Prophylactic Pancreatic Duct Stent Placement Research Articles

Current state of biliary cannulation techniques during endoscopic retrograde cholangiopancreatography (ERCP): International survey study.

Background and study aims Endoscopist techniques affect biliary cannulation success and the risk of adverse events during endoscopic retrograde cholangiopancreatography (ERCP). This survey study aims to understand the current practice of biliary cannulation techniques among endoscopists. Methods Practicing endoscopists were sent an anonymous 28-question electronic survey on biliary cannulation techniques and intraprocedural pancreatitis prophylactic strategies. Results The survey was completed by 692 endoscopists (6.2% females). A wire-guided cannulation technique (WGT) was the preferred initial biliary cannulation approach (95%). The preferred secondary approaches were a double-wire (DWT) (65.8%), precut needle-knife technique (NKT) (25.7%), transpancreatic sphincterotomy (5.9%) or other (2.6%). Overall, 18.1% of respondents were not comfortable with NKTs. In the setting of pancreatic duct (PD) access, 81.9% and 97% reported a threshold of three or more wire passes or contrast injections into the PD, respectively, before changing strategy, 34% reported placement of a prophylactic PD stent <50% of the time and 12.1% reported removal of the PD stent at the end of the procedure. Advanced endoscopy fellowship (AEF) training and high volume (>200 ERCPs per year) were associated with comfort with precut NKTs and likelihood of prophylactic PD stent ( P <0.001 for both). Conclusions A WGT technique followed by the DWT and NKT were the preferred biliary cannulation techniques; however, almost one-fifth of respondents were not comfortable with the NKT. There was considerable variability in secondary cannulation approaches, time spent attempting biliary cannulation and prophylactic PD stent placement, factors known to be associated with cannulation success and adverse outcomes.

S1005 Meta-Analysis and Systematic Review of Pancreatic Stents in Preventing Post-ERCP Pancreatitis

Introduction: Pancreatitis is a common and potentially devastating complication of ERCP. Prior studies have shown that prophylactic pancreatic duct stent (PS) placement may be effective to reduce post-ERCP pancreatitis (PEP) in high-risk patients, such as patients with sphincter of Oddi dysfunction or prior history of pancreatitis. However, prior meta-analyses are missing relevant studies both contemporaneously and since published. We aim to perform a comprehensive analysis comparing PS placement to no PS placement to prevent PEP in high-risk patients. Methods: In conjunction with a health sciences librarian, Ovid Medline, Embase and Embase Classic, Cochrane Library, and Web of Science were searched from inception to March 26, 2021. Randomized controlled trials that directly compared PS placement versus no PS placement in preventing PEP were included. Our primary outcome was the incidence of PEP. Additional outcomes included incidence of mild PEP, moderate PEP, and severe PEP, as well as the incidence of adverse outcomes including hemorrhage, infection, and pancreatic duct perforation. Quantitative data was harmonized using random effects models. Results: The search yielded 1,668 citations, 444 of which were removed as duplicates. Each study was assessed by two reviewers. 116 articles were selected for full text review, and eighteen randomized controlled trials were identified of pancreatic stent placement to prevent post-ERCP pancreatitis. In sum, 1,295 patients were assigned to pancreatic stent prophylaxis and 1,299 to no stent placement. There was a significant reduction in odds of PEP in the PS group (Figure 1, OR 0.36 [95% CI 0.28-0.46]). In addition, PS placement was strongly protective against severe pancreatitis (Table 1, OR 0.25 [95% CI 0.07-0.81]). Stent placement was successful in 98% of cases (95% CI 95-100) and there was no difference in pancreatic duct perforation, bleeding, or infection (Table 1). Conclusion: Pancreatic stent placement is an effective intervention to reduce the incidence of PEP in high-risk patients. Further, pancreatic stent placement is particularly effective against the severe forms of PEP. There is no significant difference in major non-pancreatitis adverse events for pancreatic stent placement compared to no stent placed.Figure 1.: a. Kaplan-Meier (KM) survival curves of time to hospital utilization for inpatients undergoing ERCP, stratified by ASGE 2011 complexity score Figure 1b. Post-hoc analysis of KM survival curve for inpatients undergoing ERCP, ASGE 2011 grade 1 versus 4 Figure 1c. Post-hoc analysis of KM survival curve for inpatients undergoing ERCP, ASGE 2011 grade 2 versus 4 Figure 1d. Post-hoc analysis of KM survival curve for inpatients undergoing ERCP, ASGE 2011 grade 3 versus 4.Table 1.: Odds Ratio of Major Outcomes With Pancreatic Stent Placement ERCP = endoscopic retrograde cholangiopancreatography, PS = pancreatic duct stent, OR = odds ratio, CI = confidence interval.

