pharmacoprophylactic approaches have been suggested, though not without controversy. The aim was to investigate the impact of combined therapy with diclofenac plus somatostatin on reducing the frequency and severity of post-ERCP pancreatitis (PEP). A prospective, double-blind, placebo-controlled trial was conducted in two tertiary referral centers, with 540 eligible patients randomized to receive either combined therapy with diclofenac 100 mg rectally 30 to 60 minutes before ERCP plus somatostatin 0.25 mg/h for 6 hours (group A), or a placebo suppository identical in appearance to the diclofenac along with saline solution (group B). Patients were clinically evaluated and serum amylase levels were determined before ERCP and at 6 and 24 hours post-procedure. Standardized criteria were used to diagnose and grade the severity of PEP. Adverse events were recorded prospectively. There were no statistical differences between the groups regarding demographic data, ERCP findings, and procedure risk factors for PEP. The overall incidence of acute pancreatitis was 7.2 %. The PEP rate was significantly lower in the patients who received the combination therapy than in controls (4.7 % vs. 10.4 %, P = 0.015). Previous history of acute pancreatitis (P = 0.001), pancreatic opacification of first-class branches and beyond (P = 0.008), and absence of pharmacoprophylaxis (P = 0.023) were identified as independent risk factors for PEP in multivariate analysis. Although combined prophylactic therapy with diclofenac plus somatostatin was promising in reducing frequency of PEP, further comparative large-scale studies are needed to confirm our findings before definitive conclusions can be drawn.

Nafamostat mesylate in the prevention of post-ERCP pancreatitis and risk factors for post-ERCP pancreatitis

Pancreatitis is a major complication of ERCP. To determine whether nafamostat mesylate prophylaxis decreases the incidence of post-ERCP pancreatitis (PEP). A single-center, randomized, double-blinded, controlled trial. A large tertiary-referral center. From January 2005 to December 2007, a total of 704 patients who underwent ERCP were analyzed. Patients received continuous infusion of 500 mL of 5% dextrose solution with 20 mg of nafamostat mesylate (354 patients) or without 20 mg of nafamostat mesylate (350 patients). Serum amylase and lipase levels were checked before ERCP, 4 and 24 hours after ERCP, and when clinically indicated. The incidence of PEP and risk factors associated with the development of PEP. The incidence of acute pancreatitis was 5.4%. There was a significant difference in the incidence of PEP between the nafamostat mesylate and control groups (3.3% vs 7.4%, respectively; P = .018). Univariate analysis identified history of acute pancreatitis (P < .001), difficult cannulation (P = .023), periampullary diverticulum (P = .004), age younger than 40 years (P = .009), and >/=5 pancreatic-duct contrast injections (odds ratio [OR] 2.736, P = .012) as statistically significant risk factors. A single-center study. Nafamostat mesylate prophylaxis is partially effective in preventing post-ERCP pancreatitis. Independent risk factors for PEP are a history of acute pancreatitis and multiple pancreatic-duct contrast injections.