Prophylaxis Of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis Research Articles

Body-weight adjusted NSAID dose in the prevention of post ERCP pancreatitis

Abstract Objectives: Although rectal non-steroidal anti-inflammatory drugs (NSAIDs) reduce the incidence of post endoscopic retrograde cholangiopancreatography pancreatitis (PEP), their optimal dosage is unknown. Given possible inter-individual variability in the pharmacodynamics of NSAIDs, we hypothesized that the dose required to achieve adequate PEP prophylaxis varies with body weight. Methods: We conducted an analysis using single-center, prospective, observational cohort study data. The primary outcome was PEP incidence by NSAID dosage per body weight (mg/kg). Patients meeting the inclusion criteria were classified into three groups. Results: We included 891 patients, with 400, 454, and 37 patients in the control group with no NSAID therapy, the NSAID <1.0 mg/kg group, and the NSAID ≥1.0 mg/kg group, respectively. In the adjusted cohort, the odds ratio of PEP was 0.18 (95% confidence interval [CI]: 0.041-0.79; p = 0.023) for NSAID ≥1.0 mg/kg and 1.3 (95%CI: 0.76-2.3; p = 0.31) for NSAID <1.0 mg/kg compared to the control group without NSAID. Conclusions: PEP was not prevented by NSAID dosages below 1.0 mg/kg body weight whereas a dosage above 1.0 mg/kg body weight had a significant prophylactic effect. An NSAID dosage adjusted to body weight may be necessary to achieve an adequate prophylactic effect against PEP.

A Cost-Effectiveness Analysis for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Prophylaxis in the United States

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common adverse event after endoscopic retrograde cholangiopancreatography, and is responsible for substantial morbidity and health care expenditures of at least $200 million. Therapies for PEP prevention include pancreatic stent placement (PSP), rectal indomethacin, sublingual nitrates, and aggressive lactated Ringer's hydration. Our objective was to determine which PEP prophylactic strategies are cost effective. We developed 2 separate decision trees to evaluate PEP prophylactic strategies. The first, in high-risk patients, compared rectal indomethacin, PSP, PSP with indomethacin, sublingual nitrates, aggressive hydration with lactated Ringer's, and no prophylaxis. The second, in average-risk patients, compared rectal indomethacin, sublingual nitrates, aggressive hydration, and no prophylaxis. We used incidence rates, transition probabilities, and costs from publications and public data sources. Outcome measures were reported as incremental cost-effectiveness ratios, with a willingness-to-pay (WTP) threshold of $100,000/quality-adjusted life years (QALYs). Compared with no prophylaxis, all strategies were cost effective at a WTP of $100,000 in preventing PEP in high-risk patients. When directly compared with each other, rectal indomethacin was the cost-effective strategy in high-risk patients ($31,589/QALYs). In average-risk patients, indomethacin and sublingual nitrates were cost effective at a WTP of $100,000/QALYs compared with no prophylaxis. When directly compared with each other, rectal indomethacin was the cost-effective strategy ($53,016/QALYs). Rectal indomethacin was the cost-effective strategy for preventing PEP in both average-risk and high-risk patients undergoing endoscopic retrograde cholangiopancreatography. All strategies were cost effective when compared with no prophylaxis in high-risk patients, whereas all strategies except for aggressive hydration with lactated Ringer's were cost effective in average-risk patients. Further studies are needed to improve the utilization of PEP prevention strategies.

Transabdominal ultrasonography to reduce the burden of X‐ray imaging in prophylactic pancreatic stent localization after ERCP—A prospective trial

BackgroundBefore performing endoscopy to remove prophylactic pancreatic stents placed in patients with high risk of post‐endoscopic retrograde cholangiopancreatography pancreatitis (PEP), X‐ray imaging is recommended to confirm the stents position in the pancreatic duct.ObjectivesThe aim of the present study was to investigate the feasibility of prophylactic pancreatic stent detection by transabdominal ultrasonography, to reduce the burden of X‐ray imaging, which is currently the golden standard.MethodsAll patients who received a pancreatic stent for PEP prophylaxis were included in the present prospective trial. First, stent position was determined by transabdominal ultrasonography. Afterwards, it was verified by X‐ray imaging. Retained stents were removed by esophagogastroduodenoscopy. Dislocated stents needed no further intervention.ResultsFourty‐one patients were enrolled in this study. All prophylactic pancreatic stents were straight 6 cm long 5 Fr stents with external flap. All stents were removed between day 1 and 10 (median: 3 days) in all cases. In 34 of 41 cases (83.0%), the pancreatic stent was still in place on the day of examination. Twenty‐nine of 34 (85.3%) stents were detected correctly by transabdominal ultrasonography. Overlying gas prevented visualization of the pancreas in 3/41 (7.3%) cases. Sensitivity of sonographic detection of the stent was 93.5% (29/31). Six of seven stents were determined correctly as dislocated by ultrasonography. Here, specificity was 85.7%. A positive predictive value of 96.7% (29/30) was examined. The negative predictive value was 75.0% (6/8).ConclusionTransabdominal ultrasonography detects the majority of prophylactic pancreatic stents. Thereby, it helps to identify patients with an indication for endoscopy sufficiently. X‐ray imaging could subsequently be omitted in about 70% of examinations, reducing the radiation exposure for the patient and the endoscopy staff.

