Rate Of post-ERCP Pancreatitis Research Articles

The impact of aging on post-ERCP pancreatitis and its severity

Objective To study the impact of aging on pancreatic atrophy, fibrosis and exocrine hypofunction in patients with post-ERCP pancreatitis (PEP) and its severity. Methods A retrospective study was conducted on 786 patients who underwent ERCP at the Affiliated Zhongshan Hospital of Dalian University from June 2011 to April 2018. Patients who were aged over 75 years were grouped into the elderly group while those aged less than 75 years were grouped into the younger group. The incidences and severity of post-ERCP pancreatitis in the two groups were analyzed. Results In the elderly group, there were 308 patients. The average age was (81.8±4.8) years. In the younger group, there were 478 patients. The average age was (57.7±12.0) years. The average operation time for the elderly group was (52.5±14.1) minutes, and that for the younger group was (50.7±14.9) minutes. There were no significant differences in operation time and in the related factors between the two groups (P>0.05). There was no significant difference in the rates of hyperamylasemia between the two groups (29.9% vs 30.1%, P>0.05). The overall rate of PEP was 11.3% (89/786). In the elderly group, the rate of PEP was 6.5% (20/308), which was significantly lower than that in the younger group (χ2=11.765, P<0.05). The rates of mild, moderate and severe PEP in the elderly group was significantly lower than those in the younger group (all P<0.05). Hyperamylasemia and pancreatitis in the 2 groups were alleviated after conservative treatment. Conclusions Aging (≥75 years) resulted in pancreatic atrophy, fibrosis, exocrine hypofunction which had a protective effect on PEP. Key words: Pancreatitis; Hyperamylasemia; Cholangiopancreatography, endoscopic retrograde; Jaundice, obstructive; Biliary strictures

Low-dose rectal diclofenac does not prevent post-ERCP pancreatitis in low- or high-risk patients.

The most common adverse event following an endoscopic retrograde cholangiopancreatography (ERCP) procedure is post-ERCP pancreatitis (PEP). Rectal nonsteroidal anti-inflammatory drug (NSAID) administration has shown promise to reduce the risk of PEP in high-risk patients. However, in contrast to high-risk patients, the role of NSAID administration in patients with low risk remains controversial. We performed a prospective, single-center, single-blinded, two-arm parallel group, randomized controlled trial to clarify the efficacy of low dose (50mg) rectal NSAID administration for preventing PEP in at-risk patients. Patients scheduled to undergo ERCP were randomized into two groups, those with and without rectal administration of diclofenac. Patients in the diclofenac group received 50mg of rectal diclofenac 30min before undergoing ERCP. The primary endpoint was rate of PEP. A total of 303 were randomized into the study groups. Four patients declined participation following randomization, and another two were withdrawn. As a result, a total of 147 patients were assigned to the diclofenac group and 150 to the control group. The baseline and procedural characteristics were similar in both groups. The primary endpoint of PEP occurrence was seen in 13 of 297 patients (4.4%), including eight (5.4%) in the diclofenac group and five (3.3%) in the control group (P=0.286). Additionally, those results were not significantly different when patients were classified as low or high risk. Prophylactic low-dose rectal diclofenac did not reduce the incidence of PEP following ERCP in patients classified as low or high risk.

Does melatonin addition to indomethacin decrease post endoscopic retrograde cholangiopancreatography pancreatitis? A randomized double-blind controlled trial

