Prophylactic Pancreatic Duct Research Articles

Revised Clinical Practice Guideline of Korean Pancreatobiliary Association for Common Bile Duct Stones: Endoscopic Management of Common Bile Duct Stones

For the optimal treatment of common bile duct (CBD) stones, several facts should be considered before or during endoscopic retrograde cholangiopancreatography (ERCP). Prophylactic antibiotics is necessary for the patients with high risk of post ERCP cholangitis and cessation of anticoagulant should be considered for prevention of complications associated with post ERCP bleeding. Furthermore, endoscopic papillary balloon dilatation can be replaced with endoscopic sphincterotomy in patients with bleeding tendency such as chronic kidney disease, liver cirrhosis, thrombocytopenia etc. Prophylactic pancreatic duct stent can be helpful in reducing post ERCP pancreatitis (PEP) but caution is required as excessive attempts for selective cannulation into pancreatic duct for stent insertion can cause PEP. If gallbladder stone is present and treatment for CBD stones has been completed, prophylactic cholecystectomy should be performed selectively after consideration of patient’s condition.

The Impact of Difficult Biliary Cannulation on Post-ERCP Pancreatitis: A Secondary Analysis of the Stent versus Indomethacin Trial Dataset

Background and AimsDifficult biliary cannulation (DBC) is a known risk factor for developing post-ERCP pancreatitis (PEP). To better understand how DBC increases PEP risk, we examined the interplay between technical aspects of DBC and known PEP risk factors. MethodsThis was a secondary analysis of a multicenter, randomized controlled trial comparing rectal indomethacin alone with the combination of rectal indomethacin and prophylactic pancreatic duct (PD) stent placement for PEP prophylaxis in high-risk patients. Participants were categorized into 3 groups: 1) DBC with high pre-procedure risk for PEP, 2) DBC without high pre-procedure risk, and 3) non-DBC at high pre-procedure risk. ResultsIn all, 1601 (84.1%) participants experienced DBC, which required a mean of 12 (SD 10) cannulation attempts and mean duration of 14.7 minutes (SD 14.9). PEP rate was highest (20.7%) in DBC with high pre-procedure risk, followed by non-DBC with high pre-procedure risk (13.5%) and then DBC without high pre-procedure risk (8.8%). Increasing number of PD-wire passages (aOR:1.97, 95% CI:1.25-3.1) was associated with PEP in DBC, but PD injection, pancreatic sphincterotomy and number of cannulation attempts were not associated with PEP. Combining indomethacin with PD stenting lowered PEP risk (aOR:0.61, 95% CI:0.44-0.84) in DBCs. This protective effect was evident in up to at least 4 PD wire passages. ConclusionsDBC confers higher PEP risk in additive fashion to pre-procedural risk factors. PD wire passages appear to add the greatest PEP risk in DBCs, but combining indomethacin with PD stenting reduces this risk, even with increasing PD wire passages.

Prophylactic pancreatic duct stenting to reduce the risk of post-ampullectomy pancreatitis: a comprehensive review and meta-analysis of 1858 patients.

