Prophylactic Pancreatic Stent Research Articles

Prophylactic pancreatic duct stenting precludes post-ERCP pancreatitis also in biliary stones removal in patients with näive papilla

Prophylactic pancreatic duct stenting precludes post-ERCP pancreatitis also in biliary stones removal in patients with näive papilla

Prophylactic pancreatic stent placement after duodenal endoscopic snare papillectomy; prospective, randomized single center study

Prophylactic pancreatic stent placement after duodenal endoscopic snare papillectomy; prospective, randomized single center study

Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015.

Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines. A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines. Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles. The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.

Complications of prophylactic pancreatic stent insertion in patients with increased risk of post-ERCP Pancreatitis

Complications of prophylactic pancreatic stent insertion in patients with increased risk of post-ERCP Pancreatitis

Mo1416 Outcomes of Post-ERCP Pancreatitis Have Not Improved Over the Past Decade

statistically significant. Conclusions: Incidence of post-ERCP pancreatitis does not differ at academic institutions depending on the time of year. However, LOS and total hospital charge do decrease throughout the academic year, suggesting the existence of a temporal effect. These differences may be explained by the influx of new medical trainees, on whom teaching hospitals depend for the bulk of their staffing, and further investigation is warranted. Mo1416 Outcomes of Post-ERCP Pancreatitis Have Not Improved Over the Past Decade Allison R. Schulman*, Marwan Abou Gergi, Marvin Ryou, Christopher C. Thompson Division of Gastroenterology, Brigham & Women, Boston, MA; Catalyst Medical Consulting, Towson, MD Introduction: Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Over the past several years, routine use of rectally administered nonsteroidal anti-inflammatory drugs (NSAIDs) and prophylactic pancreatic stent placement in high risk patients have been utilized in an attempt to mitigate this complication. Aims: To compare outcomes of post-ERCP pancreatitis over the past decade (2002-2012) including overall incidence, mortality, intensive care unit (ICU) transfer rate, length of stay (LOS) and attributable total charge. Methods: The Nationwide Inpatient Sample (NIS) database was used to calculate outcomes in 2012, 2010, 2007, 2004 and 2002. Discharges with an ICD-9 CM procedure code indicating ERCP and a secondary ICD-9 CM code for acute pancreatitis were included. Patients were excluded if they had a principal diagnosis of acute pancreatitis or if the ERCP was performed before or on the day of admission. The primary outcome was incidence of post-ERCP pancreatitis. Secondary outcomes were in hospital mortality, ICU transfer rate, additional LOS and attributable total charge. All charges were adjusted for inflation using the consumer price index. Total disease burden was calculated by multiplying the total number of patients by the mean attributable total charge per hospitalization. LOS and charge were adjusted for the following potential confounders using a multivariable regression model: age, sex, race, median income in the patient’s zip code, number of comorbidities, hospital location (rural vs. urban), region (Northeast, Midwest, West, or South), teaching status, and size. Fisher’s exact test and Student t-test were used to compared proportions and continuous variables, respectively. Results: A total of 119,006 patients underwent inpatient ERCP in 2012, 2010, 2007, 2004, and 2002, 14,772 of whom developed post-ERCP pancreatitis leading to a cumulative incidence of 12.4%. Incidence of post-ERCP pancreatitis by year is shown in Table 1. The mortality rate, ICU transfer rate, and LOS do not show a particular trend over the past decade, and the disease burden ranges from over $7.6 million in 2004 to over $52.7 million in 2010 (Table 1). Conclusions: The incidence of post-ERCP pancreatitis appears to be increasing over the past decade, despite the routine use of NSAIDs and prophylactic pancreatic stent placement. The ICU transfer rate, LOS, and mortality have similarly not improved over this time period. Table 1. Post-ERCP pancreatitis outcome trends between 2002 and

709 Prophylactic Pancreatic Stent Placement After Duodenal Endoscopic snare Papillectomy; Prospective, Randomized Single Center Study

Endoscopic snare papillectomy (ESP) is an efficient treatment for benign tumors of the duodenal major papilla. However, acute pancreatitis is the most common and serious complication following an ESP. The aim of this study was to compare the rate of post-ESP pancreatitis in patients who did or did not receive prophylactic pancreatic stent placement.

