Can pancreatic duct stenting prevent post-ERCP pancreatitis in patients who undergo pancreatic duct guidewire placement for achieving selective biliary cannulation? A prospective randomized controlled trial

A network meta-analysis of optimal strategies for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis

Numerous interventions have been proposed to reduce the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), but it remains uncertain which approach is the most effective. The objective of this network meta-analysis was to evaluate and compare different preventive strategies for overall, mild, and moderate-to-severe PEP in both average- and high-risk patients. A systematic search was conducted for randomized controlled trials across the PubMed, Embase, and Cochrane Central databases. The inclusion criteria encompassed studies that featured at least two of the following interventions: pre-procedural administration of 100 mg of rectal diclofenac (D) or indomethacin (I), aggressive hydration utilizing normal saline (NS) or lactated Ringer's solution (LR), 5-french pancreatic duct stent (S), and either a placebo or an active control (C). The interventions were ranked according to their surface under cumulative ranking (SUCRA) values. The study protocol has been registered in PROSPERO (CRD42024538533). Of the total 42 (n = 11,493) identified studies, 23 studies (n = 5,410) were categorized into the average-risk group and 19 studies (n = 6,083) were categorized into high-risk group. Based on SUCRA, I + NS was ranked as the best preventive method for overall and mild PEP in average-risk group. However, I + LR was the most effective method of prevention of moderate-to-severe PEP in this group. In high-risk group, I + S was the best preventive method of overall and mild PEP. However, D was the most effective method of prevention of moderate-to-severe PEP in this group. The findings of this network meta-analysis indicate that endoscopists should consider all available prophylactic options when performing ERCP, rather than favoring one over the others.

Clinical Practice Guidelines for post-ERCP pancreatitis 2023

The Clinical Practice Guidelines for post-ERCP pancreatitis (PEP) 2023 provide updated recommendations for the prevention, diagnosis, and management of PEP. Endoscopic retrograde cholangiopancreatography (ERCP), a valuable procedure for diagnosing and treating pancreatobiliary diseases, can result in PEP as the most common adverse event. Since the first guidelines were published in 2015, advances in techniques and new research findings have necessitated this revision. The guidelines developed using the GRADE methodology target adult patients undergoing ERCP. They offer a comprehensive framework for clinicians to minimize the risk of PEP. For high-risk patients, endoscopic ultrasound before ERCP is recommended to avoid unnecessary procedures. The guidelines also discuss procedural and patient-related risk factors for PEP, highlighting that operator experience does not significantly affect PEP rates if performed under the supervision of skilled endoscopists. The diagnostic criteria include monitoring serum pancreatic enzyme levels postprocedure, and early computed tomography is advised in suspected cases. For treatment, the guidelines recommend following acute pancreatitis protocols. Key preventive measures include the use of temporary pancreatic duct stents and rectal nonsteroidal anti-inflammatory drugs, both of which are supported by strong evidence for reducing the incidence of PEP. Overall, these guidelines aim to enhance clinical outcomes by reducing PEP incidence and improving its management through evidence-based practices.

Complications of Endoscopic Retrograde Cholangiopancreatography

Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.

Impact of difficult biliary cannulation on post-ERCP pancreatitis: secondary analysis of the stent versus indomethacin trial dataset

BACKGROUND AND AIMS

Difficult 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.

METHODS

This 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: DBC with high preprocedure risk for PEP, DBC without high preprocedure risk for PEP, and non-DBC at high preprocedure risk for PEP.

RESULTS

In all, 1601 participants (84.1%) experienced DBC, which required a mean of 12 cannulation attempts (standard deviation, 10) and mean duration of 14.7 minutes (standard deviation, 14.9). PEP rate was highest (20.7%) in DBC with a high preprocedure risk, followed by non-DBC with a high preprocedure risk (13.5%), and then DBC without a high preprocedure risk (8.8%). Increasing number of PD wire passages (adjusted odds ratio [aOR], 1.97; 95% confidence interval [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 stent placement lowered the risk of PEP (aOR, .61; 95% CI, .44-.84) in DBCs. This protective effect was evident in up to at least 4 PD wire passages.

CONCLUSIONS

DBC confers higher PEP risk in an additive fashion to preprocedural risk factors. PD wire passages appear to add the greatest PEP risk in DBCs, but combining indomethacin with PD stent placement reduces this risk, even with increasing PD wire passages.

Impact of Duodenal Papilla Morphology on the Success of Transpancreatic Precut Sphincterotomy

Background: This study aimed to evaluate whether the morphology of the duodenal major papilla is linked to transpancreatic precut sphincterotomy (TPS) failure. Methods: We conducted a retrospective review of patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) at our institution. The inclusion criteria involved patients with a naïve major duodenal papilla who required TPS due to difficult biliary cannulation. Papilla morphology was classified using Haraldsson's system, as follows: regular (Type 1), small (Type 2), protruding or pendulous (Type 3), and creased or ridged (Type 4). The analysis focused on identifying risk factors for TPS failure and related complications. Results: A total of 103 cases were analyzed, with an overall TPS success rate of 85.44%. There were no significant differences in age, gender, ERCP indications, or the prevalence of juxtapupillary diverticula across the four papilla types. The TPS failure rates by papilla type were Type 1 (10.53%), Type 2 (0%), Type 3 (16.67%), and Type 4 (28%). Type 4 papilla had a significantly higher failure rate compared to Type 1 and Type 2 in the univariate analysis (p = 0.028), but this was not statistically significant in the multivariate analysis (p = 0.052). Age emerged as an independent risk factor for TPS failure. Conclusions: Duodenal papilla morphology may influence the success rate of TPS, with advanced age being a key risk factor for failure. Identifying high-risk factors such as Type 4 papilla and older age can help endoscopists adjust their techniques early, potentially improving outcomes and minimizing complications.

Comparison between different advanced cannulation techniques for difficult biliary cannulation: a systematic review with a meta-analysis

OBJECTIVE

This study aimed to systematically evaluate the efficacy and safety of the double-guidewire technique along with other methods (persistent standard cannulation techniques, transpancreatic sphincterotomy, and pancreatic stent-assisted technique) for difficult biliary cannulation.

METHODS

Two researchers searched for literature on the efficacy and safety of the double-guidewire technique and other techniques in difficult biliary cannulation in databases, including PubMed, Embase, Cochrane, China National Knowledge Infrastructure, and Wanfang Data, based on the inclusion and exclusion criteria. The success rate of cannulation, duration of cannulation, post-ERCP pancreatitis, and overall postoperative complications were also analyzed using RevMan 5.4 software.

RESULTS

In total, 20 randomized controlled trial (RCT) studies involving 2008 participants were identified. The success rate of cannulation in the double-guidewire technique was much higher than that in persistent standard cannulation techniques [RR = 1.37, 95%CI (1.05, 1.79), p = 0.02]. However, it was lower than the success rate observed with transpancreatic sphincterotomy [RR = 0.89, 95%CI (0.81, 0.97), p = 0.01]. There was no significance in post-ERCP pancreatitis [RR = 1.09, 95% CI (0.85, 1.40), p = 0.49], overall postoperative complications [RR = 0.90, 95% CI (0.56, 1.45), p = 0.66], and duration of cannulation [SMD = -0.14, 95%C I (-1.43, 1.15), p = 0.83] between the double-guidewire technique and other techniques.