Post-ERCP pancreatitis (PEP) is the most prevalent complication of endoscopic retrograde cholangiopancreatography (ERCP). Melatonin has been mentioned as a protective factor against acute pancreatitis. The present study was conducted to determine whether melatonin addition to indomethacin reduces the rate of PEP occurrence. A double-blind randomized clinical trial was conducted on 411 patients undergoing ERCP. Baseline blood samples were collected, and the patients were given melatonin 3 mg tablets plus indomethacin suppository 100 mg or placebo plus indomethacin suppository 100 mg, 1 h before ERCP. The occurrence of PEP was the primary outcome. The concentrations of amylase and lipase were also measured 24 h after ERCP. Demographic characteristics of patients, characteristics of ERCP procedures, and baseline levels of amylase and lipase were found to be similar in both groups. The overall rate of PEP was equal to 9.5% in intention-to-treat (ITT) and 11.4% in per-protocol (PP) analyses. There was a significant difference in the rate of PEP between the melatonin and placebo groups (8.7% vs. 11.4% in ITT and 9.3% vs. 13.6% in PP, respectively). In addition, after 24 h, amylase and lipase levels were lower in the melatonin group than in the placebo group (P = 0.041 and 0.032, respectively). The results of the present study showed that, administration of melatonin 3 mg tablets plus indomethacin suppository 100 mg 1 h before ERCP could decrease the PEP rate and amylase and lipase levels compared to administration of indomethacin suppository 100 mg alone.

EUS-guided biliary drainage is equivalent to ERCP for primary treatment of malignant distal biliary obstruction: a systematic review and meta-analysis.

Background and study aims Although endoscopic retrograde cholangiopancreatography (ERCP) is standard of care for malignant biliary obstruction, endoscopic ultrasound-guided biliary drainage (EUS-BD) as a primary treatment has become increasingly utilized. The aim of this study was to perform a systematic review and meta-analysis to evaluate the effectiveness and safety of EUS-BD for primary treatment of malignant biliary obstruction and comparison to traditional ERCP. Methods Individualized search strategies were developed through November 2018 using PRISMA and MOOSE guidelines. A cumulative meta-analysis was performed by calculating pooled proportions. Subgroup analysis was performed for studies comparing EUS-BD versus ERCP. Heterogeneity was assessed with Cochran Q test or I 2 statistics, and publication bias by funnel plot and Egger’s tests. Results Seven studies (n = 193 patients; 57.5 % males) evaluating primary EUS-BD for malignant biliary obstruction were included. Mean age was 67.4 years (2.3) followed an average of 5.4 months (1.0). For primary EUS-BD, pooled technical success, clinical success, and adverse event (AE) rates were 95 % (95 % CI 91 – 98), 97 % (95 % CI 93 – 100), and 19 % (95 % CI 11 – 29), respectively. Among EUS-BD and ERCP comparator studies, technical and clinical success, and total AEs were not different with lower rates of post-ERCP pancreatitis and reintervention among the EUS-BD group. Conclusion Primary EUS-BD is an effective treatment with few AE. Comparing EUS-BD versus ERCP, EUS-BD has comparable efficacy and improved safety as a primary treatment for malignant biliary obstruction. Further randomized trials should be performed to identify patient populations and clinical scenarios in which primary EUS-BD would be most appropriate.

879 Post-ERCP Pancreatitis in Solid Organ Transplant Recipients

INTRODUCTION: Post-ERCP pancreatitis (PEP) is the most common post-procedure complication of ERCP with an incidence of 3.5-15%. The prevalence of PEP and the role of immunosuppression in PEP among solid organ transplant (SOT) recipients is not well established. We aimed to study the prevalence of PEP and the effect of immunosuppressants in SOT recipients. METHODS: A retrospective analysis of 55 million individuals was performed using a cloud-based database, IBM Explorys. Explorys aggregates de-identified electronic health record data from 26 health care systems across the US and rounds to the closest 10 for statistical de-identification. PEP was defined as the elevation of lipase level &gt; 500 U/L along with SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms) diagnosis code of acute pancreatitis within 72 hours of ERCP procedure. The prevalence of PEP and the all-cause 30-day re-admission rate after an episode of PEP were calculated for SOT recipients (lung/kidney/heart/liver). Characteristics were compared using univariate chi-square test between SOT and non-transplant patients as well as liver transplant (LT) recipients and non-transplant patients. P &lt; 0.05 was determined as statistically significant. RESULTS: There was no significant difference in the prevalence of PEP (8.03% vs 8.4%, P = 0.676) and re-admission rate (22.2% vs 20.3%, P = 0.645) between SOT recipients and non-transplant patients. Subgroup analysis of liver transplant (LT) recipients revealed a significantly lower rates of PEP (5.66% vs 8.4%, P = 0.002). Compared to the general population, transplant recipients were less likely to be women [Odds ratio OR 0.567, 95% confidence interval CI (0.375 – 0.866), P = 0.008] (Table 1). Among the transplant recipients, individuals with PEP were more likely to be under 50 years [OR 3.179, CI (1.980 - 5.102), P &lt; 0.001]. PEP rates were lower with SOT recipients on steroids [OR 0.240 CI (0.113 - 0.509), P &lt; 0.001] and calcineurin inhibitors [OR 0.078 CI (0.0317 - 0.194), P &lt; 0.001] (Table 2). CONCLUSION: In this population-based study, the prevalence of PEP was not elevated in SOT recipients. Steroids and calcineurin inhibitors were associated with a protective effect against PEP. To our knowledge, this is the largest cohort to report on PEP in SOT recipients. Since population level database limits access to patients’ charts, studies with details on anatomical and peri-operative risk factors of PEP will further enhance our understanding in this specific subset of population.

