Temporary prophylactic pancreatic stents: which patients need them?

Self-Administered Electroacupuncture Provides Symptomatic Relief in a Patient with Sphincter of Oddi Dysfunction: A Patient's Report

A 46-year-old woman with differentially diagnosed sphincter of Oddi dysfunction (SOD) type III is described. After two and a half years of managing the condition with a conventional medical/pharmacological approach, the patient's symptoms worsened and she sought complementary approaches, starting traditional acupuncture treatment before receiving training from a practitioner of Western medical acupuncture to self-administer electroacupuncture. The frequency and intensity of severe night-time pain attacks reduced and, additionally, self-administered manual acupuncture during pain attacks resulted in quick, lasting, complete symptomatic pain resolution. This is the first published case report using electroacupuncture in the clinical management of this condition. It shows patient-administered electroacupuncture as a low-risk well-tolerated procedure which provided effective pain relief and reduced the frequency and severity of pain attacks. Self-administered acupuncture could be considered as a potential complementary medical approach for patients with SOD type III before resorting to endoscopic SO manometry and sphincterotomy which carry significant associated risks of pancreatitis.

Risk Factors of Acute Pancreatitis in Oral Double Balloon Enteroscopy

Double balloon enteroscopy (DBE) was introduced 15 years ago. The complications of diagnostic DBE are rare, acute pancreatitis is most redoubtable one (incidence about 0.3%). Hyperamylasemia after DBE seems to be a rather common condition respectively. The most probable cause seems to be a mechanical straining of the pancreas. We tried to identify patients in a higher risk of acute pancreatitis after DBE. We investigated several laboratory markers before and after DBE (serum cathepsin B, lactoferrin, E-selectin, SPINK 1, procalcitonin, S100 proteins, alfa-1-antitrypsin, hs-CRP, malondialdehyde, serum and urine amylase and serum lipase). Serum amylase and lipase rose significantly with the maximum 4 hours after DBE. Serum cathepsin and procalcitonin decreased significantly 4 hours after DBE compared to healthy controls and patients values before DBE. Either serum amylase or lipase 4 hours after DBE did not correlate with any markers before DBE. There was a trend for an association between the number of push-and-pull cycles and procalcitonin and urine amylase 4 hours after DBE; between procalcitonin and alfa-1-antitrypsin, cathepsin and hs-CRP; and between E-selectin and malondialdehyde 4 hours after DBE. We found no laboratory markers determinative in advance those patients in a higher risk of acute pancreatitis after DBE.

Pancreatic duct guidewire placement for biliary cannulation in a single-session therapeutic ERCP

AIM: To investigate the technical success and clinical complication rate of a cannulated pancreatic duct with guidewire for biliary access.

METHODS: During a five-year study period, a total of 2843 patients were included in this retrospective analysis. Initial biliary cannulation method consisted of single-guidewire technique (SGT) for up to 5 attempts, followed by double-guidewire technique (DGT) when repeated unintentional pancreatic duct cannulation had taken place. Pre-cut papillotomy technique was reserved for when DGT had failed or no pancreatic duct cannulation had been previously achieved. Main outcome measurements were defined as biliary cannulation success and post-endoscopic retrograde cholangiopancreatography (ERCP) complication rate.

RESULTS: SGT (92.3% success rate) was characterized by statistically significant enhanced patient outcome compared to either the DGT (43.8%, P < 0.001), pre-cut failed DGT (73%, P < 0.001) or pre-cut as first step method (80.6%, P = 0.002). Pre-cut as first step method offered a statistically significantly more favorable outcome compared to the DGT (P < 0.001). The incidence of post-ERCP pancreatitis did not differ in a statistically significant manner between either method (SGT: 5.3%, DGT: 6.1%, Pre-cut failed DGT: 7.9%, Pre-cut as first step: 7.5%) or with patients’ gender.

CONCLUSION: Although DGT success rate proved not to be superior to SGT or pre-cut papillotomy, it is considered highly satisfactory in terms of safety in order to avoid the risk of a pre-cut when biliary therapy is necessary in difficult-to-cannulate cases.

Prophylaxis of post-ERCP pancreatitis: a practice survey

BACKGROUND

Prophylactic pancreatic stenting is widely used by expert biliary endoscopists to prevent post-ERCP pancreatitis (PEP); nonsteroidal anti-inflammatory drugs (NSAIDs) are thought to prevent PEP.

OBJECTIVE

To assess the use of pancreatic stenting and NSAIDs for PEP prophylaxis among endoscopists and its determinants.

DESIGN

A survey was distributed to 467 endoscopists attending a course on therapeutic digestive endoscopy.

INTERVENTION

Completed surveys were collected from 141 endoscopists performing ERCP in 29 countries (answer rate 30.2%); practices were most often located in community hospitals with an annual hospital volume of < or = 500 ERCPs (in Belgium, Spain, Italy, and France in about half of cases). For all conditions listed, including needle-knife precut, previous PEP, suspected sphincter of Oddi dysfunction, and ampullectomy, less than half of the endoscopists reported attempting prophylactic pancreatic stenting in > or = 75% of cases. Thirty (21.3%) survey respondents did not perform prophylactic pancreatic stenting in any circumstance; this was mainly ascribed to lack of experience. Measurement of PEP incidence and an annual hospital volume of > 500 ERCPs were independently associated with the use of prophylactic pancreatic stenting (P = .005 and P = .030, respectively). Most survey respondents (n = 118, 83.7%) did not use NSAIDs for PEP prophylaxis. This was mainly ascribed to lack of scientific evidence of its benefits.