Role of NSAIDs in the Prevention of Post-ERCP Pancreatitis: A Narrative Review

Acute pancreatitis is the most common complication after Endoscopic Retrograde Cholangio-Pancreatography (ERCP), occurring in about 3.5% of the procedures. NSAIDs have been shown to play a vital role in the prevention of post-endoscopic retrograde cholangio-pancreatography pancreatitis (PEP). How-ever, not much is known about the most effective drug in preventing this complication. Furthermore, there is a lot of conflict regarding the correct dose, route, and timing of the drug administration. The current study aims to investigate the role of NSAIDs in the prevention of PEP. The literature search was performed using PubMed, and after applying the inclusion and exclusion criteria, 9 published papers were found. All relevant articles on the topic have been included. Our review article has demonstrated that NSAIDs are quite effective in reducing the chances of PEP. It is best to administer drugs per-rectally and pre-procedurally for it to be more effective. However, more Randomized Controlled Trials (RCTs) need to be done to fully understand NSAIDs' role in PEP prophylaxis.

Pharmacological Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Where Do We Stand Now?

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most frequently occurring complication of endoscopic retrograde cholangiopancreatography (ERCP). PEP is associated with significant morbidity and mortality; that is why the prevention of PEP is essential. Pharmacoprevention holds a central position in PEP prophylaxis. The current literature explores the efficacy of various pharmacological agents in preventing PEP, their routes of administration, and the correct administration timing. Data was collected on PubMed using regular keywords, the latter yielded 2077 papers. After applying inclusion and exclusion criteria, 218 papers were selected and screened and 28 studies were finally chosen after the removal of duplicate and irrelevant studies. The selected 28 articles comprised 25 randomized clinical trials and three systematic reviews.The study concludes that rectal non-steroidal anti-inflammatory drugs (NSAIDs) administered before ERCP are effective in preventing PEP in high-risk patients. The efficacy of rectal NSAIDs in low to medium risk group is not well established. A combination of rectal NSAIDs and intravenous hydration provides improved prophylaxis against PEP in high-risk patients than NSAIDs alone. Nafamostat, sublingual nitrates, and intravenous hydration are potential alternatives in patients with contraindications to NSAIDs.

15 Utilization Patterns of Prophylactic Pancreatic Stents for the Prevention of Post-ERCP Pancreatitis: A 2018 National Survey Study

INTRODUCTION: Post ERCP Pancreatitis (PEP) is the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Prophylactic pancreatic stents (PPS) and rectal indomethacin (IND) prevent PEP, decrease severity in PEP and are endorsed by GI societies. It is unclear the extent to which these interventions are practiced throughout the United States (US). The impact of such factors as training, experience and practice setting on the use of PPS for PEP prophylaxis is unclear. The aims of our study are to describe utilization patterns and identify factors that impact physician decisions to use PPS for PEP prophylaxis. METHODS: A 27-question electronic survey was distributed using a cloud based program (Qualtrics). Questions assessed ERCP training, practice setting, experience, practice patterns and perceptions for PEP prophylaxis interventions. Endoscopists with practices based in the US, listed in the American Society for Gastrointestinal Endoscopy (ASGE) member directory received a survey invitation via e-mail. The invitation outlined the study and contained a link with instructions to complete the voluntary survey if they had an active ERCP practice. Data was de-identified for the purposes of analysis. RESULTS: Of survey respondents (n = 319/6276), 46% reported therapeutic endoscopy fellowship training and 37% practiced in teaching programs (Table 1). Annualized ERCP volume of >100 cases per year were reported by 47%, with pancreatic ERCP comprising ≤5% of procedures in the majority of respondents (61%). The majority of respondents utilized PPS and 54% reported frequent use (Table 2). The most common indications for PPS were: difficult cannulation, to assist biliary access and multiple pancreatic duct injections. The majority of respondents reported frequent use of IND (89%). Of physicians that do not use PPS, use of IND was the most common reason (80%). Variables associated with frequent use of PPS were therapeutic fellowship training (P = <0.001), practice at a teaching program (P = <0.001), <10 yrs in practice (P = 0.005), higher procedure volume (P = <0.001), higher proportion of pancreatic cases (P = <0.001), and selective use of IND (P = 0.002) (Table 3). CONCLUSION: Physicians with higher volume, teaching hospital based ERCP practices and regularly perform pancreatic ERCP are more likely to use PPS. Therapeutic fellowship training and recent entry into practice also associate with PPS utilization. Indomethacin use was prevalent and the most cited reason for electing not to use PPS.