897 Aggressive Hydration With Lactated Ringer for Prevention of Post-ERCP Pancreatitis: A Systematic Review and Meta-Analysis

INTRODUCTION: Pancreatitis is the leading complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in considerable morbidity and, rarely, in death. Hydration is a mainstay of treatment for acute pancreatitis, independent of etiology. Aggressive hydration with lactated ringers (LR) has been suggested for prevention of post-ERCP pancreatitis (PEP). However, recent studies have reported contradictory results. The aim of this study was to perform a systematic review and meta-analysis to evaluate the impact of aggressive LR hydration in PEP incidence. METHODS: A comprehensive search of MEDLINE, EMBASE, Scopus, Cochrane Database was conducted from each database’s inception to search for comparative studies of aggressive LR vs standard therapy for prevention of PEP. Aggressive LR is defined as 3 ml/kg/hr during the procedure, a 20 ml/kg bolus after the procedure, and 3 ml/kg/hr for 8 hours following the procedure. The primary outcome of interest was PEP rates. Secondary outcomes were other adverse events. Outcomes were reported as pooled odds ratio (OR) with 95% confidence intervals (CI) with statistical significance (P &lt; 0.05). RevMan 5.3 software was used for statistical analysis. RESULTS: Eight studies (7 randomized controlled trials and one prospective study) with a total of 3248 patients were included in the meta-analysis. There were 1623 patients in the aggressive LR group and 1625 patients in the standard therapy group. There was no difference between the groups regarding age and sex. Patients in the aggressive arm received 3 ml/kg/hr during the procedure, a 20 ml/kg bolus after the procedure, and 3 ml/kg/hr for 8 hours following the procedure compared to 1.5 ml/kg/hour during the procedure and for 8 hours after the procedure without a bolus in the standard hydration arm. The mean total fluid administered in the two groups was reported in 2 studies with a pooled mean of 3.25 L in the aggressive and 1.47 L in the standard group (P &lt; 0.001). The PEP rate was significantly lower in the aggressive LR arm compared to standard therapy (OR 0.33, 95% CI 0.21-0.50, P &lt; 0.0001). There was no heterogeneity between the studies (I2 = 0%). Peripheral edema as an adverse outcome of aggressive LR therapy was reported only in 2 (0.69%) patients in 2 studies and was managed conservatively. No significant adverse events were reported in any study. CONCLUSION: Aggressive hydration with LR is associated with a significant reduction in incidence of PEP, and therefore, should be practiced routinely.

