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Jaber F, Salahat AJ, Alsakarneh S, Alsharaeh T, Jaber M, Gangwani MK, Mohamed I, Aldiabat M, Kilani Y, ALi H, Ghoz H. Combination of Somatostatin and Rectal Nonsteroidal Anti-Inflammatory Drugs for Prevention of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis in High-Risk Patients: A Meta-Analysis of Randomized Controlled Trials. Am J Ther 2024; 31:e628-e633. [PMID: 39292849 DOI: 10.1097/mjt.0000000000001734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2024]
Affiliation(s)
- Fouad Jaber
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO
| | - Ahmed-Jordan Salahat
- Department of Medicine, The University of Jordan, Faculty of Medicine, Amman, Jordan
| | - Saqr Alsakarneh
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO
| | - Tala Alsharaeh
- Department of Medicine, The University of Jordan, Faculty of Medicine, Amman, Jordan
| | - Mohammad Jaber
- Faculty of Medicine, Al-Azhar University, Gaza, Palestine
| | | | - Islam Mohamed
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO
| | - Mohammad Aldiabat
- Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO
- Department of Epidemiology, Harvard School of Public Health, Boston, MA
| | - Yassine Kilani
- Department of Internal Medicine, NYC Health + Hospitals, Lincoln - Weill Cornell Medical College, Bronx, NY
| | - Hassam ALi
- Department of Gastroenterology, ECU Health Medical Center, Greenville, NC
| | - Hassan Ghoz
- Division of Gastroenterology and Hepatology, University of Missouri Kansas City, Kansas City, MO
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Zuo J, Li H, Zhang S, Li P. Nonsteroidal Anti-inflammatory Drugs for the Prevention of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis. Dig Dis Sci 2024; 69:3134-3146. [PMID: 39102041 DOI: 10.1007/s10620-024-08565-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/11/2024] [Indexed: 08/06/2024]
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remains the most frequent and severe complication following ERCP, elevating both patient suffering and healthcare costs, and posing challenges to the advancement of ERCP techniques. Empirical evidence supports the prophylactic use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the prevention of PEP, especially in high-risk populations, as endorsed by both the American Society for Gastrointestinal Endoscopy (ASGE) and the European Society for Gastrointestinal Endoscopy (ESGE). However, the prophylactic efficacy of NSAIDs in average-risk individuals, alongside the ideal drug selection, dosing, and timing of NSAID administration, remains to be elucidated. Furthermore, the synergistic preventive potential of NSAIDs when integrated with other interventions, such as hydration, pancreatic stenting, somatostatin administration, sublingual nitrate application, and epinephrine, warrants further clarification. In this paper, we conduct an exhaustive review of the prophylactic effect and clinical administration of NSAIDs for PEP. We comprehensively synthesize findings from clinical trials investigating NSAIDs, both in monotherapy and combination regimens, for PEP prevention. Additionally, we scrutinize the current landscape of NSAID usage in clinical practice and evaluate their cost-effectiveness. Future research should concentrate on refining NSAID prophylaxis strategies for PEP in patients at different risk levels, while also enhancing adherence to clinical guidelines and alleviating the issue of NSAID cost inflation.
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Affiliation(s)
- Jiaxuan Zuo
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, 95, Yongan Road, Xicheng District, Beijing, 100050, China
| | - Hengcun Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, 95, Yongan Road, Xicheng District, Beijing, 100050, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, 95, Yongan Road, Xicheng District, Beijing, 100050, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, 95, Yongan Road, Xicheng District, Beijing, 100050, China.