Underutilization of prophylactic rectal indomethacin and pancreatic duct stent for prevention of post-ERCP Pancreatitis.

Background and study aims Incidence of Post-ERCP pancreatitis (PEP) ranges from 1 % to 10 % in unselected patients and as high as 25 % to 30 % in high-risk patients. Rectal indomethacin administered before or immediately after an ERCP and prophylactic pancreatic duct stent placement (PPS) are associated with a reduction in the incidence of PEP. We sought to investigate the utilization rate for prophylactic rectal indomethacin and PPS in average and high-risk patients undergoing ERCP between 2014 and 2019. Patients and methods We performed a retrospective analysis in the IBM Explorys database, a pooled, national de-identified clinical database of over 72 million unique patients from 26 health care networks and 300 hospitals across the United States from 2014 to 2019. Average and high-risk patients undergoing ERCP were identified using Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) diagnosis codes. PEP was defined by the presence of SNOMED CT diagnosis of acute pancreatitis and an inpatient admission within 5 days of an ERCP procedure. Results Out of 31,050 adults who had undergone ERCP from 2014 to 2019, only 10,500 individuals (33.8 %) had a PEP prophylaxis. Rectal indomethacin and PPS accounted for 82.4 % and 12.9 % respectively. Individuals with three risk factors had the highest PEP rates followed by individuals with two risk factors. Conclusions Only one-third of all patients undergoing ERCP received prophylaxis in the form of rectal indothemacin and/or PPS in this large population-based data. Increased implementation of prophylactic use is needed in patients undergoing ERCP as supported by current guidelines.

Su1548 THE IMPACT OF INCREASED BILE DUCT PRESSURE RELATED TO PAPILLARY STENOSIS AND THE ROLE OF VISCERAL HYPERSENSITIVITY IN PATIENTS WITH REFRACTORY RIGHT UPPER QUADRANT (RUQ) PAIN POST CHOLECYSTECTOMY

Functional abdominal pain is commonly related to visceral hypersensitivity (VH) and recent studies have shown success in management of such patients with Amitriptyline. A subgroup of patients with chronic RUQ pain post cholecystectomy routinely fail medical management and are referred for evaluation of Sphincter of Oddi (SOD) dysfunction/papillary stenosis. The association of RUQ pain, dilated common bile duct (CBD) and elevated liver function tests (LFT’s) is strongly suggestive of papillary stenosis as it has been shown to benefit the most from biliary sphincterotomy. The aim of this study was to determine the risks/benefits of endoscopic sphincterotomy in this subgroup of patients with refractory RUQ pain and to delineate the role of Amitriptyline in the presence of VH. Retrospective review, from 2015 to 2018, of treatment outcomes of patients with post cholecystectomy RUQ abdominal pain refractory to medical treatment. All patients had treatment with biliary sphincterotomy by single expert endoscopist. Patients with pancreaticobiliary malignancies or prior history of pancreatitis were excluded from the study. Data including patient demographics, clinical symptoms (pre and post ERCP), elevated LFT’s, CBD size, use of narcotics, prior history of IBS, post procedure complications (pancreatitis, bleeding) and prophylactic pancreatic duct stent placement was collected. Patients with no or partial improvement were treated with low dose (10-25 mg) Amitriptyline daily for presumed VH. 75 patients were included in the study. Mean age was 52 years with 68 (93%) females. 30 (40%) of patients had a dilated CBD. 14 (19%) had elevated LFT’s. 57 (76%) had constant RUQ pain. A total of 67 (89%) patients reported improvement in symptoms post sphincterotomy (49 (65%) patients achieved partial resolution and 18 (24%) complete resolution). A total of 13 (17%) patients did not achieve symptoms resolution and were treated with Amitriptyline. 12 out of 13 patients (92%) experienced a favorable symptom response to Amitriptyline. 6 (8%) patients had minor complications (pain and mild pancreatitis) and 1 patient (1%) had a major complication (necrotizing pancreatitis). A prophylactic pancreatic duct stent was placed in 38 (50.7%) of patients. 44 (58.6%) patients were discharge home post procedure. Biliary sphincterotomy provided by expert endoscopist is a very effective and safe intervention for patients with refractory RUQ abdominal pain post cholecystectomy. Constant RUQ pain and failure to respond to medical management should raise the suspicion for papillary stenosis. Based on the response to sphincterotomy, we extrapolate that elevated CBD pressure is the cause of discomfort in these patients with visceral hypersensitivity. Therefore, low dose Amitriptyline should be used for patients with partial response to biliary sphincterotomy.Graph 1: One-sample z-test of symptom improvement in included patientsView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Practice patterns of post-ERCP pancreatitis prophylaxis techniques in the United States: a survey of advanced endoscopists