2798 Meta-Analysis and Systematic Review of Initial Endoscopic Therapy for Cholangitis

INTRODUCTION: The initial endoscopic treatment of ascending cholangitis is controversial. It has been proposed that management should be limited to decompression alone while the alternative is to additionally perform sphincterotomy and/or stone removal to address the underlying etiology. Our aim was to compare the effectiveness and safety of endoscopic decompression alone to decompression combined with other endotherapy for ascending cholangitis. METHODS: We systematically searched Embase, Medline, the Cochrane Library, and ClinicalTrials.gov from inception to April 22, 2019. Studies were screened by two independent reviewers using Covidence software and standardized extraction forms. We included trials that compared endoscopic decompression and decompression combined with other endotherapy. Our primary outcome was the odds of effective decompression by decompression alone versus combined with other endotherapy. Our secondary outcome was the odds of adverse events (post ERCP pancreatitis, hemorrhage, mortality). Pooled odds ratios and proportions were estimated using the random effects model for the two approaches. RESULTS: 10,508 abstracts and 256 full text documents were reviewed. Six comparative reports of decompression alone versus decompression with other endotherapy were included in the meta-analysis. These studies capture the results for 462 patients; 205 underwent endoscopic (stent or nasobiliary) decompression alone and 257 decompression plus other endotherapy. There was no difference in success of cholangitis therapy for decompression combined with sphincterotomy and other therapeutic maneuvers as opposed to decompression alone (OR 1.3 [95% CI 0.3-5.6]); there was also no difference in mortality (OR 0.4 [0.4-7.3]). There were more adverse events for decompression combined with sphincterotomy and other maneuvers (OR 2.5 [1.0-6.5]) driven by a higher rate of bleeding (OR 9.1 [2.4-34.7])(Figure 1); there was no difference in rates of post ERCP pancreatitis (OR 0.7 [0.2-2.1]). CONCLUSION: In cholangitic patients, the addition of therapeutic maneuvers including sphincterotomy to biliary decompression is associated with higher rates of adverse events and particularly bleeding compared to decompression alone. Nevertheless, the included studies did not account for adverse events during subsequent ERCP to remove biliary stones in those initially managed with decompression alone. In cholangitic patients who are coagulopathic or would not tolerate adverse events, decompression alone should be considered.

2940 Favorable Rates of Post-ERCP Pancreatitis With Endoscopic Sphincterotomy With Delayed Sphincteroplasty Approach

INTRODUCTION: There are multiple modalities for the management of large bile duct stones during endoscopic retrograde cholangiopancreatography (ERCP). Large bile duct stones, defined as size greater than 15 mm, are a subset of multiple clinical situations associated with difficult bile duct stone extraction. The successful extraction of common bile duct stones typically requires either a sphincterotomy or papillary balloon dilation. Multiple prior studies have shown that endoscopic papillary balloon dilation (EPBD) has less success in stone clearance with more frequent requirement for lithotripsy in addition to carrying a higher risk of post-ERCP pancreatitis. We report the technique of delayed sphincteroplasty to be effective and safe in the management of large bile duct stones. METHODS: A retrospective analysis from 2012 to 2018 was obtained from our endoscopy software of all patients who underwent a two-step ERCP with balloon dilation and analyzed in terms of patient demographics, stone size, success of stone extraction, number or procedures required for duct clearance and procedure-related complications. Patients with bile duct strictures, periampullary malignancy or coagulopathy were excluded. RESULTS: Seventy five patients had ERCP performed with balloon sphincterotomy at least 30 days after initial ERCP. Twenty seven of them were men. Age ranged from 26 to 101 with an average age of 73. 37.3% of the patients were Caucasian, 33.3% African American, 6.6% Asian, 5.3% Hispanic and 17.3% unknown. The average common bile duct size on imaging prior to ERCP was 14.2 mm. The initial ERCP was performed within an average of 4 days of admission. Total bilirubin was 3.9 on average. Most common indication was proven bile duct stone on imaging, 60.8%. 84% of patients had a plastic stent placed during initial ERCP. 13% had more than 5 stones. Balloon was dilated to an average of 14.6 mm. 97% (73/75) had no immediate complications post procedure. Three patients needed additional lithotripsy. CONCLUSION: We present our center's experience with the management of large bile duct stones with the technique using endoscopic sphincterotomy with stent placement for initial drainage and a delayed sphincteroplasty reported decreased rates of post-ERCP pancreatitis and encouraging success rates for stone extraction.

