Management Of Acute Biliary Pancreatitis Research Articles

Preventive pancreatic stents in the management of acute biliary pancreatitis (PREPAST trial): Pre-study protocol for a multicenter, prospective, randomized, interventional, controlled trial

BackgroundThe outcome of the most common biliary form of acute pancreatitis has not changed even with the better described indications for early endoscopic intervention. It may be due to the fact that this intrevention theoretically can cause further pancreatic injury or cannot always relieve the pancreatic duct obstruction. We hypothesize that maintaining the outflow of the pancreatic duct with preventive pancreatic stents at the early ERCP improves the outcome of acute biliary pancreatitis. Methods/DesignPREPAST is a prospective, randomized, controlled, multicenter trial. Patients with acute biliary pancreatitis with coexisting cholangitis are randomized to undergo urgent endoscopic intervention with or without pancreatic stenting within 48 h from the onset of pain, and in addition patients without signs of cholangitis but cholestasis are randomly allocated to recieve conservative treatment or early endoscopic intervention with or without pancreatic stenting within 48 h from the onset of pain. Patients without acute cholangitis and signs of cholestasis recieve conservative treatment. 230 patients are planned to be enrolled during a 48 months period from different centers. The primary endpoint is the outcome of acute biliary pancreatitis as described by the latest guidelines. Secondary endpoints include mortality data, and other variables not analyzed as a primary endpoint but related to the pancreatitis or the pancreatic stenting. DiscussionThe PREPAST trial is designed to show whether early endoscopic intervention with the usage of preventive pancreatic stenting improves the outcome of acute biliary pancreatitis. The study has been registered at the International Standard Randomised Controlled Trial Number (ISRCTN) Register (trial ID: ISRCTN13517695).

Early endoscopic ultrasonography in acute biliary pancreatitis: A prospective pilot study.

To investigate the clinical usefulness of early endoscopic ultrasonography (EUS) in the management of acute biliary pancreatitis (ABP). All consecutive patients entering the emergency department between January 2010 and December 2012 due to acute abdominal pain and showing biochemical and/or radiological findings consistent with possible ABP were prospectively enrolled. Patients were classified as having a low, moderate, or high probability of common bile duct (CBD) stones, according to the established risk stratification. Exclusion criteria were: gastrectomy or patient in whom the cause of biliary obstruction was already identified by ultrasonography. All enrolled patients underwent EUS within 48 h of their admission. Endoscopic retrograde cholangiopancreatography was performed immediately after EUS only in those cases with proven CBD stones or sludge. The following parameters were investigated: (1) clinical: age, sex, fever; (2) radiological: dilated CBD; and (3) biochemical: bilirubin, AST, ALT, gGT, ALP, amylase, lipasis, PCR. Association between presence of CBD stone at EUS and the individual predictors were assessed by univariate logistic regression. Predictors significantly associated with CBD stones (P < 0.05) were entered in a multivariate logistic regression model. A total of 181 patients with pancreatitis were admitted to the emergency department between January 2010 and December 2012. After exclusion criteria a total of 71 patients (38 females, 53.5%, mean age 58 ± 20.12 years, range 27-89 years; 33 males, 46.5%, mean age 65 ± 11.86 years, range 41-91 years) were included in the present study. The probability of CBD stones was considered low in 21 cases (29%), moderate in 26 (37%), and high in the remaining 24 (34%). The 71 patients included in the study underwent EUS, which allowed for a complete evaluation of the target sites in all the cases. The procedure was completed in a mean time of 14.7 min (range 9-34 min), without any notable complications.The overall CBD stone frequency was 44% (31 of 71), with a significant increase from the group at low pretest probability to that at moderate (OR = 5.79, P = 0.01) and high (OR = 4.25, P = 0.03) pretest probability. Early EUS in ABP allows, if appropriate, immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.