Prophylactic Pancreatic Stents in High-Risk Population and Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Background: Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Several medical and surgical procedures have been analyzed in prevention of post-ERCP pancreatitis as a major post-ERCP complication, so we conducted a study to assess the role of prophylactic pancreatic stents on prevention and severity of post-ERCP pancreatitis. Materials and Methods: This case control studied adult patients undergoing ERCP at the ERCP unit of a referral educational hospital. Data of the case (stent, N=90) and control (non-stent) (N=105) groups were retrieved from medical records. In our center, sphinctrerotomy was performed for 103 patients of non-stent group and successful pancreatic stent placement was done in 86 patients of stent group in a standard fashion. In stent group, a 5F, 4 centimeter pancreatic stent was emplaced over a guide wire under fluoroscopic guidance. All post–ERCP pancreatitis and major complications of all patients were retrieved too. Results: Of 255 enrolled patients, 195 were at high risk of post-ERCP pancreatitis allocated in two groups of this study. Successful pancreatic stent placement was done in 86 patients (95.6%) of stent group. There was no major complication during procedures. The migration of pancreatic duct stent was diagnostic in 3 (3.5%) patients. The overall post ERCP pancreatitis was 4.0% and 16.6% in stent and non-stent groups, respectively. Conclusion: Based on our findings in this study, we strongly recommended pancreatic duct stent placement in high-risk patients; although the experience of endoscopist plays a crucial role. [GMJ.2015;4(2):67-71]

Incidence of Post-ERCP Pancreatitis From Direct Pancreatic Juice Collection in Hereditary Pancreatitis and Familial Pancreatic Cancer Before and After the Introduction of Prophylactic Pancreatic Stents and Rectal Diclofenac

Individuals from hereditary pancreatitis (HP) and familial pancreatic cancer (FPC) kindreds are at increased risk of developing pancreatic cancer. Premalignant molecular changes may be detected in pancreatic juice collected by endoscopic retrograde cholangiopancreatography (ERCP). The objective was to determine the risk of post-ERCP pancreatitis (PEP). A prospective study (1999-2013) was undertaken of 80 ERCPs (24 in HP and 56 in FPC) from 60 individuals and the impact of PEP prophylaxis using a self-expelling pancreatic stent and 50 mg diclofenac per rectum from 2008. There was no PEP in the HP cohort and 13 (23.2%) PEP from 56 procedures in the FPC cohort (P = 0.0077). Up to 2008 PEP had occurred in 7 (43.8%) of 16 procedures in FPC individuals versus none of 18 procedures in HP individuals (P = 0.0021). After the introduction of prophylaxis, the incidence of PEP fell to 6 (15.0%) of 40 procedures in FPC individuals (P = 0.0347).The odds ratio (95% confidence interval) was 0.23 (0.06-0.84) in favor of prophylaxis (0.035). Individuals with HP are at minimal risk for PEP. Although the risk of PEP in individuals with FPC can be reduced by using prophylactic self-expelling stents and diclofenac, it remains too high for routine screening.

Systemic inflammatory response syndrome between 24 and 48 h after ERCP predicts prolonged length of stay in patients with post-ERCP pancreatitis: A retrospective study