77 Post-ERCP Pancreatitis Rates and NSAID Use in a Community Hospital

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) has been consistently used for more than 50 years as a diagnostic and therapeutic procedure in pancreaticobiliary diseases. However, its use is associated with several adverse effects including bleeding, cholangitis, pancreatitis, intestinal perforation, and death. Of these, post-ERCP pancreatitis (PEP) is the leading cause of morbidity and mortality with an estimated incidence of 1.6–15%. Endoscopic techniques, patient characteristics, and the hospital setting have been noted to put patients at higher risk of developing PEP. Williams et al. reported a significantly increased risk of PEP in community hospitals compared to university hospitals. Rectal NSAIDs, including diclofenac and indomethacin, have shown promising results in several high-quality clinical trials and meta-analysis, especially in high-risk patients. More recent trials failed to show a significant reduction of PEP after NSAID use. There is scant data on the efficacy of rectal NSAIDs in higher risk patients in community hospitals. The aim of this study is to determine if there is an increased risk of PEP in a community hospital and if the use of rectal NSAIDs for high-risk patients is beneficial within a community hospital. METHODS: After obtaining IRB approval, the charts of every adult patient admitted to a Wichita, KS community hospital for ERCP in a 2-year time period were reviewed. Primary endpoint was percentage of patients developing PEP. Secondary endpoints included NSAID use in high-risk individuals (Table 1) and the change in incidence of PEP in this group with the use of rectal NSAID. RESULTS: 422 patients underwent ERCP during the study period. Of these, about 212 (50.2%) were noted to have at least 1 high risk factor to develop PEP. 24 (5.6%) of the patients received rectal NSAIDs, of which 10 patients were noted to be high-risk for PEP. 9 patients (2.1%) developed PEP during the study time period. Of the nine patients, 3 patients were high risk and did not receive any NSAIDs. The use of NSAIDs did not cause a significant reduction in PEP in the high-risk group (p-value 0.7) or overall (P-value 0.66). CONCLUSION: PEP rates in a community hospital setting have not been well established. Our study reports an incidence of 2.1%, comparable to the PEP incidence described in academic trials. Despite the unstandardized use of rectal NSAIDs noted in the study population, there appears to be no significant benefit in their use overall or in the high-risk population.

885 Outcomes of ERCP in Patients With Acute Myocardial Infarction: A National Study

INTRODUCTION: There is limited data on the safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients with recent myocardial infarction. The objective of this study is to better assess safety and outcomes in patients with admission for acute myocardial infarction (MI) that undergo ERCP for a variety of reasons during the same admission in a national inpatient database. METHODS: The National Inpatient Sample (NIS) is the largest all-payer inpatient database in the United States. Data from the years 2008 to 2014 were collected. Patients older than 18 years with an admission diagnosis of myocardial infarction and who underwent ERCP were included (n = 259). Case-control matching (3:1) based on age and race were selected (n = 762). Mortality, length of stay, cost of hospitalization, and complications were measured against case controls. RESULTS: Between 2008 and 2014, there were 259 patients older than 18 years with acute myocardial infarction who underwent inpatient ERCP. Baseline patient demographics and hospital characteristics is available in Table 1. Complications related to ERCP were infrequent though the rate of post-ERCP bleeding was higher in patients with recent MI compared to controls (4.2% vs. 1.6%; P = 0.012). Rates of cholecystitis, post-ERCP pancreatitis and perforation were not different between groups. There was no significant difference in mortality between patients that had recent MI vs those who did not (4.6% vs. 2.5%, P = 0.083). Length of stay was higher in patients with recent MI (median 9 days vs. 5 days, P &lt; 0.001). Cost of hospitalization was also significantly higher in the MI group ($22,197.86 vs. $25,937, P &lt; 0.001). The primary indication for ERCP in patients with acute MI was choledocholithiasis while that in the control group was cholangitis. Furthermore, the time to ERCP (emergent, urgent or delayed) did not significantly affect the risk of mortality and post-ERCP hemorrhage. CONCLUSION: Patients with acute MI that undergo ERCP during the same admission have a higher risk of post-ERCP hemorrhage with longer LOS and cost of hospitalization. However, the mortality and other ERCP-related complications are not significantly different when compared to patients undergoing ERCP without recent MI. Therefore, in general it would be considered safe to perform ERCP in patients with recent MI with precautions to monitor or prevent post-ERCP bleeding.