Contemporary Management of Acute Biliary Pancreatitis

Contemporary Management of Acute Biliary Pancreatitis

Mo1549 The Role of Intraductal US for the Management of Biliary Pancreatitis After Negative ERCP Results

ERCP has been considered the standard for the evaluation and management of acute biliary pancreatitis (ABP). Identifying a bile duct (BD) stones in patients with ABP is important for the management and prevention of recurrent attack of pancreatitis. But, small BD stones may not be detected on ERCP. The aim of this study was to prospectively evaluate the usefulness of intraductal US (IDUS) in patients with suspicious ABP having no evidence of choledocholithiasis on ERCP.

Early endoscopic treatment for acute biliary pancreatitis

Objective To study the efficacy and safety of early endoscopic retrograde cholangiopancreatography(ERCP) and endoscopic sphincterotomy (EST) for patients with acute biliary pancreatitis.Methods 420 patients who were admitted to our hospital for management of acute biliary pancreatitis were divided into early endoscopic therapy group (n=218 patients) and conservative therapy group (n=202 patients).The durations for complete disappearance of abdominal pain,decrease in serum and urine amylase levels to normal,liver function recovery time,white blood cell recovery time,and the mean duration and costs of hospitalizations were analyzed.Results In the ERCP group,all patients received EST.The stones in 172 patients with choledocholithiasis were removed with dormia baskets or balloon catheters.In 20 patients with severe acute biliary pancreatitis,endoscopic pancreatic duct stents were inserted for drainage.The durations of complete disappearance of abdominal pain,decrease of serum and urine amylase values to normal,white blood cell recovery time,liver function recovery time,cost of hospitalization and duration of hospitalization were significantly shorter in the early ERCP group than the control group.The mortalities in the ERCP and the control groups were 8.0％ and 22.2％,respectively.Conclusions Early endoscopic management for patients with acute biliary pancreatitis was not only safe and efficacious,but the management helped to identify the underlying causes of pancreatitis and reduced the duration of hospital stay and expenses. Key words: Pancreatitis, acute nccrotizing; Cholelithiasis; Cholangiopancreatography, endoscopic retrograde

Acute biliary pancreatitis: an experience in a tertiary level hospital of Nepal.

Acute Biliary Pancreatitis is one of the commonest forms of pancreatitis in Nepal. Controversies exist as to the most appropriate way of management of these cases. The present study was carried out to evaluate the management and outcome of Acute Biliary Pancreatitis cases in a tertiary level hospital of Nepal. A retrospective analysis of the patients managed with Acute Biliary Pancreatits was done. All patients admitted with the diagnosis of Acute Biliary Pancreatitis over a period of 2years were included in the study. The variables measured were age, sex, clinical presentation, laboratory investigations, mode of treatment and outcome. A total of 45 cases had Acute Biliary Pancreatitis suggesting a prevalence of 28%. The mean age was 45 ± 10year. 39 patients (86.6%) were treated with conservative management. 23 patients (54%) had an uneventful recovery without any complications. 21 patients (46%) developed some form of complications but recovered successfully. Mortality was seen in only one patient in the conservatively treated group. In a resource poor setting such as Nepal, definitive management is not always possible. Conservative management of Acute Biliary Pancreatitis has a favorable outcome in the majority of our patients with acceptable morbidity and mortality. Definitive management can be safely performed during index admission where possible.

Endoscopic treatment of acute biliary pancreatitis: A national survey among Dutch gastroenterologists