Reducing the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis using 4-Fr pancreatic plastic stents placed with common-type guidewires: Results from a prospective multinational registry.

Pancreatic plastic stents (PPS) can reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Prospective multicenter documentation of PEP rate after PPS placement is scarce. A new 4-Fr stent designed to be deployed over a 0.035-inch guidewire was used to assess the effectiveness of PEP prophylaxis. High-PEP-risk patients received a 4-Fr PPS for primary or secondary prophylaxis at seven centers in four countries. Patients were followed until spontaneous PPS migration, endoscopic stent removal, or for 4months, whichever came first. Main outcome was PEP rate. One hundred six (106) patients received PPS for PEP prophylaxis [61 (58%) primary, 45 (42%) secondary prophylaxis]. Median age was 54 years. Eighty-one (76%) PPS were placed using a 0.035-inch guidewire. By investigator choice 99 (93%) stents were single pigtail. Median stent length was 8cm (range 3-12cm). Technical success achieved in 100% of cases. Two patients in the primary prophylaxis group (3%, 95% CI 0.4-11%) experienced mild/moderate PEP. Seventy-eight PPS available for analysis underwent spontaneous migration after a median of 29days. There were no reports of stent-induced ductal trauma. Post-hoc analysis of migration rate by PPS length showed no statistically significant trend. Among high-risk patients in the primary prophylaxis group, observed rates of PEP are low (3%, 95% CI 0.4-11%) with the use of prophylactic 4-Fr pancreatic duct stents compatible with a 0.035-inch guidewire. This low rate is not unequivocally due to the prophylactic stent.

ERCP in Portugal: A Wide Survey on the Prevention of Post-ERCP Pancreatitis and Papillary Cannulation Techniques

Background/Aims: Recently the European Society of Gastrointestinal Endoscopy delivered guidelines on the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and on the papillary cannulation and sphincterotomy techniques at endoscopic retrograde cholangiopancreatography (ERCP). There are no data concerning current practices in Portugal. The aim of this study was to capture practice patterns of Portuguese pancreaticobiliary endoscopists with special interest in the prevention of PEP and cannulation techniques. Methods: A written survey was distributed to all pancreaticobiliary endoscopists attending the first Portuguese meeting dedicated to ERCP in November 2016. The main outcome measures were: technique used for standard biliary cannulation, use of nonsteroidal anti-inflammatory drugs (NSAIDs) in PEP, attempting prophylactic pancreatic stenting after using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation was difficult, and use of precut as the first rescue technique when biliary cannulation was difficult. Results: Completed surveys were collected from 28 of the 32 pancreatobiliary endoscopists attending the meeting (answer rate 87.5%). Biliary cannulation was performed using a guidewire access technique by the majority (77%), usually with a sphincterotome. When cannulation was unsuccessful, precut was the first choice for 70%. NSAIDs were administered routinely for PEP by only 54%; PGW-assisted biliary cannulation was the first choice after failed standard cannulation for a minority of them, and only 27% reported to routinely attempt insertion of a pancreatic stent. High-volume endoscopists (> 150/year) tended to use NSAIDs and to insert a stent in PGW-assisted cannulation less often than low-volume-endoscopists (50 vs. 83.3%, p < 0.01, and 40 vs. 100%, p < 0.01, respectively). Precut was started without prior formal training by more than half of the endoscopists. Conclusions: There is a pronounced discrepancy between evidence-based guidelines and current clinical practice. This discrepancy is more pronounced in PEP prophylaxis, especially among high-volume endoscopists. Some advanced techniques in ERCP are initiated unsupervised, without any previous formal training. Key Message: There is a significant gap between guidelines and routine clinical practice.