CONCLUSION

This study demonstrated that the success rate of cannulation ranged from transpancreatic sphincterotomy to the double-guidewire technique and then to persistent standard cannulation techniques.

One-stage versus two-stage endoscopic management for acute cholangitis caused by common bile duct stones: A retrospective multicenter cohort study

BACKGROUND

One-stage endoscopic management, where papillary interventions and stone removal are simultaneously performed, has been reported to be an effective treatment for acute cholangitis caused by common bile duct stones (CBDS). However, there have been few reports comparing it with two-stage management, and there is no established strategy for the indication of one-stage management. The aim of the present study was to compare the short- and long-term outcomes between one- and two-stage management for acute cholangitis caused by CBDS.

METHODS

We retrospectively studied 577 patients who underwent one- or two-stage endoscopic management for acute cholangitis between May 2010 and December 2020. The patients were divided into one- and two-stage groups by endoscopic management. The clinical outcomes were compared between groups.

RESULTS

The technical and clinical success were similar in both groups, although the length of hospital stay was significantly shorter in the one-stage group. Although there was no difference in the early adverse event (AE) between two groups, post-ERCP pancreatitis was recognized in 3.4% and 10.0%, which was significantly higher in the two-stage group. The cumulative late AE rate was 22.6% and 14.1%, which was significantly higher in the one-stage group. In the multivariate analyses, intervention (one-stage), number of CBDS ≥2, biliary drainage, the use of ML, and gallbladder stone were identified as significant factors associated with the recurrence of CBDS.

CONCLUSION

Although one-stage endoscopic management is useful and safe with reducing hospital stays, diligent postoperative follow-up with consideration to recurrence of CBDS is essential.

Postendoscopic Retrograde Cholangiopancreatography Pancreatitis Pathophysiology and Prevention

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreato-biliary disorders. Pancreatitis remains the most frequent complication of the ERCP procedure, and it is, therefore, necessary to recognize the pathophysiology and risk factors contributing to the development of pancreatitis and understand the methods to prevent this complication.

Combinatorial Effect of Prophylactic Interventions for Post-ERCP Pancreatitis among Patients with Risk Factors: A Network Meta-Analysis

Background/Aims

The combinatorial effects of prophylactic methods for postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) in patients with risk factors remain unclear. In this network meta-analysis, we compared the efficacy of various prophylactic strategies to decrease the risk of PEP among patients with risk factors.

Methods

A systematic review was performed to identify randomized controlled trials from PubMed, Embase, and the Cochrane Library through July 2021. We used frequentist network meta-analysis to compare the rates of PEP among patients who received prophylactic treatments as follows: class A, rectal nonsteroidal anti-inflammatory drugs; class B, prophylactic pancreatic stent; class C, aggressive hydration; or control, no prophylaxis or active control. We selected those studies that included patients with risk factors for PEP.

Results

We identified 19 trials, comprising 4,328 participants. Class ABC (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.03 to 0.24), class AC (OR, 0.10; 95% CI, 0.02 to 0.47), class AB (OR, 0.12; 95% CI, 0.05 to 0.26), class BC (OR, 0.13; 95% CI, 0.04 to 0.41), class A (OR, 0.16; 95% CI, 0.05 to 0.50), and class B (OR, 0.26; 95% CI, 0.14 to 0.46), were associated with a reduced risk of PEP as compared to that of the control. The most effective prophylaxis was ABC (0.87), followed by AC (0.68), AB (0.65), BC (0.56), A (0.49), and B (0.24) according to P-score.

Conclusions

The results of this network meta-analysis suggest that the more prophylactic methods are employed, the better the outcomes. It appears that for patients with risk factors, we need to prevent PEP through the use of these well proven combination strategies.

Endoscopic retrograde cholangiopancreatography-related complications: risk stratification, prevention, and management

Endoscopic retrograde cholangiopancreatography (ERCP) plays a crucial role in the management of pancreaticobiliary disorders. Although the ERCP technique has been refined over the past five decades, it remains one of the endoscopic procedures with the highest rate of complications. Risk factors for ERCP-related complications are broadly classified into patient-, procedure-, and operator-related risk factors. Although non-modifiable, patient-related risk factors allow for the closer monitoring and instatement of preventive measures. Post-ERCP pancreatitis is the most common complication of ERCP. Risk reduction strategies include intravenous hydration, rectal nonsteroidal anti-inflammatory drugs, and pancreatic stent placement in selected patients. Perforation is associated with significant morbidity and mortality, and prompt recognition and treatment of ERCP-related perforations are key to ensuring good clinical outcomes. Endoscopy plays an expanding role in the treatment of perforations. Specific management strategies depend on the location of the perforation and the patient's clinical status. The risk of post-ERCP bleeding can be attenuated by preprocedural optimization and adoption of intra-procedural techniques. Endoscopic measures are the mainstay of management for post-ERCP bleeding. Escalation to angioembolization or surgery may be required for refractory bleeding. Post-ERCP cholangitis can be reduced with antibiotic prophylaxis in high risk patients. Bile culture-directed therapy plays an important role in antimicrobial treatment.

Predictive factors of difficult biliary cannulation: An experience of a tunisian tertiary center

Introduction

Selective biliary cannulation is a prerequisite for a successful endoscopic retrograde cholangiopancreatography (ERCP). However, conventional biliary access can be difficult. The aims of our study were to determine the prevalence of difficult biliary cannulation (DBC) and its associated factors and to describe the efficiency and safety of used standard and advanced cannulation techniques.

Methods

We conducted a single-center retrospective study including all patients with naïve papilla who had an ERCP procedure in Gastroenterology department of Mohamed Taher Maamouri Hospital from June 2019 to December 2021. Efficiency was defined as successful selective deep biliary cannulation. DBC was defined based on the presence of one or more of the European Society of Gastrointestinal Endoscopy (ESGE) criteria (5-5-1): more than five cannulation attempts, more than 5 min before cannulation and more than one accidental passage in the wirsung. Prevalence was measured using ESGE 5-5-1 cutoffs and chinese set cutoffs 15-10-2. Predictors of DBC were sought by univariate and multivariate analysis (SPSS software, p significant if < 0.05).

Results

We included 664 patients (mean age 62 years and sex ratio M/W = 0.8). Main indication for ERCP was choledocholithiasis (67%, n = 442) followed by malignant biliary stenosis (21%, n = 138). Based on ESGE criteria, prevalence of DBC was 42.62% (n = 283). Prevalence was 21.15% when 15-10-2 cutoffs are applied in trainee-involved procedure. Cumulative biliary success rate was 96.46%. Standard cannulation method achieved access in 98.2% while advanced methods permitted success in 92.2% in fistulotomy, 94.1% in papillotomy and 77.3% in transpancreatic sphincterotomy. Independent predictive factors of DBC in multivariate analysis were: Trainee presence OR 1.80 [1.24-2.65], SOD OR 4.71 [1.11-19.88], biliary stenosis found on imaging examinations (OR 2.53 [1.63-3.92], small papilla OR 4.09 [1.82-9.17] and difficult orientation of the papilla OR 14.90 [3.28-67.62].