BackgroundEarly systemic inflammatory response syndrome (SIRS) has been associated with severe non-iatrogenic acute pancreatitis. The aims of this study were to determine whether early SIRS could be used to predict severe post-ERCP pancreatitis (PEP) and to determine the effect of prophylactic-pancreatic stenting (PS) on SIRS and severe PEP. MethodsBetween 1/2000 and 6/2012, all patients admitted for PEP after an outpatient ERCP and who had ≥1 abdominal CT scan during hospitalization were retrospectively evaluated. The presence of SIRS was assessed between 0 and 24 h and 24 and 48 h after the time of ERCP completion. SIRS was evaluated as a predictor of severe PEP using area under receiver operating characteristic (AUROC) curve analysis. ResultsThere were 113 patients with PEP of whom 22 (19.5%) had severe PEP. SIRS was present in 44 (38.9%) and 33 (29.2%) patients between 0 and 24 h and 24 and 48 h, respectively. SIRS between 24 and 48 h had a higher predictive accuracy for severe PEP compared to SIRS between 0 and 24 h (AUROC = 0.7 vs. 0.5, p = 0.002). The prevalence of SIRS between 24 and 48 h was significantly less among the 19 patients who underwent PS (11% vs. 37%, p = 0.03). There was no difference between the prophylactic stenting and no stenting groups with regards to acute fluid collection(s), pancreatic necrosis, organ failure or mortality during hospitalization. ConclusionsSIRS between 24 and 48 h after ERCP is an accurate, easy to obtain, and inexpensive predictor of severe PEP. PS is associated with a decreased prevalence of SIRS between 24 and 48 h after ERCP.

Tips and tricks in endoscopic papillectomy of ampullary tumors: single-center experience with large case series (with videos).

Endoscopic papillectomy (EP) has been recognized as a safe and reliable treatment for ampullary adenomas. In this article, we describe important tips and tricks in EP of ampullary tumors on the basis of our large case series outcome. Between May 1999 and April 2014, 115 patients underwent EP at Tokyo Medical University hospital. The mean tumor diameter was 16.2 (6-35) mm. The final pathological diagnoses were adenoma, cancer in adenoma, cancer, and hyperplasia in 85, 13, 10, and seven patients, respectively. "En bloc" or "piecemeal" EP was performed with a polypectomy snare forceps using "Endocut® mode". Prophylactic pancreatic duct stents were placed after EP. Consequently, a single treatment session was possible in 93 (80.9%) patients. Additional treatment was required in the remaining 22 (19.1%) patients. For these 22 patients, the postresection pathological diagnoses were adenoma in 15 patients and cancer in seven patients. Two patients with cancer and venous permeation required surgical operation. The final complete resection rate was 98.2%. Several complications observed included pancreatitis (10.4%), bleeding (18.2%), perforation (2.6%), cholangitis (1.7%), and papillary stenosis (4.3%). One patient died of procedure-related complications. In conclusion, endoscopic papillectomy showed a high technical success rate. However, possible complications and occasional fatal complications should be considered when using EP.

Factors associated with post-ERCP pancreatitis and the effect of pancreatic duct stenting in a pediatric population

Risk factors for the development of post-ERCP pancreatitis (PEP) have not been identified in the pediatric population. It remains unclear what constitutes appropriate prophylaxis in this patient population. To assess the prevalence and severity of PEP in the pediatric population and identify factors associated with developing PEP and to evaluate the effect of prophylactic pancreatic duct stenting in high-risk patients. Retrospective analysis of an ERCP database at a single large pediatric center. Academic center. A total of 432 ERCPs performed on 313 patients younger than 19 years of age from January 2004 to October 2013. ERCP for any indication. Rates and severity of PEP, preprocedural and procedural risk factors for the development of PEP, and the effect of pancreatic stents on preventing PEP in high-risk patients. PEP occurred after 47 procedures (prevalence, 10.9%). Thirty-four cases were mild, 9 were moderate, and 4 were severe. There was no mortality. On multiple logistic analysis, pancreatic duct injection (P<.0001; odds ratio 30.8; 95% confidence interval [CI], 9.1-103.9) and pancreatic sphincterotomy (P<.01; OR 3.8; 95% CI, 1.6-9.8) were positively associated with PEP. A history of chronic pancreatitis was negatively associated with PEP (P<.05; OR 0.37; 95% CI, 0.15-0.93). On subset analysis, placing a prophylactic pancreatic stent was associated with significantly increased rates of PEP in patients with pancreatic duct injection compared with those who had no attempt at stent placement (P<.01). Two patients with severe pancreatitis had prophylactic pancreatic stents in place. Retrospective investigation. In the pediatric population, pancreatic duct injection and pancreatic sphincterotomy are associated with significantly increased rates of PEP, whereas a history of chronic pancreatitis is negatively associated. Prophylactic pancreatic stenting is associated with higher rates of PEP in high-risk patients and does not eliminate severe PEP.