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Bai B, Wang S, Du Y, Li M, Huang Q, Liu S, Zhang C, Fang Y, Chen X, Hong J, Li Y, Xu Z, Liu X, Hong R, Bao J, Mei Q. Indomethacin Does Not Reduce Post-ERCP Pancreatitis in High-Risk Patients Receiving Pancreatic Stenting. Dig Dis Sci 2024; 69:3442-3449. [PMID: 39009916 DOI: 10.1007/s10620-024-08542-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 06/20/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Rectal indomethacin reduces pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). However, there is insufficient evidence regarding its added benefits in patients already receiving prophylactic pancreatic stenting. Our goal was to evaluate the impact of indomethacin in high-risk patients undergoing pancreatic stenting. METHODS A cohort study was conducted on all patients who underwent the rescue cannulation technique for challenging bile duct cannulation (selected high-risk patients). Patients were split into two groups based on the prophylaxis method for post-ERCP pancreatitis (PEP): one receiving a combination of indomethacin and pancreatic stenting, while the other received pancreatic stenting alone. Comparative analyses were carried out on PEP, hyperamylasemia, gastrointestinal bleeding, and postoperative hospital stay among post-ERCP pancreatitis patients. RESULTS Between November 2017 and May 2023, a total of 607 patients with native papillae were enrolled, with 140 grouped into the indomethacin plus stent group and 467 into the stent alone group. The overall PEP rate was 4.4% in the entire cohort, with no statistical differences observed between the groups in terms of PEP rates (P = 0.407), mild PEP (P = 0.340), moderate to severe PEP (P = 1.000), hyperamylasemia (P = 0.543), gastrointestinal bleeding (P = 0.392), and postoperative hospital stay (P = 0.521). Furthermore, sensitivity analysis using multivariable analysis also validated these findings. CONCLUSIONS Indomethacin did not reduce the incidence or severity of PEP in high-risk patients who routinely received prophylactic pancreatic stent placement. Therefore, the additional administration of rectal indomethacin to further mitigate PEP appears to be not necessary.
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Affiliation(s)
- Bingqing Bai
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Shaofei Wang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
- Department of Gastroenterology, Suzhou First People's Hospital, Suzhou, 234000, Anhui, China
| | - Yemei Du
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
- Department of Gastroenterology, Xuancheng People's Hospital, Xuancheng, 242000, Anhui, China
| | - Mengwen Li
- Department of Gastroenterology, Fuyang People's Hospital, Fuyang, 236012, Anhui, China
| | - Qiming Huang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Sisi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Chenyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Yuanyuan Fang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Xinwen Chen
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Jianglong Hong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Yang Li
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Zhangwei Xu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Xiaochang Liu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Rutao Hong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Junjun Bao
- Department of Endoscopy, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Qiao Mei
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China.
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Kant K, Ahmed Z, Dama R, Karunakaran M, Arora P, Rebala P, Rao GV. Does perioperative hydrocortisone or indomethacin improve pancreatoduodenectomy outcomes? A triple arm, randomized placebo-controlled trial. Ann Hepatobiliary Pancreat Surg 2024; 28:350-357. [PMID: 38679455 PMCID: PMC11341883 DOI: 10.14701/ahbps.24-021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/14/2024] [Accepted: 04/02/2024] [Indexed: 05/01/2024] Open
Abstract
Backgrounds/Aims This trial evaluated whether anti-inflammatory agents hydrocortisone (H) and indomethacin (I) could reduce major complications after pancreatoduodenectomy (PD). Methods Between June 2018 and June 2020, 105 patients undergoing PD with > 40% of acini on the intraoperative frozen section were randomized into three groups (35 patients per group): 1) intravenous H 100 mg 8 hourly, 2) rectal I suppository 100 mg 12 hourly, and 3) placebo (P) from postoperative day (POD) 0-2. Participants, investigators, and outcome assessors were blinded. The primary outcome was major complications (Clavien-Dindo grades 3-5). Secondary outcomes were overall complications (Clavien-Dindo grades 1-5), Clinically relevant postoperative pancreatic fistula (CR-POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), surgical site infections (SSI), length of stay, POD-3 serum amylase, readmission rate, and mortality. Results Major complications were comparable (8.6%, 5.7%, and 8.6% in groups H, I, and P, respectively). However, overall complications were significantly lower in group H than in group P (45.7% vs. 80.0%, p = 0.006). CR-POPF (14.3% vs. 25.7%, p = 0.371), PPH (8.6% vs. 14.3%, p = 0.710), DGE (8.6% vs. 22.9%, p = 0.188), and SSI (14.3% vs. 25.7%, p = 0.371) were comparable between groups H and P. Major complications and overall complications in group I were 5.7% and 60.0%, respectively, which were comparable to those in groups P and H. CR-POPF rates in groups H, I, and P were 14.3%, 17.1%, and 25.7%, respectively, which was comparable. Conclusions H and I did not decrease major complications in PD.