Conclusion

DBC is a frequent endoscopic situation. Predictors of DBC can be related to trainee involvement in the procedure, anatomical and clinical factors. A thorough understanding of these factors can actively contribute to ERCP management plans.

JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis

BACKGROUND

In preparing the Japanese (JPN) guidelines for the management of acute pancreatitis 2021, the committee focused the issues raised by the results of nationwide epidemiological survey in 2016 in Japan.

METHOD

In addition to a systematic search using the previous JPN guidelines, papers published from January 2014 to September 2019 were searched for the contents to be covered by the guidelines based on the concept of GRADE system.

RESULTS

Thirty-six clinical questions (CQ) were prepared in 15 subject areas. Based on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast-enhanced computed tomography (CT) grade had a high fatality rate and that little prognosis improvement after 2 weeks of disease onset was not obtained, we emphasized the importance of Pancreatitis Bundles, which were shown to be effective in improving prognosis, and the CQ sections for local pancreatic complications had been expanded to ensure adoption of a step-up approach. Furthermore, on the facts that enteral nutrition for severe acute pancreatitis was not started early within 48 h of admission and that unnecessary prophylactic antibiotics was used in almost all cases, we emphasized early enteral nutrition in small amounts even if gastric feeding is used and no prophylactic antibiotics are administered in mild pancreatitis.

CONCLUSION

All the members of the committee have put a lot of effort into preparing the extensively revised guidelines in the hope that more people will have a common understanding and that better medical care will be spread.

Difficult biliary cannulation in patients with distal malignant biliary obstruction: An underestimated problem?

BACKGROUND

Failed biliary cannulation still poses a major challenge in patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP). To date, there is a lack of data on rates of Difficult Biliary Cannulation (DBC) in patients with distal malignant biliary obstruction (DMBO).

MATERIALS

This was a retrospective study (09/2015 to 02/2019) of consecutive patients with DMBO that underwent ERCP in four Italian centers. The primary outcome was to evaluate the rate of DBC. Secondary outcomes were: cannulation failure, rate of adverse events (AEs), the predictive factors for DBC as well as for AEs.

RESULTS

A total of 622 patients with DMBO, were included in the study, with 351(56,4%) matching the definition of DBC. One-hundred and two ERCP-related AEs occurred in 97 of 622 patients (15,6%). Subjects with DBC showed a higher risk for AEs (p = 0.02). The lack of pancreatitis prophylaxis (p = 0.03), diagnosis of cholangiocarcinoma (p = 0.02), the use of papillotomy (OR=1.98; 95%CI = 1.14-3.45) and the combination of two or more techniques for cannulation (OR = 2.88; 95%CI = 1.04-7.97) were associated with the occurrence of AEs.

CONCLUSIONS

According to the results of this study, patients with DMBO carries a higher rate of DBC thus requiring alternative techniques for biliary drainage. Furthermore, DBC carries a high risk for AEs. Further prospective multicentric studies are needed to confirm these data in this specific subgroup of patients.

Efficacy of Combining Aggressive Hydration With Rectal Indomethacin in Preventing Post-ERCP Pancreatitis: A Systematic Review and Network Meta-Analysis

Postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography pancreatitis (ERCP). No randomized controlled trial (RCT) has compared the efficacy of the American Society of Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy recommended interventions for PEP prevention. We assessed the effectiveness of these interventions using network meta-analysis. PubMed, EMBASE, and Cochrane databases were searched to identify RCTs investigating guideline-recommended interventions and their combinations [rectal nonsteroidal anti-inflammatory drugs (NSAIDs): indomethacin or diclofenac, pancreatic stent (PS), aggressive hydration (AH), sublingual nitrate) for PEP prevention. We performed direct and Bayesian network meta-analysis, and the surface under the cumulative ranking curve to rank interventions. Subgroup network meta-analysis for high-risk populations was also performed. We identified a total of 38 RCTs with 10 different interventions. Each intervention was protective against PEP on direct and network meta-analysis compared with controls. Except AH+diclofenac and NSAIDs+ sublingual nitrate, AH+indomethacin was associated with a significant reduction in risk of PEP compared with PS [odds ratio (OR), 0.09; credible interval (CrI), 0.003-0.71], indomethcin+PS (OR, 0.09; CrI, 0.003-0.85), diclofenac (OR, 0.09; CrI, 0.003-0.65), AH (OR, 0.09; CrI, 0.003-0.65), sublingual nitrate (OR, 0.07; CrI, 0.002-0.63), and indomethacin (OR, 0.06; CrI, 0.002-0.43). AH with either rectal NSAIDs or sublingual nitrate had similar efficacy. AH+indomethacin was the best intervention for preventing PEP with 95.3% probability of being ranked first. For high-risk patients, although the efficacy of PS and indomethacin were comparable, PS had an 80.8% probability of being ranked first. AH+indomethacin seems the best intervention for preventing PEP. For high-risk patients, PS seems the most effective strategy. The potential of combination of interventions need to be explored further.

Rectal NSAIDs-based combination modalities are superior to single modalities for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a network meta-analysis

BACKGROUND/AIMS

Different modalities have been employed to reduce the risk and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, there has been a paucity of studies comparing the efficacy of various prophylactic modalities for preventing PEP. This network meta-analysis (NMA) aimed to determine the relative efficacy of pancreatic duct stents and pharmacological modalities for preventing PEP.

METHODS

We performed a systematic and comprehensive search to identify and analyze all randomized controlled studies published until June 2020 that examined the effectiveness of pancreatic duct stents, rectal non-steroidal anti-inflammatory drugs (NSAIDs) based regimens, hydration, and their combinations for the prevention of PEP. The primary outcome was the frequency of PEP. An NMA was performed to combine direct and indirect comparisons of different prophylactic modalities.

RESULTS

The NMA included 46 studies evaluating 18 regimens in 16,241 patients. Based on integral analysis of predictive interval plots, and expected mean ranking and surface under the cumulative ranking curve values, combination prophylaxis with indomethacin + lactated Ringer's solution (LR), followed by diclofenac + nitrate and indomethacin + normal saline, was found to be the most efficacious modality for the overall prevention of PEP. Indomethacin + LR, followed by diclofenac and pancreatic duct stents, was the most efficacious modality for high-risk groups.

CONCLUSION

Rectal NSAIDs-based combination regimens with aggressive hydration or nitrate are superior to single modalities for the prevention of PEP.

Early double-guidewire versus repeated single-guidewire technique to facilitate selective bile duct cannulation: a randomized controlled trial

BACKGROUND

During endoscopic retrograde cholangiopancreatography (ERCP), access to the common bile duct (CBD) can be problematic after unintentional insertion of the guidewire into the pancreatic duct. We conducted a prospective, randomized study in order to compare biliary cannulation success rates of early double-guidewire (EDG) and repeated single-guidewire (RSG) techniques in patients with inadvertent passage of the guidewire into the pancreatic duct.

METHODS

Patients with a native papilla were randomly assigned to either the EDG or RSG groups after unintentional insertion of the guidewire into the pancreatic duct. The primary outcome was successful selective CBD cannulation within 10 minutes. The secondary outcomes were successful final selective bile duct cannulation, time to bile duct cannulation, and frequency of post-ERCP pancreatitis (PEP).