The American Society for Gastrointestinal Endoscopy recommends prophylactic pancreatic duct stent placement (PPS) and rectal nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk individuals and suggests that rectal indomethacin may decrease the risk and severity of PEP in average-risk individuals. The European Society for Gastrointestinal Endoscopy recommends rectal indomethacin for all patients undergoing ERCP. Previous surveys of European endoscopists revealed low adoption of PPS or rectal NSAIDs to prevent PEP. We sought to capture current practice in the prevention of PEP among endoscopists in the United States involved in advanced endoscopy fellowship programs. An anonymous online 16-item survey was e-mailed to 233 advanced endoscopists involved in advanced endoscopy fellowship programs. Of the 233 endoscopists who were invited to participate, 62 responded (26.7%). Most respondents reported working in tertiary referral centers (57; 95.0%) and performing ERCP for greater than 5 years (44; 74.6%). All respondents (60; 100.0%) reported working with fellows. Most PPS users (41; 72.0%) reported use of PPS in high-risk patients only and using PPS for PEP in≤25% of ERCPs (38; 64.4%). Most respondents reported using rectal NSAIDs for high-risk patients only (34; 59.7%) compared with respondents (23; 40.1%) who reported using rectal NSAIDs for prevention of PEP in average-risk patients undergoing ERCP. Most respondents (49; 83.0%) also reported using rapid intravenous fluids to prevent PEP. Among endoscopists involved in advanced endoscopy fellowships in the United States, rectal NSAIDs are used more frequently than PPS in the prevention of PEP. Despite mounting evidence supporting the use of rectal NSAIDs to prevent PEP in average-risk patients, less than half of the respondents in this survey reported such practice.

Stent-induced symptomatic pancreatic duct stricture after endoscopic prophylactic pancreatic duct stent placement for the normal pancreas

Background/ObjectivesStent-induced pancreatic duct stricture (SI-PDS) is a complication associated with pancreatic stent placement. However, symptomatic SI-PDS associated with prophylactic pancreatic duct stents has not been sufficiently investigated. MethodsWe examined the incidence and characteristics of symptomatic SI-PDS in patients who underwent pancreatic duct stent placement to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) between April 2007 and March 2017. ResultsWe examined 124 patients with normal pancreases consisting of 75 men and 49 women with a median age of 67.5 years [interquartile range (IQR): 61–74 years]. The median main pancreatic duct (MPD) diameter was 3.3 mm (IQR: 2.6–4.1 mm). The median duration of stent placement was 7 days (IQR: 3–14 days). Spontaneous dislodgment stents were placed in 43.5% of cases (54/124). The diameter of the stent was 5 Fr in 93.5% of cases (116/124) and 7 Fr in 6.5% of cases (8/124). Symptomatic SI-PDS was observed in 2.4% (3/124) of patients overall: 6.5% of patients with an MPD diameter of <3 mm and 0% of patients with an MPD diameter of ≥3 mm. Univariate analysis revealed that an MPD diameter <3 mm was a significant factor for symptomatic SI-PDS (p = 0.048). All cases of symptomatic SI-PDS improved with endoscopic treatment. ConclusionsSymptomatic SI-PDS occurred in 2.4% of patients who underwent prophylactic pancreatic duct stent placement for normal pancreases. Patients with an MPD diameter of <3 mm may be susceptible to symptomatic SI-PDS.

Modified prophylactic 5-fr pancreatic duct stent enhances the rate of spontaneous dislodgement: A multicenter randomized controlled trial.