Objective. Based on the ampullary obstruction and reflux theory, six endoscopic retrograde cholangiopancreatography (ERCP) studies have investigated the effect of (early) biliary decompression versus conservative management on the course and outcome of patients with acute biliary pancreatitis (ABP) showing inconsistent and contradictory outcomes. We investigated the opinion and attitude of Dutch gastroenterologists regarding the application of (early) ERCP in the clinical management of ABP by means of a nationwide survey. Material and methods. An anonymous questionnaire was sent to all registered consultant gastroenterologists (n = 283) across the Netherlands. Results. The response rate was 52%. The vast majority of consulting gastroenterologists declared that early ERCP may be indicated in ABP (96.6%). Fourteen percent stated that they always perform ERCP in ABP. The remainder of the respondents consider ERCP only if a concomitant condition is present such as a dilated CBD (95%), co-existent cholangitis (87%), common bile duct stone(s) (CBDS) (72%), jaundice (59%), ampullary stone (68%) or (predicted) severe ABP (35%). About half of the consultant gastroenterologists (51.4%) consider the optimal time point for ERCP in ABP to be within 24 h after admission or symptom onset. If ERCP is performed for suspected APB, 55% of the respondents perform an endoscopic sphincterotomy (ES), regardless of the findings on cholangiography. Conclusions. The vast majority of Dutch gastroenterologists attest to a role for ERCP in ABP, but indications when to perform ERCP, its timing, and the application of ES vary greatly and are not always in line with the Dutch or other published national guidelines. The results of this survey highlight the need for additional comparative randomized studies to define the role of (early) ERCP in ABP.

The outcome of early laparoscopic cholecystectomy in patients with acute biliary pancreatitis

Objectives: It is still controversial to perform a laparoscopic cholecystectomy (LC) for the management of acute biliary pancreatitis (ABP) at the early hospitalization period, because of adhesions and dissection difficulties. The aim of this study was to evaluate the outcome of the patients with ABP who underwent LC prior to hospital discharge. Methods: A total of 43 patients with ABP, that underwent LC after clinical and laboratory improvement, were retrospectively evaluated.Patient’s age, gender, laboratory findings; ultrasonography (USG), magnetic resonance and other imaging results, surgical operation duration, complications, mortality and postoperative hospital stay days were recorded and statistically analyzed. Results: The median age of patients was 51.8 (20-83) years. A total of 29 (67.4%) patients were women and 14 (32.6%) were male. The cause was gallstone in all patients. In addition, hyperparathyroidism was found in one patient and hyperlipidemia was present in the other one. Gallbladder stones were determined in all patients. Common bile duct enlargement and stones were detected in 7 patients. Three patients underwent sphyncterectomy and stone extraction according to clinical status. Operations were performed at the mean hospitalization day of 11.4 (3-23). LC was performed to 39 (%90.6) of patients. However, 4 (9.4%) patients had intra-abdominal adhesions secondary to infection and were switched to open surgery. The mean operation time was 70 (25-160) minutes and the mean duration of postoperative hospital stay was 3 (1-6) days. In a patient who underwent LC and ERCP preoperatively complication occurred. A second drainage operation was performed and due to development of necrotizing pancreatitis, the patient was lost at the postoperative 7th day secondary to adult type respiratory distress syndrome. Conclusions: In patients with ABP whose clinical and laboratory findings were improved, late LC can be performed safely during their first hospitalization.

Surgical management of acute biliary pancreatitis

Objective To summarize the experience in surgical intervention of acute biliary pan-creatitis to explore the features of operative treatment of acute biliary pancreatities. Methods The clinical data of 54 cases of acute biliary pancreatitis surgically treated in our hospital from Septemper 2004 to May 2007 were retrospectively analyzed. Results Forty-six patients received operation. of these 46 patients, 9 received operation at the early phase and 37 did it later. All the 46 patients recov-ered and the mean hospitalization duration was 8.4 d. There was no recurrence after operation. For the rest 8 patients, 1 died and 2 had recurrence. Conclusiun The surgical intervention is still very im-portant for the patient with acute biliary pancreatities. In the course of the disease deve]opment, we suggest selective and delayed surgery for acute biliary pancreatitis. Key words: Pancreatitis; Surgical management

Is early endoscopic retrograde cholangiopancreatography useful in the management of acute biliary pancreatitis?: A meta-analysis of randomized controlled trials