RESULTS

142 patients were randomized and selective bile duct cannulation was achieved in 57/68 patients (84 %) in the EDG group and in 37/74 patients (50 %) in the RSG group within 10 minutes (relative risk 1.34; 95 % confidence interval 1.08-6.18; P < 0.001). The overall final selective bile duct cannulation rate was 99.3 %. The time to access the CBD was shorter using the EDG technique (6.0 vs. 10.4 minutes; P = 0.002). Mild PEP was not observed more frequently in the EDG group than in the RSG group.

CONCLUSION

The EDG technique significantly increased the success rate of biliary duct cannulation within 10 minutes compared with an RSG approach.

Safety and efficacy of different techniques in difficult biliary cannulation at endoscopic retrograde cholangiopancreatography

BACKGROUND

Adverse events (AEs) are commonly seen at endoscopic retrograde cholangiopancreatography (ERCP) during difficult biliary cannulation (DBC). Therefore, attaining the right technique is essential to have improved outcomes.

METHODS

Patients who had DBC over a 3-year period were assessed for outcomes. The protocol included double guidewire (DGW) technique, wire-guided cannulation (WGC) after pancreatic stent, precut sphincterotomy/fistulotomy, and EUS-guided rendezvous (RV). The success of various techniques and AE was studied.

RESULTS

As per available case analysis, a total of 3680 patient details were assessed out of which DBC was noted in 471 (12.8%) patients with a mean (SD) age of 51.5 (17.4) years; majority being 330 (70.1%) males. Most patients underwent precut sphincterotomy 230 (48.8%); however, it was not successful in the first attempt in 10 (2.1%) patients with the success rate of 220 (95.6%). The success rate of DGW cannulation was 120 (95.2%), WGC after pancreatic stent was 64 (94.1%), EUS-RV was 34 (97.1%), and wire-guided repeat ERCP after 48 h was 10 (98.3%). AEs were noted in 52 (11.1%) patients. After precut, 32 (13.9%) patients developed AE out of which post-ERCP pancreatitis was noted in 20 (8.7%). Twenty-three patients had failed biliary access after all methods and 20 (86.9%) of those received successful percutaneous transhepatic biliary drainage.

CONCLUSION

Repeat ERCP after 48 h and EUS-RV appear prudent for DBC. Precut remains one of the preferred choices for most endoscopists when there is no entrance to PD. Further utilizing an algorithmic approach can contribute to higher success rates without compromising safety.

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.

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

BACKGROUND & AIMS

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common adverse event after endoscopic retrograde cholangiopancreatography, and is responsible for substantial morbidity and health care expenditures of at least $200 million. Therapies for PEP prevention include pancreatic stent placement (PSP), rectal indomethacin, sublingual nitrates, and aggressive lactated Ringer's hydration. Our objective was to determine which PEP prophylactic strategies are cost effective.

METHODS

We developed 2 separate decision trees to evaluate PEP prophylactic strategies. The first, in high-risk patients, compared rectal indomethacin, PSP, PSP with indomethacin, sublingual nitrates, aggressive hydration with lactated Ringer's, and no prophylaxis. The second, in average-risk patients, compared rectal indomethacin, sublingual nitrates, aggressive hydration, and no prophylaxis. We used incidence rates, transition probabilities, and costs from publications and public data sources. Outcome measures were reported as incremental cost-effectiveness ratios, with a willingness-to-pay (WTP) threshold of $100,000/quality-adjusted life years (QALYs).

RESULTS

Compared with no prophylaxis, all strategies were cost effective at a WTP of $100,000 in preventing PEP in high-risk patients. When directly compared with each other, rectal indomethacin was the cost-effective strategy in high-risk patients ($31,589/QALYs). In average-risk patients, indomethacin and sublingual nitrates were cost effective at a WTP of $100,000/QALYs compared with no prophylaxis. When directly compared with each other, rectal indomethacin was the cost-effective strategy ($53,016/QALYs).

CONCLUSIONS

Rectal indomethacin was the cost-effective strategy for preventing PEP in both average-risk and high-risk patients undergoing endoscopic retrograde cholangiopancreatography. All strategies were cost effective when compared with no prophylaxis in high-risk patients, whereas all strategies except for aggressive hydration with lactated Ringer's were cost effective in average-risk patients. Further studies are needed to improve the utilization of PEP prevention strategies.

Comparative efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis

BACKGROUND AND AIMS

Several methods with variable efficacy have been proposed for difficult biliary cannulation in ERCP. We assessed the comparative efficacy of different strategies for difficult biliary cannulation through a network meta-analysis combining direct and indirect treatment comparisons.

METHODS

We identified 17 randomized controlled trials (2015 patients) that compared the efficacy of different adjunctive methods for difficult biliary cannulation (needle-knife techniques, pancreatic guidewire-assisted technique, pancreatic-assisted technique, and transpancreatic sphincterotomy) either with each other or with persistence with the standard cannulation techniques. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) were the outcomes of interest. We performed pairwise and network meta-analysis for all treatments and used Grading of Recommendations Assessment, Development and Evaluation criteria to appraise quality of evidence.

RESULTS

Low-quality evidence supported the use of transpancreatic sphincterotomy over persistence with standard cannulation techniques (risk ratio [RR], 1.29; 95% confidence interval [CI], 1.05-1.59) and over any other adjunctive intervention (RR, 1.21 [95% CI, 1.01-1.44] vs pancreatic guidewire-assisted technique, RR, 1.19 [95% CI, 1.01-1.43] vs early needle-knife techniques, RR, 1.47 [95% CI, 1.03-2.10] vs pancreatic stent-assisted technique) for increasing the success rate of biliary cannulation. No other significant results were observed in any other comparisons. Based on the network model, transpancreatic sphincterotomy (P-score, .97) followed by early needle-knife techniques (P-score, .62) were ranked highest in terms of increasing the success rate of biliary cannulation. Early needle-knife techniques outperformed persistence with standard cannulation techniques in terms of decreasing PEP rate (RR, .61; 95% CI, .37-1.00), whereas both early needle-knife techniques and transpancreatic sphincterotomy led to lower PEP rates as compared with pancreatic guidewire-assisted technique (RR, .49 [95% CI, .23-.99] and .53 [95% CI, .30-.92], respectively).

CONCLUSIONS

Transpancreatic sphincterotomy increases the success rate of biliary cannulation as compared with persistence with the standard cannulation techniques. Early needle-knife techniques and transpancreatic sphincterotomy are superior to other interventions in decreasing PEP rates and should be considered in patients with difficult cannulation.

Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique?

Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.

New practical scoring system to predict post-endoscopic retrograde cholangiopancreatography pancreatitis: Development and validation

Background and Aim

Post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most serious adverse event of ERCP. Therefore, it is important to identify high‐risk patients who require prophylactic measures. The aim of this study was to develop a practical prediction model for PEP that identifies high‐risk patients.

Methods

Patients who underwent ERCP at three tertiary hospitals between April 2010 and September 2012 were enrolled. The dataset was divided into a training set (two centers) and validation set (one center). Using the training set, univariable and multivariable analyses were performed to identify predictive factors for PEP. We constructed a scoring system and evaluated reproducibility using the validation set.