Prophylaxe der Post-ERCP-Pankreatitis: Update der Leitlinie der Europäischen Gesellschaft für Gastrointestinale Endoskopie (ESGE) – Juni 2014

Diese Leitlinie ist ein offizielles Statement der Europaischen Gesellschaft fur Gastrointestinale Endoskopie (ESGE). Sie behandelt die Prophylaxe der durch eine endoskopische retrograde Cholangiopankreatikografie verursachten akuten Pankreatitis (Post-ERCP-Pankreatitis). Hauptempfehlungen

Is the Balloon Dilation Duration in Endoscopic Papillary Balloon Dilation (EPBD) Related to the Occurrence of Post-EPBD Pancreatitis?

See Twenty-Second versus Sixty-Second Dilation Duration in Endoscopic Papillary Balloon Dilation for the Treatment of Small Common Bile Duct Stones: A Prospective Randomized Controlled Multicenter Trial by Byoung Wook Bang, Tae Hoon Lee, Tae Jun Song, et al., on page 59-65 Endoscopic papillary balloon dilation (EPBD) was proposed as an alternative to endoscopic sphincterotomy (EST) for opening the bile duct orifice to allow stone extraction with functional preservation of the biliary sphincter. Since its introduction in 1982,1 EPBD has been widely performed because it is associated with lower bleeding and perforation risks compared to EST.2,3,4,5,6 However, EPBD is more likely to cause pancreatitis than EST, resulting in an increased mortality rate.7,8 Therefore, EPBD is reserved for selective patients with a bleeding diathesis or altered anatomy, especially in Western countries. The reported incidence of post-EPBD pancreatitis varies greatly, ranging from 0% to 15.4%.9,10,11,12,13 This disparity may be explained by differences in the stone size, bile duct size, balloon diameter, and balloon dilation duration (BDD). Although the mechanism is unknown, post-EPBD pancreatitis has been associated with papillary edema or spasm resulting from balloon dilation and papillary trauma during stone extraction through an insufficiently dilated sphincter. Therefore, papillary injury resulting in increased post-EPBD pancreatitis may frequently occur in cases with relatively large stones in small bile ducts and balloon diameters larger than the stone size or bile duct diameter. BDD was found to correlate with post-EPBD pancreatitis in previous studies, although the results were conflicting. In a prospective randomized trial,14 the risk of pancreatitis was higher with a 1-minute BDD (15.1%, 13/86) than with a 5-minute BDD (4.8%, 4/84; p=0.038). In a systemic review of randomized trials that compared EPBD and EST,15 short EPBD (≤1 minute) had a higher risk for pancreatitis (odds ratio [OR], 3.87; 95% confidence interval [CI], 1.08 to 13.84) compared to EST, but long EPBD (>1 minute) did not pose a higher risk than EST (OR, 1.14; 95% CI, 0.56 to 2.35). A longer BDD may achieve greater loosening of the sphincter of Oddi and cause less papillary damage during stone extraction, resulting in a lower pancreatitis rate. In contrast, however, an initial 2-minute BDD was modified to 15 seconds during the later period of a retrospective study.16 A lesser tendency toward post-EPBD pancreatitis was observed in the modified group (4%, 13/324) relative to the initial group (7.4%, 24/324; p=0.063). A shorter BDD may be less traumatic to the papilla, thus reducing post-EPBD pancreatitis. Bang et al.17 evaluated the risk of pancreatitis after EPBD with a 20- or 60-second BDD in patients with relatively small bile duct stones (≤12 mm) while using balloon diameters (6 to 10 mm) selected according to the stone size and bile duct diameter. The authors also used a prophylactic pancreatic stent in patients at a high risk of post-ERCP pancreatitis. As a result, all factors that might affect the occurrence of post-EPBD pancreatitis were well controlled except for the BDD. However, they observed no difference in the occurrence of post-ERPD pancreatitis between the 20- and 60-second BDD groups (6.4%, 7/109 vs. 7.5%, 9/119). Bang and colleague17 proposed that EPBD could be adequately performed with a 20-second BDD in carefully selected patients because the BDD had little effect on the incidence of post-EPBD pancreatitis, a difficult finding to accept when compared with previous EPBD studies. Although this study may not appear to make sense, new approaches and data have made us rethink the best approach for bile duct stone removal. Therefore, we continue to seek the safest and most effective bile duct stone removal method.