Prophylactic pancreatic duct stent placement effectively reduces post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients, but the optimal stent remains unclear. We modified a 5-Fr, 3 cm pancreatic stent by removing the flange on the pancreatic side and compared the rate of spontaneous dislodgement and complications with the ordinary stent. This was a randomized controlled trial at six tertiary endoscopic centers. Patients deemed high risk for post-endoscopic retrograde cholangiopancreatography pancreatitis randomly received modified or ordinary pancreatic stent. The primary outcome was spontaneous stent dislodgement at five days and 14 days. Secondary outcomes were the success rate of stent placement and complications. A total of 276 patients were randomly assigned to receive modified stents (mS group) and ordinary stents (oS group). The placement of a pancreatic stent was successful in all 276 patients. There were no significant differences between groups with respect to age, sex, major diagnosis, or indications for stenting. At five days the spontaneous dislodgement rate was 47.72% for the mS group and 15.67% for the oS group (p<0.001); at 14 days the rates were 84.21% and 42.65%, respectively (p < 0.001). Post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in 6.52% of all patients. There were no significant differences regarding the incidences of post-endoscopic retrograde cholangiopancreatography pancreatitis, hemorrhage or fever. The modified short 5-Fr stent has a higher spontaneous dislodgement rate than ordinary pancreatic stent, thus obviating the need for endoscopic removal. The modified pancreatic stent does not increase the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis or other complications. The endoscopist can consider removing the flange on the pancreatic duct side for prophylactic pancreatic duct manipulation.

How to Improve Cannulation Rates During Endoscopic Retrograde Cholangiopancreatography

How to Improve Cannulation Rates During Endoscopic Retrograde Cholangiopancreatography

Sa1490 The Safety and Efficacy of Pancreatic Duct Stent Placement in the Emergency ERCP of Acute Biliary Pancreatitis

Several prospective, randomized trials have demonstrated that early ERCP and biliary endoscopic sphincterotomy (ES) with/without stone extraction was superior in reducing the mortality and morbidity rates in acute biliary pancreatitis (ABP) compared with conservative treatment. Prophylactic pancreatic duct (PD) stent placement has been shown to reduce the risk of post-ERCP pancreatitis. However, there are few reports about PD stent placement in the emergency ERCP of ABP. The aim of current study was to evaluate the safety and effectiveness of emergency ERCP and PD stent placement in patients with ABP.

Mo1407 Post ERCP Complications: Comparing Standard Biliary Cannulation With Needle Knife Fistulotomy

Mo1406 Pancreatic Duct Stenting for the Prevention of Post-ERCP Pancreatitis: National Trends Mohammad H. Shakhatreh*, Somashekar G. Krishna, Jeffery R. Groce, Sheetal Sharma, Jon P. Walker, Alice Hinton, Samer El-Dika Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH; Division of Biostatistics, School of Public Health, The Ohio State University, Columbus, OH Introduction: Studies have emerged to support the use of prophylactic pancreatic duct (PD) stent placement for the prevention of post-ERCP pancreatitis. Patients with choledocholithiasis do not usually have a PD stent placed during ERCP unless it is for the sole purpose of preventing post-ERCP pancreatitis. The aim of the present study was to evaluate the effect these studies have had on national trends in prophylactic PD stent placement. Methods: Using the Nationwide Inpatient Sample from 2003 to 2011, we retrospectively collected data on inpatients undergoing ERCP for choledocholithiasis. We analyzed the overall number of ERCPs and the number done when a PD stent was placed and evaluated the trend of utilization during the study period. We also evaluated the demographics and hospital characteristics for these patients. Results: During the study period, the number of admissions for choledocholithiasis increased from 112,675 (0.29% of all admissions) in 2003 to 149,271 (0.39% of all admissions) in 2011 (p!0.0001) (Figure 1). There was a decrease in the proportion of inpatient ERCPs among patients admitted with choledocholithiasis from 67.0% in 2003 to 62.8% in 2007, but then this gradually increased to 65.6% in 2011 (Figure 1). During the same study period, an increase in the use of pancreatic duct stenting was noted, starting in 2005 and peaking at 3.6% in 2010 (Figure 1). The mean age of patients who underwent ERCP with PD stent placement was 56.8 years (95%CI 55.9-57.7). Most PD stents were placed in women (64.8%) and in Whites (68.8%). The use of PD stents was more common in urban teaching hospitals (51.8%) and large size hospitals (67.5%). Most patients who underwent placement of a PD stent had an Elixhauser comorbidity index of less than 3 (64.2%). Conclusion: Despite the decline in the proportion of inpatient ERCPs among patients admitted with choledocholithiasis between 2003 and 2011, the use of PD stenting has significantly increased, especially since 2005, after multiple studies were published reporting decreased rates of post-ERCP pancreatitis with the use of prophylactic PD stents.

