Post-ERCP biliary complications in patients with biliary type sphincter of Oddi dysfunction

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.

Endoscopic retrograde cholangiopancreatography guided interventions in the management of pancreatic cancer

Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9% in the United States. At presentation, the majority of patients have painless jaundice, pruritis, and malaise, a triad that develops secondary to obstruction, which often occurs late in the course of the disease process. The technical advancements in radiological imaging and endoscopic interventions have played a crucial role in the diagnosis, staging, and management of patients with pancreatic cancer. Endoscopic retrograde cholangiopancreatography (ERCP)-guided diagnosis (with brush cytology, serial pancreatic juice aspiration cytologic examination technique, or biliary biopsy) and therapeutic interventions such as pancreatobiliary decompression, intraductal and relief of gastric outlet obstruction play a pivotal role in the management of advanced pancreatic cancer and are increasingly used due to improved morbidity and complication rates compared to surgical management. In this review, we highlight various ERCP-guided diagnostic and therapeutic interventions for the management of pancreatic cancer.

Microbial Profiles and Risk Factors of Preexisting Biliary Infection in Patients with Therapeutic Endoscopy

Background

The bile infection may already exist before the administration of an interventional procedure, despite no clinical manifestations of cholangitis detected. Blood cultures remained negative even in more than half of the febrile cases with cholangitis. Risk factors associated with bacterial growth in bile before the intervention are not well defined. To establish the bacterial profiles isolated from the bile samples and to identify risk factors for bacterial colonization in the bile system.

Methods

Individuals who underwent endoscopic retrograde cholangiopancreatography (ERCP) interventions were enrolled. Bile samples were aspirated and were immediately transferred into a sterile tube for storage.

Results

Positive bile cultures were detected in 363 (38.0%) of 956 patients, including 322 benign diseases and 41 malignances. Of 363 positive cases, 351 (96.7%) were monoinfection and 12 (3.3%) multi-infection. Escherichia coli were the most common Gram-negative bacteria (210, 56.0%), followed by Klebsiella pneumoniae (45, 12.0%). Enterococcus faecalis represented the most common Gram-positive microorganism (19, 5.07%), while Candida albicans (11, 2.93%) were the dominant fungi. Klebsiella pneumoniae were more frequently detected in malignant diseases (P = 0.046). Age, previous ERCP history or OLT history, and CBD diameter were independent risk factors for positive cultures (P < 0.05) while preoperative jaundice drug therapy was the protective factor for bile infection (P < 0.05).

Conclusion

Monomicrobial infection was dominant among all infections, and Klebsiella pneumoniae strains were more frequently isolated from patients with malignant diseases. To effectively manage patients who are at a high risk for bile infection, a detailed diagnosis and treatment plan for each case should be prepared.