Results

A total of 2719 ERCPs were analyzed. PEP developed in 133 cases (4.9%). Risk factors (adjusted odds ratios [OR]) in the training set were a history of PEP (OR: 4.2), intact papilla (OR: 2.4), difficult cannulation (OR: 1.9), pancreatic guidewire‐assisted biliary cannulation (OR: 2.2), pancreatic injection (OR: 2.1), pancreatic intraductal ultrasonography (IDUS)/sampling from the pancreatic duct (OR: 2.2), and biliary IDUS/sampling from the biliary tract (OR: 2.8). A scoring system was constructed using these seven clinical variables. The areas under the receiver‐operating characteristic curve of this model were 0.799 in the training set and 0.791 in the validation set. In the high‐risk group at a score of 3 or higher, the incidence of PEP was 13.4%, and all severe/fatal cases were in the high‐risk group.

Conclusions

This scoring system helps to predict each patient's risk and select preventive measures.

Non-steroidal anti-inflammatory drugs, intravenous fluids, pancreatic stents, or their combinations for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and network meta-analysis

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs), intravenous fluid, pancreatic stents, or combinations of these have been evaluated in randomised controlled trials (RCTs) for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, but the comparative efficacy of these treatments remains unclear. Our aim was to do an exploratory network meta-analysis of previous RCTs to systematically compare the direct and indirect evidence and rank NSAIDs, intravenous fluids, pancreatic stents, or combinations of these to determine the most efficacious method of prophylaxis for post-ERCP pancreatitis.

METHODS

We searched PubMed, Embase, and the Cochrane Central Register from inception to Nov 15, 2020, for full-text RCTs that evaluated the efficacy of NSAIDs, pancreatic stents, intravenous fluids, or combinations of these for post-ERCP pancreatitis prevention in adult (aged ≥18 years) patients undergoing ERCP. Summary data from intention-to-treat analyses were extracted from published reports. We analysed incidence of post-ERCP pancreatitis across studies using network meta-analysis under the frequentist framework, obtaining pairwise odds ratios (ORs) and 95% CIs. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system for the confidence rating. This study is registered with PROSPERO, CRD42020172606.

FINDINGS

We identified 1503 studies, of which 55 RCTs evaluating 20 interventions in 17 062 patients were included in the network meta-analysis. The mean incidence of post-ERCP pancreatitis in the placebo or active control group was 12·2% (95% CI 11·4-13·0). Normal saline plus rectal indometacin (OR 0·02, 95% CI 0·00-0·40), intramuscular diclofenac 75 mg (0·24, 0·09-0·69), intravenous high-volume Ringer's lactate plus rectal diclofenac 100 mg (0·30, 0·16-0·55), intravenous high-volume Ringer's lactate (0·31, 0·12-0·78), 5-7 Fr pancreatic stents (0·35, 0·26-0·48), rectal diclofenac 100 mg (0·36, 0·25-0·52), 3 Fr pancreatic stents (0·47, 0·26-0·87), and rectal indometacin 100 mg (0·60, 0·50-0·73) were all more efficacious than placebo for preventing post-ERCP pancreatitis in pairwise comparisons. 5-7 Fr pancreatic stents (0·59, 0·41-0·84), intravenous high-volume Ringer's lactate plus rectal diclofenac 100 mg (0·49, 0·26-0·94), intravenous standard-volume normal saline plus rectal indometacin 100 mg (0·04, 0·00-0·66), and rectal diclofenac 100 mg (0·59, 0·40-0·89) were more efficacious than rectal indometacin 100 mg. The GRADE confidence rating was low to moderate for 98·3% of the pairwise comparisons.

INTERPRETATION

This systematic review and network meta-analysis summarises the available literature on NSAIDs, pancreatic stents, intravenous fluids, or combinations of these for prophylaxis of post-ERCP pancreatitis. Rectal diclofenac 100 mg is the best performing rectal NSAID in this network meta-analysis. Combinations of prophylaxis might be more effective, but there is little evidence. These findings help to establish prophylaxis of post-ERCP pancreatitis for future research and practice, and could reduce costs and increase adoption of prophylaxis.

FUNDING

None.

Network meta-analysis of prophylactic pancreatic stents and non-steroidal anti-inflammatory drugs in the prevention of moderate-to-severe post-ERCP pancreatitis

BACKGROUND

There is an ongoing debate that non-steroidal anti-inflammatory drugs (NSAID) or prophylactic pancreatic stents (PPS) are more beneficial in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). In our present network meta-analysis, we aimed to compare PPSs to rectal NSAIDs in the prevention of moderate and severe PEP in average- and high-risk patients.

METHODS

We performed a systematic search for randomized controlled trials (RCT) from MEDLINE (via PubMed), Embase and Cochrane Central databases. RCTs using prophylactic rectal NSAIDs or PPSs in patients subjected to ERCP at average- and high-risk population were included. The main outcome was moderate and severe PEP defined by the Cotton criteria. Pairwise Bayesian network meta-analysis was performed, and interventions were ranked based on surface under cumulative ranking (SUCRA) values.

RESULTS

Seven NSAID RCTs (2593 patients), and 2 PPS RCTs (265 patients) in the average-risk, while 5 NSAID RCTs (1703 patients), and 8 PPS RCTs (974 patients) in the high-risk group were included in the final analysis. Compared to placebo, only PPS placement reduced the risk of moderate and severe PEP in both patient groups (average-risk: RR = 0.07, 95% CI [0.002-0.58], high-risk: RR = 0.20, 95% CI [0.051-0.56]) significantly. Rectal NSAID also reduced the risk, but this effect was not significant (average-risk: RR = 0.58, 95% CI [0.22-1.3], high-risk: RR = 0.58, 95% CI [0.18-2.3]). Based on SUCRA, PPS placement was ranked as the best preventive method.

CONCLUSION

Prophylactic pancreatic stent placement but not rectal NSAID seems to prevent moderate-to-severe PEP better both, in average- and high-risk patients.

Biliary Cannulation in Endoscopic Retrograde Cholangiography: How to Tackle the Difficult Papilla

BACKGROUND

In the setting of a naïve papilla, biliary cannulation is a key step in successfully performing endoscopic retrograde cholangiography. Difficult biliary cannulation (DBC) is associated with an increased risk of post-ERCP pancreatitis and failure of the whole procedure.

SUMMARY

Recommendations for biliary cannulation can be divided into (a) measures to reduce the likelihood of a difficult papilla situation a priori and (b) rescue techniques in case the endoscopist is actually facing DBC. (a) Careful inspection of the papillary anatomy and optimizing its accessibility by scope positioning is fundamental. A sphincterotome in combination with a soft-tip hydrophilic guidewire rather than a standard catheter with a standard guidewire should be used in most situations. (b) The most important rescue techniques are needle-knife precut, double-guidewire technique, and transpancreatic sphincterotomy. In few cases, anterograde cannulation techniques are needed. To this regard, the EUS-guided biliary drainage followed by rendezvous is increasingly used as an alternative to percutaneous transhepatic biliary drainage. Key Messages: Biliary cannulation can be accomplished with alternative retrograde or less frequently by salvage anterograde techniques, once conventional direct cannulation attempts have failed. Considering recent favorable data for the early use of transpancreatic sphincterotomy, an adopted version of the 2016 European Society for Gastrointestinal Endoscopy (ESGE) algorithm on biliary cannulation is proposed.