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Affiliation(s)
- Kislay Kant
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Zeeshan Ahmed
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rohit Dama
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Monish Karunakaran
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Prateek Arora
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Pradeep Rebala
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Guduru Venkat Rao
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Janssens LP, Yamparala A, Martin J, O'Meara J, Harmsen WS, Sathi T, Lemke E, Abu Dayyeh BK, Bofill-Garcia A, Petersen BT, Storm AC, Topazian M, Vargas EJ, Chandrasekhara V, Law RJ. Incidence of Post-ERCP Pancreatitis in Patients Receiving Rectal Indomethacin vs. Compounded Rectal Diclofenac Prophylaxis. Dig Dis Sci 2024:10.1007/s10620-024-08604-5. [PMID: 39215866 DOI: 10.1007/s10620-024-08604-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND AIMS Endoscopic retrograde cholangiopancreatography (ERCP) carries a 3-15% risk of post-ERCP pancreatitis (PEP). Rectal indomethacin reduces the risk of PEP, but its cost has increased more than 20-fold over the past decade. Rectal diclofenac is also used to prevent PEP but is not commercially available in the United States. The aim of this study is to compare the incidence of PEP after administration of commercially available rectal indomethacin versus compounded rectal diclofenac and assess financial implications. METHODS ERCP cases at our institution with administration of 100 mg rectal indomethacin or 100 mg compounded rectal diclofenac between May 2018 and January 2022 were retrospectively reviewed. The incidence and severity of PEP was compared between the indomethacin (n = 728) and diclofenac (n = 304) groups. Risk factors (young age, female sex, history of pancreatitis or PEP, sphincterotomy during procedure, pancreatic indication, trainee involvement) and protective factors (prior sphincterotomy, pancreatic duct stenting) for PEP were compared between groups. RESULTS 60 patients (8.2%) in the rectal indomethacin group and 25 patients (8.2%) in the compounded rectal diclofenac group developed PEP, resulting in moderate or severe PEP in 9 (15.0%) and 2 (8.0%) patients, respectively. The compounded rectal diclofenac group had more trainee involvement (46.1% vs. 32.8%, p = 0.0001) and more prior sphincterotomy cases (15.8% vs. 10.6%, p = 0.0193) compared to the rectal indomethacin group; no statistically significant differences were observed in all other risk and protective factors. Following switch to compounded rectal diclofenac, institutional annual cost savings amounted to $441,460.62 and patient charge decreased 45-fold. CONCLUSION This retrospective single-center real-world analysis showed similar efficacy of rectal indomethacin and compounded rectal diclofenac in preventing PEP but demonstrates substantial cost savings after switching to compounded rectal diclofenac.