Aims To compare early endoscopic retrograde cholangiopancreatography with conservative management for the treatment of acute biliary pancreatitis: a meta-analysis of prospective randomized trials. Method Pertinent studies were selected from the Medline, Embase, and the Cochrane Library Databases, references from published articles and reviews. Conventional meta-analysis according to DerSimonian and Laird method was used for the pooling of the results. The rate difference (95% CI) and the number needed to treat were used as a measure of the therapeutic effect. Results Five prospective randomized trials including 702 patients were selected. Overall complications and mortality rates were 31% and 6%, respectively. In predicted severe pancreatitis the pooled rate difference for complications in early endoscopic retrograde cholangiopancreatography was 38.5% (95% CI −53% to −23.9%); p < 0.0001; number needed to treat = 3. In predicted mild pancreatitis the pooled rate difference for complications in early endoscopic retrograde cholangiopancreatography was 1.8% (95% CI −5.6% to 9.3%); p = 0.6. No mortality was observed in predicted mild pancreatitis. In predicted severe pancreatitis the pooled rate difference for mortality in the early endoscopic retrograde cholangiopancreatography group was 4.3% (95% CI −16% to 7.5%); p < 0.24. Conclusions Early endoscopic retrograde cholangiopancreatography reduces pancreatits-related complications in patients with predicted severe pancreatitis although mortality rate is not affected. In predicted mild pancreatitis early endoscopic retrograde cholangiopancreatography has no advantage compared to conservative management.

Management of Acute Biliary Pancreatitis

Management of Acute Biliary Pancreatitis

Comparison of Early Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography in the Management of Acute Biliary Pancreatitis: A Prospective Randomized Study

The role and potential benefits of endoscopic ultrasonography (EUS) in the management of acute biliary pancreatitis have not been documented. We report a large prospective randomized study comparing early EUS and endoscopic retrograde cholangiopancreatography (ERCP) in the management of these patients. A prospective randomized study was performed on 140 patients with acute pancreatitis suspected to have a biliary cause. The patients were randomized to have EUS (n = 70) or ERCP (n = 70) within 24 hours from admission. In the EUS group, when EUS detected choledocholithiasis, therapeutic ERCP was performed during the same endoscopy session. In the ERCP group, diagnostic ERCP was performed, followed by therapeutic endoscopy when choledocholithiasis was detected. Examination of the biliary tree by EUS was successful in all patients in the EUS group, whereas cannulation of the common duct during ERCP was unsuccessful in 10 patients (14%) in the ERCP group (P = .001). Combined percutaneous ultrasonography and ERCP missed detection of cholelithiasis in 6 patients in the ERCP group. The overall morbidity rate was 7% in the EUS group, and that in the ERCP group was 14% (P = .172). The hospital stay and mortality rates were comparable in both groups. In selected patients with acute biliary pancreatitis, EUS could safely replace diagnostic ERCP in the management for selecting patients with choledocholithiasis for therapeutic ERCP with a higher successful examination rate, a higher sensitivity in the detection of cholelithiasis, and a comparable morbidity rate.

Endoscopic Interventions and Jejunal Feeding in the Management of Acute Biliary Pancreatitis