Risk Factors for Post-Endoscopic Retrograde Pancreatography Pancreatitis: A Retrospective Chart Review in a Regional Hospital in Japan

Background: Endoscopic retrograde pancreatography (ERCP) is sometimes complicated by post-ERCP pancreatitis (PEP), which is a severe adverse effect. Objective: The present study was performed to (i) evaluate the risk factors for PEP and (ii) compare the risk of PEP after ERCP performed in the off hours versus regular hours. Methods: This retrospective study included 374 patients who underwent ERCP from January 2013 to December 2017. Among these patients, 38 (10.2%) developed PEP. The potential risk factors for PEP were evaluated by multivariate regression analysis, and the risk of PEP was compared between ERCP performed during regular hours and off hours. Results: The independent risk factors for PEP were a relatively younger age (<75 years; p = 0.024), female sex (p = 0.002), a history of pancreatitis (p = 0.044), and performance of pancreatography (p = 0.010). Use of a diclofenac suppository and performance of pancreatic stenting were not preventive for PEP after ERCP. The complication rate of PEP did not differ between ERCP performed during the off hours versus regular hours. Conclusions: A relatively younger age (<75 years), female sex, a history of pancreatitis, and performance of pancreatography were potential risk factors for PEP, whereas the risk of PEP was not different between ERCP performed during the off hours versus regular hours.

Factors affecting ampullary access of ERCP after Billroth II gastrectomy

Objective To investigate factors affecting ampullary access of endoscopic retrograde cholangiopancreatography (ERCP) in patients undergoing Billroth Ⅱ gastrectomy. Methods A retrospective analysis was performed on data of 261 patients with Billroth Ⅱ gastrectomy who underwent ERCP at Changhai Hospital from January 2008 to December 2017. Multivariate logistic regression analysis was used to analyze the potential factors affecting successful ampullary access, and receiver operating characteristic (ROC) curve was used to assess the predictive ability of potential factors. Results A total of 345 ERCP sessions were collected. The successful ampullary access and cannulation rate were 82.3% (284/345) and 89.1% (253/284), respectively. The main reasons for ERCP procedural failure were unable to reach the duodenal blind end and find the papilla (66.3%, 61/92) and failure of selective cannulation (33.7%, 31/92). The ERCP-related complication rate was 14.2% (49/345), with post-ERCP pancreatitis rate was 3.2% (11/345). Multivariate logistic regression analysis indicated that the first ERCP attempt (OR=7.717, 95%CI: 2.581-23.068. P<0.001), with Braun anastomosis (OR=8.737, 95%CI: 2.479-30.797, P=0.001), and no cap-assisted forward-viewing gastroscope (OR=2.774, 95%CI: 1.283-5.997, P=0.009) were independent risk factors for failure of ampullary access. According to the B value of each risk factor in logistic regression analysis, that is, no cap-assisted as 1 point, the first ERCP attempt as 2 points, and Braun anastomosis as 2 points, the area under ROC curve was 0.773. When the cut-off point was 2.5, the sensitivity and specificity were 75.0% and 70.8%, respectively. Conclusion The first ERCP attempt, with Braun anastomosis, and no cap-assisted forward-viewing gastroscope are risk factors for failure of ampullary access of ERCP in Billroth Ⅱ gastrectomy patients. Early identification of high-risk patients may help to improve the success rate of ampullary access. Key words: Cholangiopancreatography, endoscopic retrograde; Gastrectomy, Billroth Ⅱ; Risk factors

Pancreatic stenting to prevent post-ERCP pancreatitis: a randomized multicenter trial