The effectiveness of prophylactic pancreatic duct stenting (PPDS) in preventing post-ampullectomy pancreatitis (PAP) at the time of endoscopic ampullectomy (EA) has been reported, however, results are conflicting. We conducted a systematic review and meta-analysis looking at the use of PPDS in reducing PAP as well as overall post-ampullectomy complications. Multiple databases were searched through May 2023 for studies reporting on EA. Meta-analysis was performed to determine pooled proportions and relative risk (RR) with 95% confidence intervals (CI) of PAP, with and without PPDS. Pooled rates of adverse events including perforation, delayed bleeding, cholangitis, and procedure related mortality were assessed. Random effects model was used for our meta-analysis and heterogeneity was assessed using the I2 statistics. Thirty-four studies (14 case series, 18 cohort studies and 2 randomized controlled trials) with 1868 patients were included. The overall pooled rate of PAP was 12.3% (CI 10.3-14.5). We found no statistically significant difference in rates of PAP among patients with PPDS, 11.9% (CI 8.9-15.7) and without PPDS, 16.6% (CI 13.4-20.4), RR 0.8 (CI 0.51-1.28), p = 0.4. In terms of severe PAP, we found no difference between the two groups. The overall pooled rates of successful en-bloc and piecemeal resection were 74.8% (CI 67.3-81.1) and 25.1% (CI 19-32.4). Additionally, pooled rates of ampullary stenosis, post procedural bleeding, perforation, cholangitis, and procedure related mortality were 3.6%, 11.1%, 4.2%, 3.5%, and 1.3%, respectively. Our analysis shows that PPDS at the time of EA does not offer a significant protective effect against PAP. While the incidence of PAP was higher among the no PPDS group, it is plausible that this is more likely due to variation among studies in terms of lesion size, length/size of pancreatic stent used and etiology of ampullary lesions. Future well-designed randomized controlled trials are needed to validate our findings.

S32 Prophylactic Pancreatic Duct Stenting to Reduce the Risk of Post Ampullectomy Pancreatitis: A Comprehensive Review and Meta-Analysis of 1858 Patients

S32 Prophylactic Pancreatic Duct Stenting to Reduce the Risk of Post Ampullectomy Pancreatitis: A Comprehensive Review and Meta-Analysis of 1858 Patients

S20 Delayed Evaluation and Clearance of Prophylactic Pancreatic Duct Stent Placed During ERCP

S20 Delayed Evaluation and Clearance of Prophylactic Pancreatic Duct Stent Placed During ERCP

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.

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

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

Risk Factors for Post-ERCP Pancreatitis in Pediatric and Young Adult Patients.

Post-ERCP pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Limited existing data suggest that prophylactic pancreatic duct (PD) stenting in pediatric patients may increase the risk of PEP. The aim of this study is to identify factors associated with PEP in pediatric patients. Patients at a single institution who underwent ERCP between 2012 and 2020 were retrospectively reviewed. Patient and procedure-related factors were collected. Data were analyzed using Chi-square or Fisher exact tests as appropriate and Mann-Whitney-Wilcoxon tests. Seven hundred thirty-six ERCPs were performed for 402 unique patients. Ninety-four cases were complicated by PEP (12.8%), of which 91 were mild and 3 were moderately severe. Pancreatic indication, native major papilla, PD cannulation and injection, and higher American Society for Gastrointestinal Endoscopy (ASGE) complexity were associated with PEP. A higher proportion of patients who received rectal indomethacin (65% vs 47%, P = 0.002), or who had placement of a prophylactic (31% vs 20%, P = 0.01) or therapeutic PD stent (37% vs 27%, P = 0.04) developed PEP; however, in a subgroup analysis of high-risk patients, this association was not persistent. A smaller proportion of PEP patients had PRSS1 mutation compared to non-PEP patients (22% vs 40%, P = 0.04). This study evaluates factors associated with developing PEP in a large pediatric cohort. A high rate of PEP was observed, likely secondary to higher rates of pancreatic indication and higher ASGE complexity scores compared to previously reported literature. Randomized prospective trials are needed to better define the utility of various interventions.

Successful endoscopic retrieval of a migrated pancreatic stent using a basket catheter for peroral cholangioscopy through a biliary plastic stent pusher tube: a case report.