Endoscopic ampullectomy: A technical review

This article provides a practical review to undertaking safe endoscopic ampullectomy and highlights some of the common difficulties with this technique as well as offering strategies to deal with these challenges. We conducted a review of studies regarding endoscopic ampullectomy for ampullary neoplasms with special focus on techniques. Accurate preoperative diagnosis and staging of ampullary tumors is imperative for predicting prognosis and determining the most appropriate therapeutic approach. The optimal technique for endoscopic ampullectomy is dependent on the lesions size. En bloc resection is recommended for lesions confined to the papilla. There is no significant evidence to support the submucosal injection before ampullectomy. There is no consensus regarding the optimal current and power output for endoscopic ampulectomy. The benefits of a thermal adjunctive therapy remain controversial. A prophylactic pancreatic stent reduces the incidence and severity of pancreatitis post-ampullectomy. Endoscopic ampullectomy is a safe and efficacious therapeutic procedure for papillary adenomas in experienced endoscopist and it can avoid the need for surgical intervention.

Endoscopic Sphincterotomy for Sphincter of Oddi Dysfunction: Inefficacious Therapy for a Fictitious Disease

Endoscopic Sphincterotomy for Sphincter of Oddi Dysfunction: Inefficacious Therapy for a Fictitious Disease

The risk of post-ERCP pancreatitis and the protective effect of rectal indomethacin in cases of attempted but unsuccessful prophylactic pancreatic stent placement

It is believed, based on limited observational data, that an unsuccessful attempt to place a prophylactic pancreatic stent substantially increases the risk of post-ERCP pancreatitis (PEP). To better understand the risk of PEP in patients with failed pancreatic stent placement (FPS) and the impact of rectal indomethacin on this risk. Secondary analysis of randomized, controlled trial data. University of Michigan and Indiana University. A total of 577 clinical trial participants at elevated risk for PEP. Pancreatic stent placement. Within the placebo group, we compared PEP rates in patients with FPS, patients who underwent successful stent placement, and in those without a stent attempt. We also performed a regression analysis evaluating the association between FPS and PEP. To define the protective effect of indomethacin, we repeated these analyses in the indomethacin group and in the full study cohort. The incidence of PEP among patients in the placebo group who experienced FPS was 34.7%, significantly exceeding rates in patients who underwent successful stent placement (16.4%) and in those without a stent attempt (12.1%). After we adjusted for known PEP risk factors, FPS was found to be independently associated with PEP. Among the indomethacin group and in the full cohort, FPS was not associated with a higher risk of PEP. Low event rate, FPS not prospectively captured. FPS appears to confer an increased risk of PEP, which is attenuated by rectal indomethacin administration. These findings highlight the importance of adequate training and proficiency before endoscopists attempt pancreatic stent placement and the routine use of rectal indomethacin in high-risk ERCP cases.

Quality indicators for ERCP

ERCP is one of the most technically demanding and high-risk procedures performed by GI endoscopists. It requires significant focused training and experience to maximize success and to minimize poor outcomes (1, 2). ERCP has evolved from a purely diagnostic to a predominately therapeutic procedure (3). ERCP and ancillary interventions are effective in the non-surgical management of a variety of pancreaticobiliary disorders, most commonly the removal of bile duct stones and relief of malignant obstructive jaundice (4). The American Society for Gastrointestinal Endoscopy (ASGE) has published specific criteria for training and granting of clinical privileges for ERCP, which detail the many skills that must be developed to perform this procedure in clinical practice with high quality (5, 6, 7).