Su1681 Timing of Prophylactic Pancreatic Duct Stent Placement Can Affect the Risk of Post ERCP Pancreatitis in High-Risk Patient Population

Post ERCP pancreatitis (PEP) can be as high as 30% in high-risk patients. Prophylactic pancreatic duct (PD) stent placement has been shown to decrease the risk of PEP in high-risk patients. The aim of our study is to investigate if the risk of PEP is reduced with earlier placement of prophylactic PD stent following PD cannulation or injection in high-risk patient population.

Su1689 Urgent ERCP With Pancreatic Duct Stent Placement for the Management of Post-ERCP Pancreatitis: Results of Large Case Series At the District Central Hospital in Japan

Pancreatitis remains one of the most serious post-endoscopic retrograde cholangiopancretograpy (ERCP) complications. Previous meta-analyses show that prophylactic pancreatic duct (PD) stent placement reduces the risk of post-ERCP pancreatitis (PEP) in both high-risk and low-risk patients (pts). There is only one prior report of urgent ERCP and PD stent placement against PEP (Madácsy L, et al. Surg Endosc 2009).

Prophylactic pancreatic stent placement for endoscopic duodenal ampullectomy: a single-center retrospective study.

Background/AimsWe investigated the efficacy of prophylactic pancreatic stent placement for preventing postprocedure pancreatitis in patients undergoing endoscopic papillectomy.MethodsThis retrospective study included 82 consecutive patients who underwent endoscopic papillectomy for benign ampullary neoplasm at Samsung Medical Center between August 2002 and June 2011. The patients were subdivided into two groups, namely, those who received prophylactic pancreatic stent placement and those who did not. Patient demographics, baseline blood test, tumor characteristics, and endoscopic treatment data were collected. The primary endpoint was postprocedure pancreatitis.ResultsThere was no difference in the development of postprocedure pancreatitis between the stent group and the no stent group (6/54, 10.5% and 2/28, 7.14%, respectively; p=1.00). At baseline, there were no significant differences between the two groups in terms of their risk factors for pancreatitis except pancreatic duct dye injection. The stent group was more likely to have dye injection than the nonstent group (100% vs 42.8%, p<0.001). However, in a logistic regression analysis, no significant difference was observed in the risk factors for pancreatitis including dye injection.ConclusionsOur data suggest that routine prophylactic pancreatic duct stent placement in all patients undergoing endoscopic papillectomy may not be necessary and that large-scale prospective studies are required to identify the subgroup of patients who would benefit.

Prophylactic pancreatic duct stent placement after endoscopic snare papillectomy of duodenal major papillary tumors; prospective, randomized study, preliminary report

Prophylactic pancreatic duct stent placement after endoscopic snare papillectomy of duodenal major papillary tumors; prospective, randomized study, preliminary report

Mo1447 Prophylactic Pancreatic Duct Stent Placement After Endoscopic SNARE Papillectomy of Duodenal Major Papillary Tumors; Prospective, Randomized Study, Preliminary Report

Mo1447 Prophylactic Pancreatic Duct Stent Placement After Endoscopic SNARE Papillectomy of Duodenal Major Papillary Tumors; Prospective, Randomized Study, Preliminary Report

Mo1448 Utility of the Short Single-Balloon Enteroscope (Short-SBE) to Perform Therapeutic ERCP in Patients With Surgically Altered Anatomy