Objective: Retrieval is challenging once prophylactic pancreatic stents migrate deep into the pancreatic duct. Herein, we describe a case of successful endoscopic retrieval of a migrated prophylactic pancreatic stent using a basket catheter through a biliary plastic stent pusher tube.Patient: A 71 year-old man was referred to our hospital for removal of a straight-shaped migrated 5-Fr 3-cm prophylactic pancreatic stent with a flap on the duodenal side. There were no subjective symptoms at the time of the hospital visit.Results: During endoscopic retrograde cholangiopancreatography, we inserted an 8.5-Fr plastic biliary stent pusher tube in front of the migrated pancreatic stent. The stent was then grasped using a basket catheter for peroral cholangioscopy through the biliary stent pusher tube. The stent was pulled into the pusher tube and was successfully retrieved from the pancreatic duct. No complications were associated with endoscopic retrograde cholangiopancreatography.Conclusion: Although rare, prophylactic pancreatic duct stent migration after pancreatic duct guidewire placement should be noted. In our case, endoscopic retrieval of a migrated prophylactic pancreatic stent using a basket catheter for peroral cholangioscopy through the biliary plastic stent pusher tube was successful.

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.

Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

1: ESGE recommends against diagnostic/therapeutic papillectomy when adenoma is not proven.Strong recommendation, low quality evidence. 2: ESGE recommends endoscopic ultrasound and abdominal magnetic resonance cholangiopancreatography (MRCP) for staging of ampullary tumors.Strong recommendation, low quality evidence. 3: ESGE recommends endoscopic papillectomy in patients with ampullary adenoma without intraductal extension, because of good results regarding outcome (technical and clinical success, morbidity, and recurrence).Strong recommendation, moderate quality evidence. 4: ESGE recommends en bloc resection of ampullary adenomas up to 20-30 mm in diameter to achieve R0 resection, for optimizing the complete resection rate, providing optimal histopathology, and reduction of the recurrence rate after endoscopic papillectomy.Strong recommendation, low quality evidence. 5: ESGE suggests considering surgical treatment of ampullary adenomas when endoscopic resection is not feasible for technical reasons (e. g. diverticulum, size > 4 cm), and in the case of intraductal involvement (of > 20 mm). Surveillance thereafter is still mandatory.Weak recommendation, low quality evidence. 6: ESGE recommends direct snare resection without submucosal injection for endoscopic papillectomy.Strong recommendation, moderate quality evidence. 7: ESGE recommends prophylactic pancreatic duct stenting to reduce the risk of pancreatitis after endoscopic papillectomy.Strong recommendation, moderate quality evidence. 8: ESGE recommends long-term monitoring of patients after endoscopic papillectomy or surgical ampullectomy, based on duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and thereafter yearly for at least 5 years.Strong recommendation, low quality evidence.

S0079 Prophylactic Rectal Indomethacin and Prophylactic Pancreatic Duct Stents (PPS) for Prevention of Post-ERCP Pancreatitis Are Underutilized in Average and High-Risk Patients Undergoing ERCP

INTRODUCTION: 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 (RI) administered before or immediately after an ERCP is associated with a 35% to 65% reduction in the incidence of PEP. Prophylactic pancreatic duct stent (PPS) placement in high risk patients is also regarded as the most effective mechanical prophylactic approach to reduce the incidence and severity of PEP. We sought to investigate utilization rate of prophylactic RI and PPS in average and high-risk patients undergoing ERCP between 2014 and 2019. 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. We examined demographics, high-risk features [history of acute pancreatitis at least 30 days before ERCP, sphincter of Oddi dysfunction (SOD), sphincterotomy] and incidence of PEP in patients with cumulative risk factors. The subjects were risk-stratified as either average-risk (absence of any of the studied risk factors) or high risk (presence of at least one risk factor). 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. RI and PPS accounted for 82.4% and 12.9% respectively. About 4.8% of patients had both RI and PPS within a day of ERCP procedure. Young individuals (< 40 years) had significantly higher RI use (32.1% vs 26.8%, P < 0.0001) than older individuals but lower PPS placement than older individuals (2.6% vs 4.7%, P < 0.0001). Women had higher RI use compared to men (29.2% vs 25.8%, P < 0.0001) but lower PPS placement (4.6% vs 5.2%, P = 0.016) than men. Individuals with three risk factors had the highest PEP rates: female + young + SOD: 20%; female + AP + sphincterotomy: 11.8%, followed by individuals with two risk factors: female + SOD: 11.1% and young + sphincterotomy: 10.7%. CONCLUSION: Only a third of all patients undergoing ERCP received prophylaxis in the form of RI and PPS in this large population-based data. Increased implementation of prophylactic use is needed in patients undergoing ERCP as supported by current guidelines.