Urgent ERCP with pancreatic stent placement or replacement for salvage of post-ERCP pancreatitis.

Urgent placement or replacement of pancreatic stents shortly after endoscopic retrograde cholangiopancreatography (ERCP) might attenuate the course of evolving post-ERCP pancreatitis (PEP). Salvage ERCP with de novo pancreatic stent placement or replacement of outwardly migrated stents was performed within 2 - 48 hours in patients with evolving PEP accompanied by severe pain, systemic inflammatory response syndrome (SIRS), and major elevations in serum amylase and lipase. Serial pain scores, amylase and lipase levels, and hospital course were studied. PEP according to Cotton consensus criteria developed after 64 (2 %) of 3216 ERCPs over 3 years. Of the 64 patients with PEP, 14 underwent salvage ERCP (5 without and 9 with prior pancreatic stents, 7 of which had migrated outwards prematurely). All patients had SIRS and a high score (≥ 3) for the bedside index for severity in acute pancreatitis. Median clinical onset of PEP was at 5 hours (range 0 - 68 hours) in patients with prophylactic pancreatic stents vs. 2 hours (range 0.5 - 2.5 hours) in patients without prophylactic pancreatic stents (P < 0.05). Salvage ERCP was performed at a median of 10 hours (interquartile range [IQR] 2.4 - 22.7 hours). Improvement in pain, amylase, lipase, and resolution of SIRS were statistically significant at 24 hours after salvage ERCP (P = 0.003). Median length of hospital stay was 2 days (IQR 1 - 4.75). No necrotizing pancreatitis or late complications occurred. Urgent salvage ERCP with de novo pancreatic stent placement or replacement of a migrated stent is a novel approach in the setting of early PEP, and was associated with rapid resolution of clinical pancreatitis and reduction in levels of amylase and lipase.

Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated June 2014.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the prophylaxis of post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis. Main recommendations 1 ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication. In addition to this, in the case of high risk for post-ERCP pancreatitis (PEP), the placement of a 5-Fr prophylactic pancreatic stent should be strongly considered. Sublingually administered glyceryl trinitrate or 250 µg somatostatin given in bolus injection might be considered as an option in high risk cases if nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated and if prophylactic pancreatic stenting is not possible or successful. 2 ESGE recommends keeping the number of cannulation attempts as low as possible. 3 ESGE suggests restricting the use of a pancreatic guidewire as a backup technique for biliary cannulation to cases with repeated inadvertent cannulation of the pancreatic duct; if this method is used, deep biliary cannulation should be attempted using a guidewire rather than the contrast-assisted method and a prophylactic pancreatic stent should be placed. 4 ESGE suggests that needle-knife fistulotomy should be the preferred precut technique in patients with a bile duct dilated down to the papilla. Conventional precut and transpancreatic sphincterotomy present similar success and complication rates; if conventional precut is selected and pancreatic cannulation is easily obtained, ESGE suggests attempting to place a small-diameter (3-Fr or 5-Fr) pancreatic stent to guide the cut and leaving the pancreatic stent in place at the end of ERCP for a minimum of 12 - 24 hours. 4 ESGE does not recommend endoscopic papillary balloon dilation as an alternative to sphincterotomy in routine ERCP, but it may be advantageous in selected patients; if this technique is used, the duration of dilation should be longer than 1 minute.

PTH-015 Post-ercp Pancreatitis In Secondary Care: Can We Predict Who Would Benefit From A Prophylactic Pancreatic Stent?

IntroductionPancreatitis is a recognised complication of ERCP. Measures taken to reduce the incidence in high-risk patients include placement of prophylactic pancreatic stents and use of NSAIDs, but current practice varies...