Pre-endoscopic retrograde cholangiopancreatography (ERCP) administration of rectal indomethacin in unselected patients to reduce post-ERCP pancreatitis: A systematic review and meta-analysis

Risk factors for post-endoscopic retrograde cholangiopancreatography complications in very elderly patients aged 90 years or older-No additional risk

AIM

In recent years, the majority of patients eligible for endoscopic retrograde cholangiopancreatography (ERCP) have been aged ≥75 years. We investigated ERCP safety in very elderly patients (aged ≥90 years).

METHODS

We included patients aged ≥75 years who underwent ERCP between January 2015 and December 2020. We compared background factors, comorbidities, ERCP indications, complications, and outcomes and identified risk factors for complications using binary logistic regression and inverse probability of treatment weighting with propensity scores.

RESULTS

The study included 1344 patients aged ≥75 years (137 and 1207 very elderly and elderly patients, respectively). The very elderly group had more women, less frequent diabetes, fewer antithrombotic medications, more frequent parapapillary diverticulum, less frequent post-cholecystectomy, and worse performance status. No significant differences were observed in the ERCP indications. Experienced endoscopists were likely to perform the procedure, and the procedure time was shorter for the very elderly. Complications occurred in 21 (15%) very elderly patients and 120 (10%) elderly patients, with no significant differences. The very elderly did not have an increased risk of complications but were less likely to be discharged home and had a significantly worse performance status at discharge.

CONCLUSIONS

ERCP could be safely performed in the very elderly, and age did not increase the risk of complications. Geriatr Gerontol Int 2025; 25: 54-60.

Value of indomethacin suppository for preoperative analgesia and anti-inflammation in laparoscopic appendectomy: a protocol of prospective, double-blinded, single-centre, randomised controlled trial in China

INTRODUCTION

Postoperative pain has always been a problem for patients and surgeons. Local inflammation, surgical trauma and pain in the body can cause a systemic stress response and immune imbalance, which can affect the patient's rapid recovery. Currently, most of the perioperative pain management is focused on the postoperative phase. The non-steroidal anti-inflammatory drug indomethacin suppository has antipyretic and analgesic effects. This study will evaluate the value of indomethacin suppository for analgesia and anti-inflammation before laparoscopic appendectomy (LA).

METHODS AND ANALYSIS

A single-centre, double-blinded (clinician, assessor, data entry), randomised controlled trial will be conducted in 128 adult patients undergoing LA under emergency general anaesthesia with a Visual Analogue Scale (VAS) >2. The trial was divided into two groups (n=64) using a randomised number table: group A will be given 100 mg of indomethacin suppository rectally and group B will be given 8 mg of intravenous lornoxicam. The postoperative analgesic effect, inflammatory response and incidence of postoperative adverse effects will be compared.

ETHICS AND DISSEMINATION

The study is in accordance with the Declaration of Helsinki and will be conducted in accordance with the principles of Good Clinical Practice. This trial was approved by the Ethics Committee of Beijing Luhe Hospital, Capital Medical University (2021-LHKY-123-02). We will disseminate our study findings at national and international paediatric research conferences.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2200062004).

Efficacy and safety of endoscopic retrograde cholangiopancreatography in patients over 75 years of age

Background

To investigate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly choledocholithiasis patients compared with younger groups.

Methods

This was a case-control study conducted from January 2018 to December 2020 at Fuyang People's Hospital, with 596 patients included. Patients who underwent ERCP were classified as two groups based on age stratification definitions from the National Institute of Health and the World Health Organisation: Patients <75 ages (n = 204) and patients ≥75 ages (n = 392). Demographic characteristics, details of endoscopic therapy, complications were retrospectively reviewed and compared between two groups. The subgroup was pre-formed to further explore the efficacy and safety of ERCP in the elderly population.

Results

Between patients ≥75 ages and patients <75 ages, there were no significant differences in the complete stone removal rate and a second ERCP. Intubation difficulty (odds rate [OR]: 1.723, 95% confidence interval [CI]: 1.118-2.657) and longer ERCP operation time (β = 4.314, 95% CI: 2.366-6.262) were observed in the elderly group at a higher frequency than the younger group. Elder patients were more likely to have intra-operative complications (χ2 = 18.158, P < 0.001), and post-operative complications (χ2 = 8.739, P = 0.003). In the subgroup group, ERCP was efficacious and safe in elderly patients with comorbidities.

Conclusions

ERCP may be efficaciously performed on elderly patients. However, intra-operative and post-operative complications of ECRP should also be taken into consideration when selecting therapeutic options.

Ketorolac and Predicted Severe Acute Pancreatitis: A Randomized, Controlled Clinical Trial

Objective: We evaluated the effect of ketorolac on reducing the severity of acute pancreatitis.Design and Setting: Randomized clinical trial performed in a University hospital.Participants: There were 56 adult patients, with predicted severe acute pancreatitis, randomly divided into two groups.Methods: The patients in the study group received intravenous ketorolac, 10 mg, three times daily from the time of enrollment for a maximum of 5 days, as needed, along with standard medical treatment. Primary outcome measure was the change in the serum level of high sensitive C-reactive protein (hs-CRP). Patients were also followed up in terms of hospitalization duration, need for intensive care unit (ICU), organ failure development, persistent organ failure, pancreatic necrosis, nutritional assessment, and mortality. The study continued to gather clinical follow-up information up to 4 months.Results: Serum level of hs-CRP was significantly lower in the ketorolac group compared with the control group on days 3, 4, and 5. There were no significant differences in organ failure, pseudocyst formation, acute necrotic collection, mortality, and ICU transfer between groups. Days of hospitalization were significantly lower in the study group. The feeding start time was significantly shorter in the study group with no need for tube feeding in the ketorolac group. Frequency of NPO (not per oral) was significantly lower in the ketorolac group.Conclusion: The use of ketorolac may improve feeding outcomes and shorten length of hospitalization in predicted severe acute pancreatitis.