Utility and safety of a new uneven double-lumen sphincterotome in cases of difficult biliary cannulation

Background

We investigated the utility and safety of a new uneven double-lumen sphincterotome in biliary cannulation in comparison with the conventional pancreatic guidewire (PGW) method.

Methods

We retrospectively evaluated 119 patients who required PGW placement because of difficult biliary cannulation. Endoscopic retrograde cholangiopancreatography (ERCP) was performed using a conventional ERCP catheter or a new uneven double-lumen sphincterotome. The success rate of bile duct cannulation, the operation time of bile duct cannulation, and the incidence of post-ERCP pancreatitis (PEP) were evaluated.

Results

Forty-four patients were treated with a new double-lumen sphincterotome (the new sphincterotome group) and 75 patients underwent conventional PGW placement (the conventional group). The success rate of bile duct cannulation was 39/44 (88.6%) in the new sphincterotome group and 63/75 (84.0%) in the conventional group (not significant). The total biliary cannulation time (from the reach to the papilla to the finish of biliary cannulation) was 16.0 (6.5–78) min in the new sphincterotome group and 26.0 (5–80) min in the conventional group (P < 0.01). The time from PGW placement to bile duct cannulation was 3.5 (0.3–57) min in the magictome group and 12.0 (1–65) min in the conventional group (P < 0.01). Hyperamylasemia was observed in 13/44 (29.5%) and 17/75 (22.7%), respectively (not significant). Five of 44 (11.3%) of the new sphincterotome group and 14/75 (18.7%) of the conventional group were diagnosed with PEP (not significant).

Conclusion

A new double-lumen sphincterotome allows selective bile duct cannulation to be performed in a shorter time than the conventional PGW method.

Advances in Biliary Access

PURPOSE OF REVIEW

Bile duct cannulation using conventional techniques fails in up to 16% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. Advanced techniques to gain biliary access include ERCP-based maneuvers, and newer endoscopic ultrasound (EUS)-guided interventions. In this article, we review the evidence supporting the use of various ERCP and EUS techniques for biliary access, as well as studies comparing these different techniques.

RECENT FINDINGS

In comparative studies, biliary access after failed conventional cannulation was more successful with EUS-rendezvous compared to precut papillotomy. EUS-guided drainage compares favorably with percutaneous drainage with respect to clinical success, safety profile, and cost-efficiency. Recent randomized trials comparing EUS to ERCP drainage in malignant obstruction have found similar success rates between these techniques. EUS-guided techniques compare favorably to ERCP-based methods for biliary access and drainage. The advent of newer technologies to facilitate interventional EUS may further change current treatment approaches.

Rectal nonsteroidal anti-inflammatory drugs and pancreatic stents in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: A network meta-analysis

BACKGROUND

100 mg rectal nonsteroidal anti-inflammatory drugs (NSAIDs) and pancreatic stents both significantly reduce the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Direct comparison of randomized controlled trials (RCTs) between them in high-risk patients is absent. We conducted this network meta-analysis to indirectly compare the efficacies of 100 mg rectal NSAIDs and pancreatic stents in preventing post-ERCP pancreatitis (PEP) in high-risk patients and help us decide which is preferred in clinical practice.

METHODS

A comprehensive search was done to identify RCTs published in English full-text. Interventions included 100 mg rectal NSAIDs (diclofenac or indomethacin) and pancreatic stents. Only studies with high-risk patients of PEP were included. Meta-analyses of NSAIDs and pancreatic stents were conducted respectively. A network meta-analysis using the Bayesian method was performed.

RESULTS

We included 14 RCTs, 8 on pancreatic stents and 6 on 100 mg rectal NSAIDs in high-risk patients. There was no direct comparison between them. After excluding an outlier study on NSAIDs (n = 144), meta-analyses showed they both significantly and statistically reduced the incidence of PEP in high-risk patients (pancreatic stents: n = 8 studies, random-effects risk ratio (RR)0.41, 95%CI 0.30-0.56, I = 0%; NSAIDs: n = 5 studies, random-effects RR 0.37, 95%CI 0.25-0.54, I = 0%). And network meta-analysis showed efficacy of 100 mg rectal NSAIDs was equal to pancreatic stents (random-effects RR 0.94, 95%CI 0.50-1.8).

CONCLUSIONS

The efficacy of 100 mg rectal NSAIDs (diclofenac or indomethacin) seems equally significant to pancreatic stents in preventing PEP in high-risk patients. Considering the cost-effectiveness and safety, 100 mg diclofenac or indomethacin may be preferred.

Wire-guided biliary cannulation: a comprehensive approach to a set of techniques

Biliary cannulation represent a challenge for the endoscopists that approach to endoscopic retrograde cholangiopancreatography, with non-negligible rate of failure even in expert hands. In order to achieve the biliary tree, two main technique are nowadays mainly used, namely the contrast-assisted cannulation and the wire-guided cannulation (WGC) techniques. The WGC technique is widely used because it seems to be related to higher success rate of cannulation of the common bile duct and, at the same time, to lower rates of complications. Particularly, this approach is associated with lower risk of post endoscopic retrograde cholangiopancreatography pancreatitis, although the pathogenesis of this adverse event is still not completely understood. The outspread of this technique among endoscopists promoted the development of different methods of performing WGC-assisted endoscopic retrograde cholangiopancreatography, such as the touch technique, the no-touch technique and the double guide-wire cannulation. Furthermore, the variety of guide wires and accessories, with their different characteristics, contribute to make the scenario extremely heterogeneous. To date, the published studies did not highlight which is the best strategy that maximizes the rate of success and minimizes the percentage of complications, even because the experience of the operator represents an important variable that conditions the outcomes. The aim of this review is to define state of the art in WGC technique, in order to better understand the possible advantages in using this approach and to bring to light the possible area that may be object of further studies.

Post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review for prevention and treatment

BACKGROUND

Post endoscopic retrograde cholangiopancreatography (ERCP) is comparatively complex application. Researchers has been investigated prevention of post-ERCP pancreatitis (PEP), since it has been considered to be the most common complication of ERCP. Although ERCP can lead various complications, it can also be avoided.

AIM

To study the published evidence and systematically review the literature on the prevention and treatment for PEP.

METHODS

A systematic literature review on the prevention of PEP was conducted using the electronic databases of ISI Web of Science, PubMed and Cochrane Library for relevant articles. The electronic search for the review was performed by using the search terms “Post endoscopic retrograde cholangiopancreatography pancreatitis” AND “prevention” through different criteria. The search was restricted to randomized controlled trials (RCTs) performed between January 2009 and February 2019. Duplicate studies were detected by using EndNote and deleted by the author. PRISMA checklist and flow diagram were adopted for evaluation and reporting. The reference lists of the selected papers were also scanned to find other relevant studies.