MAIN OUTCOME MEASUREMENTS

Proportion of cases in which pancreatic stenting is attempted during ERCP; reasons for not using prophylactic pancreatic stenting or NSAIDs.

LIMITATIONS

Survey, not an audit of practice.

CONCLUSIONS

Despite scientific evidence of its benefits, use of prophylactic pancreatic stenting is not as widely adopted as previously thought; use of NSAIDs for PEP prophylaxis is marginal.

The safety and utility of prophylactic pancreatic duct stents in the prevention of post-ERCP pancreatitis: an analysis of practice in a single UK tertiary referral center

BACKGROUND

The use of temporary prophylactic pancreatic duct (PD) stents in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients has been shown to be effective in multiple trials. However, there are limited data on the clinical implications of PD stents and their impact on practice outside of the trial setting.

METHODS

The utility of prophylactic pancreatic stenting was evaluated in a retrospective analysis of 1,000 consecutive ERCPs performed in a single tertiary referral pancreatobiliary center over a 24-month period, based upon a predetermined protocol to identify patients at high risk of postprocedure pancreatitis.

RESULTS

One thousand procedures performed in 688 patients were studied. Sixty-one patients were considered for stent placement and stents were successfully placed in 58 cases. The overall rate of post-ERCP pancreatitis in our study population was 3.6%. The rate of pancreatitis in the stented patients was considered high at 22.4%, but the majority (69%) were classified as mild and there were no reported severe episodes. This compares to pancreatitis in the nonstented group, in whom the majority (73.9%) experienced either moderate or severe episodes.

CONCLUSION

A strategy of prophylactic PD stents in this study has eliminated severe post-ERCP pancreatitis in high-risk patients. However, the high pancreatitis rate in stented patients may represent the cost to achieve this, while stent type and size employed are likely contributing factors. To maximize the benefits of PD stenting, there is a need to identify and treat all those considered at high risk.

Sphincter of Oddi: Function, dysfunction, and its management

The most common functional disorder of the biliary tract and pancreas relates to the activity of the Sphincter of Oddi. The Sphincter of Oddi is a small smooth muscle sphincter strategically placed at the junction of the bile duct, pancreatic duct, and duodenum. The sphincter controls flow of bile and pancreatic juices into the duodenum and prevents reflux of duodenal content into the ducts. Disorder in its motility is called Sphincter of Oddi dysfunction. Clinically this presents either with recurrent abdominal biliary type pain or episodes of recurrent pancreatitis. Manometry may identify the motility abnormalities, the most clinically significant being an abnormally elevated basal pressure. The most effective treatment once an abnormal basal pressure is identified is division of the sphincter. This is associated with good long-term results.

Electrosurgery in gastrointestinal endoscopy: principles to practice

An electrosurgery generator unit is a critical piece of equipment in any therapeutic endoscopy setting. Electrosurgery generators produce high-frequency alternating electric current and differ from electrocautery units in that both cutting and coagulation effects can be achieved. This ability to cut and coagulate at the same time makes electrosurgery an ideal therapeutic tool for gastrointestinal endoscopy. Although education and familiarity with these devices are accepted as the primary avenue to the safest and most effective clinical outcomes, concise information linking the basic properties of electrosurgery directly to clinical practice is not widespread. The following are the aims of this article: (i) to relate the fundamental electrosurgical principles to commonly performed procedures such as snare polypectomy, hot biopsy, sphincterotomy, bipolar hemostasis, and argon plasma coagulation, and (ii) to provide practical suggestions for the use of these devices on the basis of an understanding of electrosurgical principles and the available clinical data.

Alcohol use and cigarette smoking as risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND & AIMS

Alcohol use and cigarette smoking are associated with various pancreatic diseases, but it is not known whether they associate with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). We performed a retrospective case-control study to determine if these activities increase the risk of PEP.

METHODS

We identified 7638 patients who had undergone ERCP in the University of Michigan Health System and applied exclusion criteria to identify 123 with PEP. We randomly selected 308 age- and sex-stratified controls (2.5-fold case sample); after applying exclusion criteria 248 remained. In a masked fashion, we collected data for alcohol use, cigarette smoking, and 5 internal control variables: suspected sphincter of Oddi dysfunction (SOD), pancreatic sphincterotomy, moderate/difficult cannulation, 2 or more pancreatic injections, and pancreatic stent placement.

RESULTS

The univariate model showed an increased frequency of PEP in current drinkers (P < .001), former drinkers (P < .001), and former smokers (P < .001), as well as patients who were suspected of having SOD (P < .001), had undergone pancreatic sphincterotomy (P < .001), had a moderate/difficult cannulation (P = .001), and/or had 2 or more pancreatic injections (P = .007). The frequency of PEP was reduced in current smokers (P < .001). The multivariate model showed that the only independent significant predictors of PEP were current drinking (odds ratio [OR], 4.70; 95% confidence interval [CI], 2.60-8.50; P < .0001), former cigarette smoking (OR, 3.29; 95% CI, 1.28-8.44; P < .013), suspected SOD (OR, 3.69; 95% CI, 1.94-7.02; P < .001), and pancreatic sphincterotomy (OR, 5.91; 95% CI, 2.04-17.14; P = .001).

CONCLUSIONS

Current alcohol use and potentially former cigarette smoking are new risk factors for PEP. It is important to consider these variables in designing PEP prevention trials.