Digestive Disease Center, Soonchunhyang University, College of Medicine, Seoul, Republic of Korea Introduction Endoscopic snare papillectomy (ESP) is an efficient treatment for benign tumors of the duodenal major papilla. However, post-ESP pancreatitis is a common and serious complication. Since one prospective randomized controlled trial showed that pancreatic duct stent placement reduced post-ESP pancreatitis, almost physicians have tried to place pancreatic duct stent after EPS. Aims and Methods: The aim of this prospective, randomized trial is to compare the rates of post-ESP pancreatitis in patients who did or did not receive prophylactic pancreatic duct stent placement. Consecutive patients who were to undergo ESP were randomized to pancreatic duct stent placement group (stent group) after endoscopic snare papillectomy or to no pancreatic duct stent placement group (no stent group). Result The groups were similar with regard to patient demographics. In total, 24 patients were enrolled. Fourteen patients were assigned to the stent group and 10 patients to the no stent group. Post-ESP pancreatitis developed in 5 patients (20.8 %, 5/24), 3 cases occurred in the stent group and 2 case occurred in the no stent group. One case of moderate grade pancreatitis developed in the stent group. The overall incidence of post-EPS pancreatitis was 21.4% (3/14) in the stent group and 20.0 % (2/10) in the no stent group (p 0.932). The rates of hyperamylasemia were 14.3% (2/14) in the stent group and 0.0% (0/10) in the no stent group (p 0.493). There was no significant difference in other complications (ex, bleeding and perforation etc.) between the groups. Conclusion: There was no significant difference in the occurrence of post-ESP pancreatitis and hyperamylasemia between patients with and without pancreatic duct stent placement after endoscopic snare papillectomy. Our findings suggest that a pancreatic duct stent placement after ESP did not confer a protective effect in reducing post-ESP pancreatitis. Therefore, more large scaled prospective, randomized controlled studies regarding the effectiveness of pancreatic duct stent placement to reduce the incidence rates of post-ESP pancreatitis are needed.

Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy–associated pancreatitis? A randomized, prospective study

Pancreatitis is the most common major complication of ERCP and precut endoscopic sphincterotomy (ES). Prophylactic pancreatic duct (PD) stent placement has been shown to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk settings. To determine whether leaving a main PD stent in place after precut ES would reduce the incidence and severity of PEP. Single-center, randomized, prospective study. Tertiary care ERCP referral center. Consecutive patients who underwent ERCP with a clear indication for biliary access and standard biliary ES whereby free cannulation of the bile duct was not possible and precut ES was undertaken. When free bile duct cannulation for ES was not possible and selective PD cannulation was achieved, a PD stent was placed. Using the PD stent as a guide, we used a needle-knife sphincterotome to perform precut ES. The patients were then randomized to either leaving the PD stent in place for 7 to 10 days (stent group) or immediate removal after the procedure (stent removed group). The remaining patients who did not undergo selective PD cannulation and stent placement were not randomized (no stent group) and had a free-hand needle-knife ES performed. Patients were prospectively followed for the development of complications. Standardized criteria were used to diagnose and grade the severity of PEP. A total of 151 patients were enrolled. The groups were similar with regard to patient demographics and patient and procedure risk factors for PEP. The overall incidence of PEP was 13.2% (20/151). It occurred in 4.3% (2/46), 21.3% (10/47), and 13.8% (8/58) of patients in the stent, stent removed, and no stent groups, respectively. The stent group had a significantly lower frequency and severity of PEP compared with the stent removed group (4.3% vs 21.3%; P = .027 for frequency and 0% vs 12.8%; P = .026 for moderate and severe pancreatitis). Single center. Randomization scheme not optimal. These data suggest that placing and maintaining a PD stent for needle-knife precut ES reduces the frequency and severity of postprocedure pancreatitis.

Mo1476 Prophylactic 3F Pancreatic Duct Stent to Prevent Post-ERCP Pancreatitis in Patients With Difficult Biliary Cannulation

Prophylactic 3F Pancreatic Duct Stent to Prevent Post-ERCP Pancreatitis in Patients With Difficult Biliary Cannulation Seung Hyo Han, Jong Ho Moon, Hyun Jong Choi, Hee Yong Yoo, Hyung Su Ahn, Seul Ki Min, Hyun Cheol Koo, Tae Hoon Lee, Young Koog Cheon, Young Deok Cho, Sang-Heum Park Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Republic of Korea; Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Seoul, Republic of Korea Objectives: Post-ERCP panreatitis is the most common and serious complication of ERCP. Difficult biliary cannulation can be one of procedure-related risk factors of post-ERCP pancreatitis. Recent studies have reported that prophylactic pancreatic stent reduce the frequency of post-ERCP pancreatitis. The aim of this study was to evaluate the efficacy of 3 Fr pancreatic stent to prevent post-ERCP pancreatitis in patients with difficult biliary cannulation. Methods: A total of 65 patients with difficult biliary selective cannulation were randomly divided into the stent group (S group, n 30) or the non-stent group (nS group, n 35). The stents used was 3 Fr Zimmon pancreatic stents. Difficult biliary cannulation was defined as the failure to achieve biliary access with more than 5 times of cannulation attempts or over 10 minutes of cannulation time. The incidence of post-ERCP pancreatitis was compared between S group and nS group. The diagonisis and severity assessment were according to Cotton’s criteria. Results : Pancreatic duct stenting was successful in all patients of S group. Spontaneous stent dislodgment within 7 days was recognized in 96.6% (29/30). No procedurerelated complication occurred. Mean serum amylase level after ERCP were 197.13 U/L and 420.77 U/L in S and nS group, respectively (p 0.005). The incidence rate of post-ERCP pancreatitis were 10% (3/30) and 31.4% (11/35) in S and nS group, respectively (p 0.036). The severity of pancreatitis was 1 moderate and 2 mild in in S group, whereas 1 severe, 2 moderate and 8 mild in nS group. Conclusions: Prophylactic pancreatic duct stent placement in patient with difficult cannulation during ERCP seems to be a safe and effective procedure to prevent for post-ERCP pancreatitis.