Endoscopic Interventions and Jejunal Feeding in the Management of Acute Biliary Pancreatitis Tibor Gyokeres, Maria Burai, Eszter Schafer, Richard Schwab, Akos Pap Introduction: Acute biliary pancreatitis (ABP) is one of the most severe complications of the biliary stone disease. Its management is early endoscopic papillotomy followed by stone extraction if necessary, and conservative treatment of pancreatitis. Patients: During last four years we have treated twenty-nine patients (age: 21-92 years) with ABP, 17 of them had severe pancreatitis evaluated bymodified Imrie score. Twenty-six patients had stones in the gallbladder, twohad previous cholecystectomy and in one patient the gallbladder was stonefree. Methods: In case of suspected biliary origin of the pancreatitis we have performed duodenoscopy, endoscopic retrograde cholangiography and endoscopic papillotomy followed by stone extraction. At the end of the procedure we inserted feeding tube into the second loop of the jejunum. At the first day we have administered saline, on the second day diluted nutrient and from the third day to the healing we applied 1 ml/kcal nutrient in continuous infusion into the jejunum. Results: We performed 25 papillotomy, followed by stone extraction in 11 patients, and jejunal feeding was applied in 26 patients. The median time from the start of the symptoms to the interventionwas 1.5 (1-21) days. The hospital staywas 11 (2-81) days in average. One old patient died of pneumonia with healed pancreatitis and five died of complicated pancreatitis. All patient with fatal outcome had severe pancreatitis. Suprisingly not only the modified Imrie score, but the initial amylase value and the rate of the decrease had prognostic value: the higher initial amylase and the slow decrease was associated with poor outcome. In summary: Our results confirmed that acute biliary pancreatitis has a significant mortality even in case of proper timing of endoscopic papillotomy and with the best conservative treatment. *T1540 Endoscopic Treatment for Main Pancreatic Duct Rupture Following Silastic Ring Vertical Banded Gastroplasty Marianna Arvanitakis, Reza Chamlou, Myriam Delhaye, Celso Matos, Jean Closset, Jacques Deviere Background: Acute pancreatitis (AP) has been described as a rare complication of Silastic ring vertical banded gastroplasty (SRVG). It can be attributed to a pancreatic trauma occurring during surgery leading to segmental injury, AP and formation of pancreatic fluid collections (PFC). Endoscopic therapy is technically difficult in these patients, because of the presence of the small outlet channel formed by the ring, which limits the access to the distal part of the stomach and the transmural endoscopic approach of adjacent PFC. Patients and Methods: Four cases of patients having had SRVG (4 women, median age: 33 years (19-50)) for morbid obesity who presented post-operative AP, accompanied by main pancreatic duct disruption (MPDD) and PFC were managed endoscopically. Results: During a period of 16 months, out of 150 SRVG performed in our institution, AP associated with MPDD was recorded in 2 patients. Another two similar patients were referred fromother institutions. AP occurred at amedian of 4 (4-6) days after SRVG and MPDD (located at the body and tail junction) was documented 10 (6-35) days after SRVG by means of S-MRCP. Median interval between SRVG and endoscopic treatment was 15 (7-45) days. Indications for drainage were pain (n=2) and sepsis (n=2). All four patients had transmural drainage of PFC (median maximal diameter: 80mm (70-100)) under endoscopic guidance (n=4), associated with endoscopic ultrasonography (n=2) and/or fluoroscopic guidance (n=4) guidance, followed by the insertion of one or more plastic stents. Two patients had complementary transpapillary drainage including pancreatic sphincterotomy (n=2) and pancreatic stenting (n=1). Access to the distal gastric cavity through the outlet channel with the duodenoscope was technically difficult in all patients requiring the use of a guidewire, associated with pneumatic dilation up to 20 mm of the outlet channel in 2 patients and we performed a distal cystogastrostomy through the retroperitoneal cavity in one patient. Endoscopic therapy was successful in all patients, with subsequent resolution of PFC. One patient required drainage of a recurring collection 6 months following initial treatment. They are all asymptomatic with resolution of collections during a median follow up of 11 months (5-23). Conclusions: Endoscopic therapy is particularly useful in post SRVG AP with MPDD and, although technically difficult, should be considered as a first-line approach in the management of these patients.

A survey of the timing and approach to the surgical management of cholelithiasis in patients with acute biliary pancreatitis and acute cholecystitis in the UK.