Effect of body weight on fixed dose of diclofenac for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Objective: The aim of this study was to assess the influence of patient body weight on the clinical effect of 100 mg diclofenac administered as a single dose for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).Materials and methods: All patients subjected to endoscopic retrograde cholangiopancreatography (ERCP) from 2009 to 2014 were evaluated for inclusion. In total, 772 patients were included of whom 378 (49%) received diclofenac prophylaxis.Results: In the diclofenac prophylaxis group, body weight was higher in patients with PEP (mean ± SD: 82 ± 18 kg) than in patients without PEP (74 ± 18 kg) (p = 0.029). In patients not receiving prophylaxis, body weight was not associated with the occurrence of PEP (mean ± SD: 77 ± 18 vs 75 ± 18 kg, respectively, p = 0.450). In an adjusted analysis, higher patient body weight was inversely associated with the clinical effect of 100 mg diclofenac for the prophylaxis of PEP.Conclusions: High patient body weight was associated with a reduced effect of 100 mg diclofenac for prophylaxis of PEP.

Prevention of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis: An Endoscopic Perspective

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) remains to be the most common adverse event, even in experienced hands. While most of the PEP has a mild clinical course, it could be severe pancreatitis or into mortality. Recently, several endoscopic techniques, such as pancreatic stent placement, guidewire-assisted cannulation, or early precut cannulation, have been suggested as a possible techniques for the PEP prophylaxis. Since several pharmacologic agents are turned out to be non-effective or equivocal except for the rectal non-steroidal anti-inflammatory drugs which are not available in Korea, this paper will describe the general aspects of PEP and focus on the endoscopy-techniques for PEP prophylaxis. Keywords: Endoscopic retrograde cholangiopancreatography, ERCP, Pancreatitis, Prophylaxis Keywords: 내시경 역행성 ë‹´ì·Œê´€ì¡°ì˜ìˆ , 췌장염, 예방

Meta-analysis of prophylactic corticosteroid use in post-ERCP pancreatitis

BackgroundAcute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography and benefit of pharmacological treatment is unclear. Although prophylactic use of corticosteroid for reduction of pancreatic injury after ERCP has been evaluated, discrepancy about beneficial effect of corticosteroid on pancreatic injury still exists. The aim of current study is to evaluate effectiveness and safety of corticosteroid in prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).MethodsWe employed the method recommended by the Cochrane Collaboration to perform a meta-analysis of seven randomized controlled trials (RCTs) of corticosteroid in prevention of post-ERCP pancreatitis (PEP) around the world.ResultsMost of the seven RCTs were of high quality. When the RCTs were analyzed, odds ratios (OR) for corticosteroid were 1.13 [95% CI (0.89~1.44), p = 0.32] for PEP, 1.61 [95% CI (0.74~3.52), p = 0.23] for severe PEP, 0.92 [95% CI (0.57~1.48), p = 0.73] for post-ERCP hyperamylasemia respectively. The results indicated that there were no beneficial effects of corticosteroid on acute pancreatitis and hyperamylasemia. No evidence of publication bias was found.ConclusionCorticosteroids cannot prevent pancreatic injury after ERCP. Therefore, their use in the prophylaxis of PEP is not recommended.

Gabexate in the prophylaxis of post-ERCP pancreatitis: a meta-analysis of randomized controlled trials

BackgroundAcute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography and the benefit of its pharmacological treatment is unclear. Although prophylactic use of gabexate for the reduction of pancreatic injury after ERCP has been evaluated, the discrepancy about gabexate's beneficial effect on pancreatic injury still exists. This study aimed to evaluate the effectiveness and safety of gabexate in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).MethodsWe employed the method recommended by the Cochrane Collaboration to perform a meta-analysis of randomized controlled trials (RCTs) of gabexate in the prevention of post-ERCP pancreatitis (PEP) including three RCTs conducted in Italy and one in China.ResultsAll of the four RCTs were of high quality. When the RCTs were analyzed, odds ratios (OR) for gabexate mesilate were 0.67 [95% CI (0.31~1.47), p = 0.32] for PEP, 3.78 [95% CI (0.62~22.98), p = 0.15] for severe PEP, 0.68 [95% CI (0.19~2.43), p = 0.56] for the case-fatality of PEP, 0.88 [95% CI (0.72~1.07), p = 0.20] for post-ERCP hyperamylasemia, 0.69 [95% CI (0.39~1.21), p = 0.19] for post-ERCP abdominal pain, thus indicating no beneficial effects of gabexate on acute pancreatitis, the death rate of PEP, hyperamylasemia and abdominal pain. No evidence of publication bias was found.ConclusionGabexate mesilate can not prevent the pancreatic injury after ERCP. It is not recommended for the use of gabexate mesilate in the prophylaxis of PEP.