Background and study aims Acute pancreatitis (AP) is one of the most common gastrointestinal disorders leading to hospitalization and the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Besides pharmaco-prophylaxis, pancreatic stenting has been demonstrated to protect from post-ERCP pancreatitis (PEP). However, it remains unclear which patients benefit from pancreatic stenting. We therefore hypothesized that in an unselected population, inadvertent cannulation of the pancreatic duct during first-time ERCP increases risk of PEP and that this risk can be significantly reduced by pancreatic stenting. Patients and methods This study was a multicenter, prospective, randomized controlled trial conducted at four European centers. A total of 167 patients undergoing first-time ERCP were enrolled in this trial. In the case of inadvertent cannulation of the pancreatic duct, patients were randomly assigned to receive either a 5 French plastic pancreatic stent of various length or no routine prophylactic intervention for PEP. Results A total of 167 patients were included in the final analysis. Prophylactic stent insertion significantly reduced the rate of PEP during first-time ERCP (odds ratio 0.43; 95% confidence interval 0.19 – 0.98; P = 0.04). The number needed to treat to prevent one case of PEP by prophylactic stent insertion after inadvertent cannulation of the pancreatic duct was 8.1 for the intention-to-treat population. Conclusion In an unselected patient population, inadvertent cannulation of the pancreatic duct during first-time ERCP is associated with a high risk for PEP. This risk can be significantly reduced by prophylactic pancreatic stenting, which is a safe and feasible procedure.

Effect of Dexketoprofene Trometamol on Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

To evaluate the efficacy of dexketoprofene trometamol solution following the administration of contrast agent for Endoscopic Retrograde Cholangiopancreatography (ERCP) in decreasing the rate of pancreatitis, in experimental rat model. Experimental study. Faculty of Medicine, Research and Animal Laboratory of Bezmialem University, Istanbul, Turkey in January 2018. Forty Wistar-Albino® male rats of 250-300g were divided into 4 equal groups. Group I underwent cannulation; group II had cannulation with saline; group III had cannulation and contrast agent; group IV had cannulation with contrast agent and dexketoprofene trometamol intra-muscular (IM). Twenty four hours following the procedure, the rats were sacrified and pancreatic tissues were examined histopathologically, with evaluation of blood levels of leukocyte, glucose, SGOT, LDH, amylase, and C-reactive protein (CRP) level. Histopathological grading of acute pancreatitis was performed using haematoxylin and eosin staining. Mean levels of amylase and leukocyte were found to be significantly higher in groups II, III, IV when compared to group I (p=0.001). CRP level was found to be highest in group III (p=0.001). Histopathological grade of pancreatitis was found to be significantly higher in groups II, III, IV than group I (p: 0.001, 0.001, 0.028, and 0.001, respectively). Scores of edema, acinar necrosis, inflammation and perivascular infiltration of group III were higher than in group IV (p=0.001). Intra-muscular administration of dexketoprofen trometamol during ERCP procedure may be beneficial in decreasing the rate of post-ERCP pancreatitis, as shown by histopathological and laboratory profile.

Sa1416 EARLY IMPLEMENTATION OF NEEDLE KNIFE PRECUTTING PAPILLOTOMY SEEMS TO BE PREVENTION OF POST-ERCP PANCREATITIS IN DIFFICULT CASES

Needle knife precutting papillotomy (NKPP) is a powerful tool to make a successful selective deep biliary cannulation in difficult cases. However, this procedure is thought to increase a risk of post-ERCP pancreatitis (PEP). This retrospective study validates that early implementation of NKPP reduces PEP rate in difficult cases. Furthermore, we evaluate preventive effect of PEP in an endoscopic pancreatic stent (EPS).

Safety and Efficacy of a Small J-Tipped Guidewire for Pancreatic Duct Endoscopic Intervention.

Background and Aims The insertion of the guidewires (GWs) into the pancreatic duct is technically difficult, and there is a risk of post-ERCP pancreatitis (PEP). The aim of this study was to evaluate the safety and efficacy of a small J-tipped guidewire for pancreatic duct endoscopic intervention. Methods This single-site retrospective study was conducted to assess the procedural success rate and adverse events of endoscopic transpapillary interventions to the pancreatic duct in 114 cases using the small J-tipped GW and 180 cases using the angle-tipped GW. Results The procedural success rate was significantly higher in the small J-tipped GW group compared with that in the angle-tipped GW group (76% versus 47%, P < 0.001). The procedural success-related factors were chronic pancreatitis (OR 0.43, 95% CI 0.22–0.82, P = 0.01), flexion angle of the pancreatic duct < 90° (OR 0.50, 95% CI 0.30–0.80, P = 0.01), and use of the small J-tipped GW (OR 4.63, 95% CI 2.61–8.20, P < 0.001). The rates of total post-ERCP pancreatitis were significantly lower in the small J-tipped GW group compared with that in the angle-tipped GW group (3.5% versus 12.2%, P = 0.01). Multivariate analysis of pancreatitis risk factors indicated that only the use of the small J-tipped GW was a factor in decreasing the risk of developing pancreatitis (OR 0.12, 95% CI 0.09–0.85, P = 0.02). Conclusions Small J-tipped GWs increase the success rate of the pancreatic duct endoscopic intervention as well as a reduced risk of developing postoperative pancreatitis.