Recent management guidelines and randomised clinical trials have provided evidence-based guidance to the management of acute biliary pancreatitis and acute cholecystitis. A questionnaire was sent to the 1086 members of the Association of Surgeons of Great Britain and Ireland. There were 583 responders (54%). A policy of cholecystectomy during the index admission or within 4 weeks in fit patients recovering from mild acute biliary pancreatitis was adopted by 58% of surgeons, and was significantly associated with an upper gastrointestinal and hepato-pancreato-biliary subspecialty interest and a volume of more than 50 cholecystectomies per annum (OR, 0.43; 95% CI, 0.26-0.72; P = 0.001: and OR, 0.46; 95% CI, 0.29-0.74; P = 0.001, respectively). A policy of urgent cholecystectomy for acute cholecystitis was adopted by 20% of surgeons, and was significantly associated with an upper gastrointestinal/hepato-pancreato-biliary subspecialty interest and the 'routine' adoption of laparoscopic approach to cholecystectomy (OR, 0.34; 95% CI, 0.19-0.60; P < 0.001: and OR, 0.51; 95% CI, 0.3-0.86; P = 0.01, respectively). The management of cholelithiasis in patients with acute biliary pancreatitis in the UK remains suboptimal. Moreover, only a minority of surgeons offer patients presenting with acute cholecystitis the benefits of early laparoscopic cholecystectomy. The management of acute biliary disease may be improved if these cases were concentrated in the hands of surgeons with upper gastrointestinal/hepato-pancreato-biliary interest and those who perform laparoscopic cholecystectomy regularly.

Where do ERCP, endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography fit in the management of acute biliary pancreatitis? A decision analysis model

OBJECTIVES: The role of ERCP in acute biliary pancreatitis (ABP) is controversial. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) are modalities for bile duct visualization that could lower costs and prevent ERCP-related complications. We analyzed costs and examined the cost-effectiveness of these modalities to define their role in ABP. METHODS: A decision analysis model of ABP was constructed. The strategies evaluated were 1) ERCP, 2) MRCP followed by ERCP if positive for common bile duct stones (CBDS) or if biliary sepsis ensued, 3) EUS followed by ERCP if positive or if biliary sepsis ensued, and 4) observation with intraoperative cholangiography at the time of cholecystectomy with ERCP only if biliary sepsis ensued. We compared costs and performed cost-effectiveness analysis between strategies at probabilities of CBDS ranging from 0% to 100%. The outcome measures were total costs and costs per ABP death prevented. RESULTS: At probabilities of CBDS < 15%, observation with intraoperative cholangiography is the least expensive strategy, whereas EUS and ERCP are the least expensive strategies at probabilities of 15–58% and >58%, respectively. In terms of cost-effectiveness, at probabilities of CBDS of 7–45%, EUS is the most cost-effective alternative, and at a probability of >45% ERCP is the most cost-effective option. CONCLUSIONS: Total costs and cost-effectiveness ratios of these strategies in patients with ABP are highly dependent on the probability of CBDS.

Where do ERCP, endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography fit in the management of acute biliary pancreatitis? A decision analysis model.

The role of ERCP in acute biliary pancreatitis (ABP) is controversial. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) are modalities for bile duct visualization that could lower costs and prevent ERCP-related complications. We analyzed costs and examined the cost-effectiveness of these modalities to define their role in ABP. A decision analysis model of ABP was constructed. The strategies evaluated were 1) ERCP, 2) MRCP followed by ERCP if positive for common bile duct stones (CBDS) or if biliary sepsis ensued, 3) EUS followed by ERCP if positive or if biliary sepsis ensued, and 4) observation with intraoperative cholangiography at the time of cholecystectomy with ERCP only if biliary sepsis ensued. We compared costs and performed cost-effectiveness analysis between strategies at probabilities of CBDS ranging from 0% to 100%. The outcome measures were total costs and costs per ABP death prevented. At probabilities of CBDS < 15%, observation with intraoperative cholangiography is the least expensive strategy, whereas EUS and ERCP are the least expensive strategies at probabilities of 15-58% and >58%, respectively. In terms of cost-effectiveness, at probabilities of CBDS of 7-45%, EUS is the most cost-effective alternative, and at a probability of >45% ERCP is the most cost-effective option. Total costs and cost-effectiveness ratios of these strategies in patients with ABP are highly dependent on the probability of CBDS.