S0921 Pancreatitis Following Endoscopic Resection of Ampullary Masses: A Single Center Retrospective Study

INTRODUCTION: Endoscopic resection of ampullary masses has emerged as an effective and first line treatment approach compared to surgery. Post-ampullectomy pancreatitis is a potential significant adverse outcome of endoscopic resection. The effectiveness of prophylactic pancreatic duct stent during ampullectomy is unclear, however it is considered widely. We aim to evaluate factors associated with post-ampullectomy pancreatitis and the role of prophylactic pancreatic duct stenting. METHODS: A retrospective review was performed of patients who underwent endoscopic ampullectomy of ampullary masses using craniocaudal snare technique 2003–2019 at Georgetown University Hospital. Z-test and descriptive statistics were used. RESULTS: 90 patients underwent ampullectomy for ampullary mass. 11.1% (10/90) developed pancreatitis. 5.6% (3/54) of patients with adenomas developed pancreatitis, compared to 19.4% (7/36) of patients with non-adenomas (P = 0.04). Of the 10 patients who developed pancreatitis compared to those that did not develop pancreatitis, average age was 58.2 y (vs 59 y, P = 0.89). Average adenoma size was 1.19 cm (vs. 1.36 cm, P = 0.5). 50% were male. 100% had PD stents placed (P = 0.17), and 10% underwent APC (vs. 14.4%, P = 0.67). Pathology of the masses showed 3 adenoma, 1 carcinoma, 1 gangliocytic paraganglioma, 3 normal mucosa, 1 adenomyoma, and 1 granulation tissue. CONCLUSION: Ampullectomy offers patients with ampullary masses an intervention with high success rates and decreased morbidity and mortality, compared to surgery. However, ampullectomy confers increased risk for postoperative pancreatitis. We observed a pancreatitis rate of 11.1%, similar to reported rates ranging from 4.5% to 33%. Our use of craniocaudal snare technique, compared to caudocranial, may explain our relatively lower pancreatitis rates. Identifying risk factors for post ampullectomy pancreatitis is challenging and the literature is sparse. In our cohort, we observed a statistically significant increase in pancreatitis among patients with non-adenomas. There was no significant difference by age, mass size, use of PD stent, or use of APC between patients who developed pancreatitis and those that did not. All patients in our cohort who developed pancreatitis had prophylactic PD stents placed. Ultimately, our single-center study is limited by a small sample size and selection bias, and there is a need for further studies to determine which factors contribute the most to post-ampullectomy pancreatitis.Table 1.: Patient CharacteristicsGraph 1.: Pancreatitis in Patients with Adenoma vs. Non-Adenoma.

Influence of fully covered metal stenting on the risk of post‐endoscopic retrograde cholangiopancreatography pancreatitis: A large multicenter study·

Fully covered self-expandable metal stents (FCSEMSs) have been increasingly used in the management of benign or malignant biliary disorders. However, the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) with transpapillary placement of the FCSEMS remains controversial. This study therefore aimed to investigate the risk of PEP in patients who received FCSEMS implantation. In total, 602 patients who underwent endoscopic transpapillary FCSEMS placement at five Chinese medical centers, between 2011 and 2018, were included in this retrospective study. Patients who were younger than 18years and with stent placement above the papilla were excluded from the study. PEP and the risk factors were reviewed. PEP occurred in 56 (9.3%) patients, and eight (1.3%) of them experienced moderate-to-severe PEP. The incidence of PEP rose to 14.6% (51/349) when patients had no pancreatic duct (PD) dilation, and even to 18.6% if no prophylactic approaches were adopted. Prophylactic PD stenting showed better efficacy in reducing the incidence of PEP than did rectal use of indomethacin (3.5% vs 10.8%, P=0.023). Multivariate logistic regression revealed that difficult cannulation (OR 2.837, 95% CI 1.245-6.465, P=0.013), PD dilation (OR 0.145, 95% CI 0.05-0.422, P<0.001), and PD stenting (OR 0.247, 95% CI 0.089-0.686, P=0.007) were significantly associated with PEP risk. Post-procedure cholecystitis was found in 4.0% of patients. The risk of post-procedure pancreatitis is modestly increased in patients receiving transpapillary FCSEMS placement, particularly when there is absence of PD dilation. Thus, prophylactic pancreatic stenting is recommended in such a condition.