Primary Needle-Knife Fistulotomy versus Conventional Cannulation Method in High Risk Cohort of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Multicenter Randomized Controlled Trial

Background: Successful biliary cannulation is a prerequisite and important component of endoscopic retrograde cholangiopancreatography (ERCP), but conventional cannulation methods (CCMs) have a post-ERCP pancreatitis (PEP) rate of 14.1% in patients at high risk for PEP. The aims of this study were to evaluate the effectiveness and safety of needle-knife fistulotomy (NKF), compared with a CCM, when used for primary biliary access in patients at high risk for developing PEP. Methods: A total of 207 patients with one or more risk factors for PEP were prospectively enrolled. The patients were randomly allocated to one of two groups according to the primary biliary cannulation technique (NKF or CCM). We compared biliary cannulation success rates, cannulation and procedure times, and the incidence of adverse events, including PEP, between the groups. Findings: The mean number of PEP risk factors was similar between the groups (NKF, 2.2 ± 1.0; CCM, 2.2 ± 0.9). PEP occurred in eight patients in the CCM group and in no patients in the NKF group (9.2% vs. 0%, p < 0.001). The rates of other complications did not differ between the groups. The biliary cannulation success rate was higher in the NKF group than in the CCM group (97.9% vs. 89.7%, p = 0.005). The mean cannulation time and total procedure time were longer in the NKF group than in the CCM group. Interpretation: NKF is an effective and safe procedure to gain primary biliary access in patients at high risk for developing PEP. Trial registration number: ClinicalTrials.gov, NCT02916199. Funding Statement: The authors state: None. Declaration of Interests: The authors state: None. Ethics Approval Statement: The study was approved by the institutional review boards of each institution (Approval number: 3-2017-0092).

Endocut Versus Conventional Blended Electrosurgical Current for Endoscopic Biliary Sphincterotomy: A Meta-Analysis of Complications.

Endoscopic biliary sphincterotomy (EST) is commonly performed during therapeutic endoscopic retrograde cholangiopancreatography (ERCP), but is an independent risk factor for post-ERCP pancreatitis, bleeding and duodenal perforation. These are partly ascribed to the electrosurgical current mode used for EST, and currently the optimal current model for EST remains controversial. In this study, we aimed to compare the rate of complications undergoing EST using the Endocut versus the blended current. A systematic search of databases was performed for relevant published and prospective studies including randomized clinical trials (RCTs) to compare Endocut with blended current modes for EST. Data were collected from inception until 1 July 2018, using post-ERCP pancreatitis, bleeding and perforation as primary outcomes. Three RCTs including a total of 594 patients met the inclusion criteria. Our meta-analysis results showed the rate of post-ERCP pancreatitis, primarily mild to moderate pancreatitis, was no different between Endocut versus blended current modes [risk ratio (RR) 0.61, 95% confidence interval (CI) 0.25-1.52, P = 0.29]. However, the risk of endoscopically bleeding events, primarily mild bleeding, was lower in studies using Endocut versus blended current (RR 0.54, 95% CI 0.31-0.95, P = 0.03). Notably, none of the patients experienced perforation in these three trials. The rate of post-ERCP pancreatitis was not significantly different when using the Endocut versus blended current during EST. Nevertheless, compared with the blended current, Endocut reduced the incidence of endoscopically evident bleeding; however, the available data were insufficient to assess the perforation risk.

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

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

Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist.

Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.