RESULTS

726 studies meeting the search criteria and 4 relevant articles found in the edited books about ERCP were identified. Duplicates and irrelevant studies were excluded by screening titles and abstracts and assessing full texts. 54 studies were evaluated for full text review. Prevention methods were categorized into three groups as (1) assessment of patient related factors; (2) pharmacoprevention; and (3) procedural techniques for prevention. Most of studies in the literature showed that young age, female gender, absence of chronic pancreatitis, suspected Sphincter of Oddi dysfunction, recurrent pancreatitis and history of previous PEP played a crucial role in posing high risks for PEP. 37 studies designed to assess the impact of 24 different pharmacologic agents to reduce the development of PEP delivered through various administration methods were reviewed. Nonsteroidal anti-inflammatory drugs are widely used to reduce risks for PEP. Rectal administration of indomethacin immediately prior to or after ERCP in all patients is recommended by European Society for Gastrointestinal Endoscopy guidelines to prevent the development of PEP. The majority of the studies reviewed revealed that rectally administered indomethacin had efficacy to prevent PEP. Results of the other studies on the other pharmacological interventions had both controversial and promising results. Thirteen studies conducted to evaluate the efficacy of 4 distinct procedural techniques to prevent the development of PEP were reviewed. Pancreatic Stent Placement has been frequently used in this sense and has potent and promising benefits in the prevention of PEP. Studies on the other procedural techniques have had inconsistent results.

CONCLUSION

Prevention of PEP involves multifactorial aspects, including assessment of patients with high risk factors for alternative therapeutic and diagnostic techniques, administration of pharmacological agents and procedural techniques with highly precise results in the literature.

Early pancreatic stent placement in wire-guided biliary cannulation: A multicenter retrospective study

BACKGROUND AND AIM

Guidewire insertion to a pancreatic duct under wire-guided cannulation (WGC) during endoscopic retrograde cholangiopancreatography (ERCP) is associated with a high incidence of post-ERCP pancreatitis (PEP). Pancreatic stent placement followed by WGC (PS-WGC) is considered for these cases to reduce PEP. This study was aimed to examine the effectiveness of PS-WGC compared with repeated WGC.

METHODS

The consecutive data of patients without history of ERCP who underwent ERCP for biliary intervention were retrospectively collected from five centers. Patients without guidewire insertion to the pancreatic duct were excluded. Pancreatic stent was immediately placed after guidewire insertion to the pancreatic duct in the PS-WGC group. The association between the method of biliary cannulation (PS-WGC or repeated WGC) and PEP was analyzed using multivariable logistic regression model.

RESULTS

A total of 590 patients (183 in the PS-WGC and 407 in the repeated WGC group) were included. PS-WGC decreased PEP (8.7% vs 19%, P = 0.001) and improved its severity (moderate and severe PEP; 2.2% vs 6.4%, P = 0.04) compared with repeated WGC. PS-WGC was associated with reduction of PEP in the multivariable model (Odds ratio 0.31, P < 0.001). The rates of difficult cannulation and overall successful biliary cannulation were not different between the two groups (66% vs 70%, P = 0.39 and 98% vs 96%, P = 0.21 in the PS-WGC and repeated WGC group, respectively).

CONCLUSIONS

Pancreatic stent placement followed by WGC reduced PEP in patients with guidewire insertion to the pancreatic duct during WGC for native papilla compared with repeated WGC.

Prophylactic efficacy of a novel method against postendoscopic papillary balloon dilation pancreatitis

OBJECTIVE

This study aimed to investigate whether a novel method including prophylactic pancreatic stent (PS) placement prevents postendoscopic papillary balloon dilation pancreatitis.

PATIENTS AND METHODS

This study enrolled 200 consecutive patients with bile duct stones measuring up to 8 mm in diameter and retrospectively recruited 113 patients undergoing ordinary endoscopic papillary balloon dilation (EPBD) without PS placement from our previous study. In the novel method, EPBD and PS placement was attempted with a guidewire left in the main pancreatic duct for patients in whom stable guidewire placement in the main pancreatic duct was possible. EST was performed for patients in whom stable guidewire placement was impossible. The incidence rate of pancreatitis was compared between the novel method and ordinary EPBD, and risk factors for pancreatitis were analyzed.

RESULTS

Of 194 patients undergoing the novel method, EPBD and EST were performed in 180 and 14 patients, respectively. Following EPBD, PS placement was successful in 177/180 (98.3%) of patients. Pancreatitis occurred in 7/194 (3.6%) of patients after the novel method and 9/113 (8.0%) of patients after ordinary EPBD. There was a trend toward lower incidence rate of pancreatitis in the novel method. Stent dislodgement by the first postoperative morning and no previous endoscopic nasobiliary drainage (ENBD) were identified as risk factors for pancreatitis after EPBD with PS placement. No previous ENBD was also identified as a risk factor for pancreatitis after ordinary EPBD.

CONCLUSION

Our novel method is likely to be superior to ordinary EPBD in preventing pancreatitis. Previous ENBD may prevent post-EPBD pancreatitis regardless of PS placement.

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.

Wire-guided cannulation over a pancreatic stent method increases the need for needle-knife precutting ın patients with difficult biliary cannulations

BACKGROUND AND AIMS

Cannulation of the major papilla can be problematic, and selective biliary cannulation may fail in up to 18% of cases. Various techniques, such as double-guidewire technique (DGWT), wire-guided cannulation over a pancreatic stent (WGC-PS), the precut endoscopic sphincterotomy (needle-knife precutting technique (NKP), and transpancreatic septostomy have been used to improve the success rate of biliary cannulation. We conducted a prospective, randomized study in order to compare the biliary cannulation success rates of DGWT and WGC-PS techniques in patients with inadvertent passage of guidewire to the pancreatic duct.

METHODS

A total of 100 patients were included in the study and randomized to DGWT (n = 50) or WGC-PS (n = 50) groups. The primary outcome was successful selective cannulation, defined as deep cannulation with selective injection of radiographic contrast material into the common bile duct within 5 minutes by DGW or WGC-PS techniques without performing precut sphincterotomy.

RESULTS

Successful selective cannulation was achieved in 45 patients in the DGWT group (90%) and in 27 patients in the WGC-PS group (54%) (P < .001). Five patients (10%) in the DGWT group and 23 (46%) in the WGC-PS group required NKP for biliary access (P < .001). The overall cannulation rate was 98% for DGWT and 98% for WGC-PS (P = 1.00).

CONCLUSIONS

In patients with unintentional passage of a guidewire into the pancreatic duct during biliary cannulation attempts, the WGC-PS technique significantly increased the need for NKP compared with DGWT.

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

Background/Aims

Recently the European Society of Gastrointestinal Endoscopy delivered guidelines on the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and on the papillary cannulation and sphincterotomy techniques at endoscopic retrograde cholangiopancreatography (ERCP). There are no data concerning current practices in Portugal. The aim of this study was to capture practice patterns of Portuguese pancreaticobiliary endoscopists with special interest in the prevention of PEP and cannulation techniques.

Methods

A written survey was distributed to all pancreaticobiliary endoscopists attending the first Portuguese meeting dedicated to ERCP in November 2016. The main outcome measures were: technique used for standard biliary cannulation, use of nonsteroidal anti-inflammatory drugs (NSAIDs) in PEP, attempting prophylactic pancreatic stenting after using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation was difficult, and use of precut as the first rescue technique when biliary cannulation was difficult.