3390 Role of early ercp and sphincterotomy in the management of acute pancreatitis.

Background: The role of early ERCP ± endoscopic sphincterotomy (ES) in patients with acute pancreatitis of biliary origin remains controversial. The aim of this study is to pool the conflicting results of various studies through a systematic review and to show if early ERCP (within 72 hrs) as compared to conservative management decreases the risk of both local and systemic complications and of death from acute biliary pancreatitis. Methods: Using Medline, from the years 1985-1997, along with a manual search of abstracts from major national conferences, and screening the references of the published studies and reveiws, controlled trials were identified in which early ERCP ± ES were used in the management of acute biliary pancreatitis (ABP). Five controlled trials were identified. Out of these two were excluded; one each for lack of randomization and for availability of data in abstract form only. Data from remaining three trials for all patients (n=470) in both treated (n= 243) and control groups (n=227) with suspected ABP were pooled using a fixed effects model (Mantel - Haenszel method) and assessed for the three main outcomes, i.e. mortality (in-hospital and upto 3 months), systemic complications (respiratory failure, renal failure, shock, DIC) and local complications (pancreatic abscess, phlegmon, psuedocyst, hemmorhagic pancreatitis and acute cholangitis). Results: The individual (for each study) and pooled estimates for all three outcomes were expressed as Mantel - Haenszel weighted odds ratios (O.R.) and presented in a standard meta-analysis plot (here in a tabulated form) with confidence intervals (CI) of 95%. Conclusions: Early ERCP and endoscopic sphincterotomy in acute biliary pancreatitis greatly decreased the risk of local complications. The effect on systemic complications and mortality is inconclusive and requires a further study

The management of acute biliary pancreatitis: A decision analysis

The management of acute biliary pancreatitis: A decision analysis

Endoscopic Management of Acute Biliary Pancreatitis: A Meta-Analysis

Endoscopic therapy (endoscopic retrograde cholangiopancreatography with biliary endoscopic sphincterotomy -- ERCP/ES) has been advocated for the

Metaanalysis of randomized controlled trials of endoscopic retrograde cholangiography and endoscopic sphincterotomy for the treatment of acute biliary pancreatitis.

Endoscopic retrograde cholangiography with endoscopic sphincterotomy (ERC+ES) has been advocated for the management of acute biliary pancreatitis. However, it is also viewed as dangerous. Our objective was to review published randomized, controlled trials (RCTs) of ERC+ES in patients with acute biliary pancreatitis and, by metaanalysis, to estimate the overall efficacy and safety of this approach. We performed a fully recursive literature search for published RCTs of ERC+ES in gallstone-related acute pancreatitis. RCTs were pooled. Individual and overall mortality and complication rates were calculated, together with their 95% confidence intervals (CI), absolute risk reduction (ARR), relative risk reduction (RRR), and numbers needed to treat (NNT) for avoidance of complications or death. Four published RCTs had a numerically lower complication rate, and three had a numerically lower mortality rate, in the treated groups than in controls. After pooling, there were 460 treated patients and 374 controls. Complications occurred in 115 (25.0%) treated patients and 143 (38.2%) controls (z = 4.10; p < 0.001). Twenty-four treated patients (5.2%) and 34 controls (9.1%) died (z = 2.15; p < 0.05). ERC+ES had a 34.6% RRR for complications and a 42.9% RRR for death; ARR for complications and death was 13.2% (95% CI: 6.9-19.5%) and 3.9% (95% CI: 0.35-7.45%), respectively. The NNT for avoidance of complications and death was 7.6 and 25.6, respectively. ERC+ES reduces morbidity and mortality in patients with acute biliary pancreatitis. Treating 26 such patients with ERC+ES is predicted to save one life.