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)

728 SUSTAINED CLINICAL RESPONSE WITH EUS GUIDED RFA OF PANCREATIC INSULINOMA

Insulinoma is the commonest functional Pancreatic Neuro-Endocrine Tumor (f-PNET). Surgical resection is the standard management, often associated with significant morbidity. Alternate less invasive management options with EUS guided local therapy (Radio-frequency ablation or alcohol injection) are reportedly effective in short term follow-up. To evaluate the long-term efficacy of EUS guided RFA (EUS-RFA) used for the ablation of f-PNET. EUS-RFA of f-PNET was performed using a dedicated internally cooled 19G device. Lesions located close (≤5mm) to the pancreatic duct (PD) underwent prophylactic PD stent. Patients with a persistent symptomatic lesion or those with multiple lesions were considered for subsequent session/s of EUS-RFA. All patients post RFA underwent systematic follow up (3 monthly in the first year, 6 monthly in next year and at 1-year interval thereafter). 10 Insulinoma patients with 13 lesions underwent EUS-RFA over 5 years. One patient had 4 lesions. The mean tumor size was 11.5 mm (range ?). Three patients had prophylactic PD stent. Eight subjects had one EUS-RFA session. Two patients required >1 session. All subjects had rapid relief of symptoms along with biochemical improvement (blood sugar, insulin, C-peptide) within 24 hours that has remained sustained over the next 10 – 64 months. Post-procedure, one subject had mild self-limiting abdominal pain. Another patient developed acute pancreatitis after 3rd session of EUS RFA leading to pseudocyst that required EUS drainage. Tumor size decreased in 10/14 lesions (undetectable in 6, significantly reduced in 4). Remaining 4 lesions are stable in size with reduced vascularity. EUS guided RFA is safe and effective with sustained beneficial outcomes for Pancreatic Insulinoma.

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.

Prophylactic pancreatic duct stenting in severe acute necrotizing pancreatitis: a prospective randomized study.

Pancreatic duct disruption is common and is associated with high morbidity in cases of acute necrotizing pancreatitis (ANP). In this study, we tested the feasibility and safety of prophylactic pancreatic duct stenting (PPDS) in ANP and compared PPDS with conservative treatment. We prospectively enrolled patients (aged 18 - 75 years) diagnosed with ANP between February 2011 and July 2015. These patients were prospectively randomized to receive PPDS or conservative treatment at two tertiary centers. PPDS was performed as soon as possible after randomization. Concern regarding iatrogenic infections with pancreatic necrosis in the PPDS group prompted interim analysis, which confirmed a highly elevated risk. Thus, the trial was terminated prematurely for ethical reasons. Of the 11 patients in the PPDS group, all patients with successful pancreatic duct placement (5/5, 100 %) presented with infection, compared with only 3 of the 13 patients (23.1 %) in the conservative treatment group (P = 0.01). Analysis revealed success rates of 63.6 % for pancreatic duct cannulation, 45.5 % for pancreatic duct stenting, and 18.2 % for placement of a stent bridging the necrosis. Cannulation and stenting failures were due to duodenal edema and pancreatic duct stenosis. PPDS in ANP is associated with an unacceptably high risk of pancreatic necrosis infection. In addition, the procedure is technically challenging due to duodenal edema and ductal stenosis.