Results

Completed surveys were collected from 28 of the 32 pancreatobiliary endoscopists attending the meeting (answer rate 87.5%). Biliary cannulation was performed using a guidewire access technique by the majority (77%), usually with a sphincterotome. When cannulation was unsuccessful, precut was the first choice for 70%. NSAIDs were administered routinely for PEP by only 54%; PGW-assisted biliary cannulation was the first choice after failed standard cannulation for a minority of them, and only 27% reported to routinely attempt insertion of a pancreatic stent. High-volume endoscopists (> 150/year) tended to use NSAIDs and to insert a stent in PGW-assisted cannulation less often than low-volume-endoscopists (50 vs. 83.3%, p < 0.01, and 40 vs. 100%, p < 0.01, respectively). Precut was started without prior formal training by more than half of the endoscopists.

Conclusions

There is a pronounced discrepancy between evidence-based guidelines and current clinical practice. This discrepancy is more pronounced in PEP prophylaxis, especially among high-volume endoscopists. Some advanced techniques in ERCP are initiated unsupervised, without any previous formal training.

Key Message

There is a significant gap between guidelines and routine clinical practice.

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.

How to Avoid Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Pancreatitis remains the most common and potentially devastating complication of endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Recent advances in prophylaxis have improved but not eliminated this problem, underscoring the importance of ongoing research toward this goal. This review aims to provide an evidence-based approach to post-ERCP pancreatitis prevention through patient selection, risk stratification, procedural technique, and multimodality prophylaxis, and discusses ongoing and future research initiatives in this important area.

Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis After Double-Guidewire Biliary Cannulation in an Average-Risk Population

OBJECTIVES

Double-guidewire cannulation (DGC) for selective biliary access has been associated with increased risk of post-ERCP pancreatitis (PEP) in patients who have had pancreatic duct (PD) contrast injection. The objective of this study was to determine whether DGC increases PEP risk in standard risk individuals when controlling for procedural aspects such as PD contrast injection.

METHODS

Consecutive adults with native papillae who underwent endoscopic retrograde cholangiopancreatography from 2009 to 2014 were retrospectively identified, and clinical data were collected.

RESULTS

There were 879 subjects who met inclusion criteria. Increased incidence of PEP was observed after DGC (18% with DGC vs 4% without DGC, P < 0.005). Additional factors associated with increased PEP risk included the following: PD contrast injection, PD wire cannulations, and biliary stent placement. The association between DGC and increased PEP risk remained significant in a multivariate model controlling for age, sex, PD contrast injection, biliary sphincterotomy, biliary stent placement, and rectal indomethacin administration (odds ratio = 2.87, 95% confidence interval = 1.23-6.36).

CONCLUSIONS

Double-guidewire cannulation is associated with increased risk of PEP when controlling for confounding variables. Prospective studies should be undertaken to assess whether prophylactic interventions reduce risk of PEP after DGC in an average-risk population.

Pancreatic stents for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis should be inserted up to the pancreatic body or tail

AIM

To investigate the location to which a pancreatic stent should be inserted to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

METHODS

Over a ten-year period at our hospital, 296 patients underwent their first ERCP procedure and had a pancreatic stent inserted; this study included 147 patients who had ERCP performed primarily for biliary investigation and had a pancreatic stent inserted to prevent PEP. We divided these patients into two groups: 131 patients with a stent inserted into the pancreatic head (head group) and 16 patients with a stent inserted up to the pancreatic body or tail (body/tail group). Patient characteristics and ERCP factors were compared between the groups.

RESULTS

Pancreatic amylase isoenzyme (p-AMY) levels in the head group were significantly higher than those in the body/tail group [138.5 (7.0-2086) vs 78.5 (5.0-1266.5), P = 0.03] [median (range)]. No cases of PEP were detected in the body/tail group [head group, 12 (9.2%)]. Of the risk factors for post-ERCP hyperamylasemia (≥ p-AMY median, 131 IU/L), procedure time ≥ 60 min [odds ratio (OR) 2.65, 95%CI: 1.17-6.02, P = 0.02) and stent insertion into the pancreatic head (OR 3.80, 95%CI: 1.12-12.9, P = 0.03) were identified as independent risk factors by multivariate analysis.

CONCLUSION

Stent insertion up to the pancreatic body or tail reduces the risk of post-ERCP hyperamylasemia and may reduce the risk of PEP.

Pursuing excellence in ERCP

The term "ERCP cannulation" returns 1,563 items in Pubmed. In 1980 there were 7 papers, and 92 were included in 2015. Any gastroenterologist knows ERCP is often a complex procedure, at times with uncertain results, that unfortunately leads every so often to lawsuits. Most issues derive from attempts at biliary cannulation, despite the improved instruments available since the days of the first sphincterotomy back in 1974. The initial priority goal of ERCP learning is a satisfactory rate of choledochal cannulation. Such rate has been somewhat arbitrarily set as at least 80% of successful biliary access.

Risk of pancreatitis after pancreatic duct guidewire placement during endoscopic retrograde cholangiopancreatography

BACKGROUND & AIMS

Advanced techniques have been developed to overcome difficult cannulation cases in endoscopic retrograde cholangiopancreatography (ERCP). Pancreatic duct guidewire placement method (PGW) is performed in difficult cannulation cases; it is possible that it places patients at risk of post-ERCP pancreatitis (PEP). The mechanism of PEP is still unclear, but pancreatic duct pressure and injury of pancreatic duct are known causes of PEP. Therefore, we hypothesized a relationship between pancreatic duct diameter and PEP and predicted that PGW would increase the risk of PEP in patients with non-dilated pancreatic ducts. This study aimed to investigate whether PGW increased the risk of PEP in patients with pancreatic duct diameter ≤ 3 mm.

METHODS

We analyzed 332 patients with pancreatic duct ≤ 3 mm who performed first time ERCP session. The primary endpoint was the rate of adverse event of PEP. We evaluated the risk of PEP in patients who had undergone PGW compared to those who had not, using the inverse probability of treatment weighting (IPTW) analysis.

RESULTS

PGW was found to be an independent risk factor for PEP by univariate analysis (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.12-5.38; p = 0.03) after IPTW in patients with pancreatic duct diameter ≤ 3 mm. Adjusted for all covariates, PGW remained an independent risk factor for PEP (OR, 3.12; 95% CI, 1.33-7.33; p = 0.01).

CONCLUSION

Our results indicate that PGW in patients with pancreatic duct diameter ≤ 3 mm increases the risk of PEP.

Biliary Obstruction: Endoscopic Approaches

Painless jaundice is a harbinger of malignant biliary obstruction, with the majority of cases due to pancreatic adenocarcinoma. Despite advances in treatment, including improved surgical techniques and neoadjuvant (preoperative) chemotherapy, long-term survival from pancreatic cancer is rare. This lack of significant improvement in outcomes is believed to be due to multiple reasons, including the advanced stage at diagnosis and lack of an adequate biomarker for screening and early detection, prior to the onset of jaundice or epigastric pain. Close attention is required to select appropriate patients for preoperative biliary decompression, and to prevent morbid complications from biliary drainage procedures, such as pancreatitis and cholangitis. Use of small caliber plastic biliary stents during endoscopic retrograde cholangiopancreatography should be minimized, as metal stents have increased area for improved bile flow and a reduced risk of adverse events during neoadjuvant therapy. Efforts are underway by translational scientists, radiologists, oncologists, surgeons, and gastroenterologists to augment lifespan for our patients and to more readily treat this deadly disease. In this review, the authors discuss the rationale and techniques of endoscopic biliary intervention, mainly focusing on malignant biliary obstruction by pancreatic cancer.