Risk Factors for Post-ERCP Pancreatitis in High Risk Patients Who Have Undergone Prophylactic Pancreatic Duct Stenting: A Multicenter Retrospective Study

Pancreatitis remains a serious complication after endoscopic retrograde cholangiopancreatography (ERCP). The efficacy of prophylactic pancreatic duct stent placement to prevent post-ERCP pancreatitis in patients at high risk has been established in several randomized controlled trials. The aim of this study was to investigate the frequency and risk factors of post-ERCP pancreatitis in patients who had undergone prophylactic pancreatic duct stenting. Between July 2002 and January 2010, ERCP-related procedures were performed in 9192 cases of pancreatobiliary diseases at seven institutions. Among them, 414 patients (246 men, 168 women; mean age, 68 yr; age range, 22-91 yr) at high risk of post-ERCP pancreatitis who had undergone prophylactic pancreatic duct stenting were included in this study. The stent used in the present study was a 5-Fr stent with a single duodenal pigtail, which is made of soft polyethylene and has no flange (Pit-stent: Cathex, Co., Ltd., Tokyo, Japan). The pancreatic duct stent was placed via the channel of the duodenoscope over a guidewire with the assistance of fluoroscopy at the end of the procedure. The frequency and risk factors of post-ERCP pancreatitis were investigated. Post-ERCP pancreatitis was defined based on the consensus criteria. Therapeutic ERCP was performed in 52% of the patients. Indications for prophylactic pancreatic duct stenting were as follows: difficult cannulation of the bile duct, 192; pancreatic duct cytology/biopsy, 95; precut sphincterotomy, 40; pancreatic sphincterotomy, 29; female gender, 28; papillectomy, 25; sphincter of Oddi dysfunction, 12; history of pancreatitis, 10. Hyperamylasemia at 18-24 h after ERCP was observed in 64% (267 patients) of the patients. Pancreatitis occurred in 9.9% (41 patients: mild, 37; moderate, 2; severe, 2). Univariate analysis revealed intraductal papillary mucinous neoplasm (IPMN) of the pancreas to be the only significant risk factor for pancreatitis (OR 2.9, 95% CI 1.2, 7.1). Multivariate analysis also showed IPMN to be the only risk factor for pancreatitis (OR 3.1, 95% CI 1.2, 7.8). The mean diameter of the pancreatic head duct in patients with IPMN who developed post-ERCP pancreatitis was significantly smaller than that in those who did not develop pancreatitis (3.0 ± 1 mm vs 4.7 ± 2.6 mm, p=0.0037). Post-ERCP pancreatitis developed in 9.9% of the patients at high risk who had undergone prophylactic pancreatic duct stenting. Since the majority of cases of post-ERCP pancreatitis were mild, pancreatic duct stenting may contribute to lessening the severity of pancreatitis. The present results suggest that IPMN without a dilated pancreatic head duct is a possible risk factor for post-ERCP pancreatitis after prophylactic pancreatic duct stenting.

M1462: Rescue ERCP and Emergency Pancreatic Duct Stent Placement Against Post-ERCP Pancreatitis

Pancreatitis is the most common and potentially serious complications of endoscopic retrograde cholangiopancretograpy (ERCP), depending on patients and procedure-related factors. Prophylactic pancreatic duct (PD) stent placement reduces the risk of post-ERCP pancreatitis (PEP) in high risk patients. Impaired drainage of the PD resulting from papillary edema is the one of the possible triggers for PEP. Rescue ERCP and emergency PD stent placement against PEP as a possible endoscopic therapy has not been reported except for Madácsy L et al (Surg Endosc 2009).