Is the Combination of Rectal Diclofenac and Intravenous Ringer Lactate Superior to Individual Therapy for Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Prospective, Open-Label, Single-Center Randomized Trial

METHODS

This was single-center, open-label, randomized trial. Patients who were undergoing ERCP and who were at high risk for the development of PEP were selected for the study. Patients were randomized into 3 treatment groups: diclofenac suppository group, RL group, and a combination group.

RESULTS

Eight of 57 patients (14.03%) in the diclofenac group, 9 of 57 patients (15.78%) in the RL group, and 6 of 57 patients (10.52%) in the combination group developed PEP. The incidence of PEP between the three groups was not statistically significant (P = 0.70). Serum amylase level of >252 U/L had 91.3% sensitivity and 92.6% specificity for the diagnosis of PEP.

CONCLUSIONS

Post-ERCP pancreatitis is usually mild to moderate 95% times. Female sex, age younger than 50 years, a benign indication of ERCP, and low bilirubin levels have higher chances of PEP. A combination of rectal diclofenac and hydration with RL does not offer better protection for PEP, as compared with individual prophylaxis.

Endoscopic Transpapillary Gallbladder Drainage for Acute Cholecystitis

The mainstay of management of acute cholecystitis has been surgical, with percutaneous gallbladder drainage in patients deemed high risk for surgical intervention. Endoscopic management of acute cholecytitis with transpapillary and transmural drainage of the gall bladder is emerging as a viable alternative in high-risk surgical patients. In this article, we discuss the background, current status, technical challenges and strategies to overcome them, adverse events, and outcomes of endoscopic transpapillary gallbladder drainage for management of acute cholecystitis.

Endoscopic Retrograde Cholangiopancreatography-Related Complications and Their Management Strategies: A "Scoping" Literature Review

Endoscopic retrograde cholangiopancreatography (ERCP) is a well-known procedure with both diagnostic and therapeutic utilities in managing pancreaticobiliary conditions. With the advancements of endoscopic techniques, ERCP has become a relatively safe and effective procedure. However, as ERCP is increasingly being utilized for different advanced techniques, newer complications have been noticed. Post-ERCP complications are known, and mostly include pancreatitis, infection, hemorrhage, and perforation. The risks of these complications vary depending on several factors, such as patient selection, endoscopist's skills, and the difficulties involved during the procedure. This review discusses post-ERCP complications and management strategies with new and evolving concepts.

Identification and management of pancreas divisum

Introduction: Pancreas divisum is the most common congenital malformation of the pancreas with the majority asymptomatic. The etiological role, pathogenesis, clinical significance and management of pancreas divisum in pancreatic disease has not been clearly defined and our understanding is yet to be fully elucidated.Areas covered: This review describes the role of pancreas divisum in the development of pancreatic disease and the ambiguity related to it. In our attempt to offer clarity, a comprehensive search on PubMed, Ovid, Embase and Cochrane Library from inception to May 2019 was undertaken using key words "pancreas divisum", "idiopathic recurrent acute pancreatitis" and "chronic pancreatitis".Expert opinion: Current research fails to define a clear association between pancreas divisum and pancreatic disease. Though debatable, several studies do suggest a pathological role of pancreas divisum in pancreatic disease and a benefit of minor papilla therapy in the setting of acute recurrent pancreatitis. Surgical and endoscopic therapeutic modalities have not been directly compared. With the current data available, it would be imprudent to advise a definitive line of management for pancreatic disease associated with pancreas divisum and should involve a comprehensive discussion with the individual patient to define expectations before embarking on any medical and/or interventional therapy.

Nursing care of elderly patients with drug-induced severe pancreatitis by continuous closed high flow peritoneal lavage combined with continuous blood purification

AIM

To explore the nursing effect of closed high-flow peritoneal lavage combined with continuous blood purification in elderly patients with drug-induced severe pancreatitis.

METHODS

A total of 50 elderly patients with drug-induced severe acute pancreatitis who received continuous closed high flow peritoneal lavage combined with blood purification between January 2017 and January 2018 at our emergency internal medicine department were enrolled as an experimental group. Fifty elderly patients with drug-induced severe pancreatitis who received basic nursing measures only were included as a control group. The average frequency of complications, number of treatment cycles, number of cycles required for serum amylase recovery, and duration of abdominal pain in the two groups were statistically analyzed. The changes of liver and kidney function, APACHE Ⅱ, and CTSI score were also recorded and compared.

RESULTS

The average frequency of complications, number of treatment cycles, number of cycles required for serum amylase recovery, and duration of abdominal pain were significantly lower in the experimental group than in the control group (P < 0.05). The liver and kidney function of the patients in the experimental group were obviously superior to those before treatment (P < 0.05), while the difference in the control group did not reach statistical significance. The APACHE Ⅱ and CTSI scores in the experimental group were significantly lower than those in the control group (P < 0.05).

CONCLUSION

Continuous closed high-flow peritoneal lavage combined with blood purification can effectively reduce symptoms, shorten the treatment cycle, and improve prognosis in elderly patients with drug-induced severe acute pancreatitis.