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Affiliation(s)
- Laurens P Janssens
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Aishwarya Yamparala
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John Martin
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John O'Meara
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Thanmay Sathi
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elizabeth Lemke
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Aliana Bofill-Garcia
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Bret T Petersen
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mark Topazian
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Eric J Vargas
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ryan J Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Kotha R, Saad-Omer SI, Singh S, Olayinka OT, Orelus J, Nisar MR, Nassar ST. Efficacy of Diclofenac and Indomethacin for Prevention of Post-Endoscopic Cholangiopancreatography (ERCP) Pancreatitis: A Systematic Review. Cureus 2024; 16:e66386. [PMID: 39246923 PMCID: PMC11379097 DOI: 10.7759/cureus.66386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 08/07/2024] [Indexed: 09/10/2024] Open
Abstract
Endoscopic cholangiopancreatography (ERCP) is a widely used diagnostic and therapeutic tool for pancreaticobiliary conditions. One of its major complications is pancreatitis. This study aims to understand the incidence of post-ERCP pancreatitis after using rectal diclofenac and Indomethacin as prophylactic measures. We retrieved 2870 articles from the PubMed, ScienceDirect, and Google Scholar databases. Using the Medical Subject Headings (MeSH) strategy in PubMed, we chose research articles published in the last five years. Exclusion criteria included paid full-text articles, abstracts, letters to editors, patients not undergoing ERCP, ages more than 45 years, animal studies, and non-English studies. The 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) criteria were used in the design of our systematic reviews. It was found that the medical world is still debating whether rectal diclofenac and Indomethacin are beneficial in avoiding post-ERCP pancreatitis (PEP). Rectal diclofenac is used. Although its effectiveness is debated due to mixed findings and concerns about certain outcomes, it is also considered beneficial in specific circumstances, such as before ERCP. Studies on rectal Indomethacin also yield contradictory results; while some emphasize the drug's large reduction in PEP incidence, especially in low-risk people, others question its efficacy. We need further studies to clarify the remaining uncertainties.
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Affiliation(s)
- Rudrani Kotha
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sabaa I Saad-Omer
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Shivani Singh
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Oluwatoba T Olayinka
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jaslin Orelus
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mah Rukh Nisar
- Neurology/Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sondos T Nassar
- Medicine and Surgery, Jordan University of Science and Technology, Amman, JOR
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Yared RA, Chen CC, Vandorpe A, Arvanitakis M, Delhaye M, Viesca MFY, Huberty V, Blero D, Toussaint E, Hittelet A, Verset D, Margos W, Le Moine O, Njimi H, Liao WC, Devière J, Lemmers A. Intravenous Hemin, a potential heme oxygenase-1 activator, does not protect from post-ERCP acute pancreatitis in humans: Results of a randomized multicentric multinational placebo-controlled trial. Pancreatology 2024; 24:363-369. [PMID: 38431445 DOI: 10.1016/j.pan.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 02/06/2024] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Hemin, a heme oxygenase 1 activator has shown efficacy in the prevention and treatment of acute pancreatitis in mouse models. We conducted a randomized controlled trial (RCT) to assess the protective effect of Hemin administration to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in patients at risk. METHODS In this multicenter, multinational, placebo-controlled, double-blind RCT, we assigned patients at risk for PEP to receive a single intravenous dose of Hemin (4 mg/kg) or placebo immediately after ERCP. Patients were considered to be at risk on the basis of validated patient- and/or procedure-related risk factors. Neither rectal NSAIDs nor pancreatic stent insertion were allowed in randomized patients. The primary outcome was the incidence of PEP. Secondary outcomes included lipase elevation, mortality, safety, and length of stay. RESULTS A total of 282 of the 294 randomized patients had complete follow-up. Groups were similar in terms of clinical, laboratory, and technical risk factors for PEP. PEP occurred in 16 of 142 patients (11.3%) in the Hemin group and in 20 of 140 patients (14.3%) in the placebo group (p = 0.48). Incidence of severe PEP reached 0.7% and 4.3% in the Hemin and placebo groups, respectively (p = 0.07). Significant lipase elevation after ERCP did not differ between groups. Length of hospital stay, mortality and severe adverse events rates were similar between groups. CONCLUSION We failed to detect large improvements in PEP rate among participants at risk for PEP who received IV hemin immediately after the procedure compared to placebo. TRIAL REGISTRATION NUMBER ClinicalTrials.gov number, NCT01855841).
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Affiliation(s)
- Rawad A Yared
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Chieh-Chang Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taiwan
| | - Astrid Vandorpe
- Pharmacy, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles (ULB) Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Myriam Delhaye
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Michael Fernandez Y Viesca
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Vincent Huberty
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Daniel Blero
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium; Department of Gastroenterology, CHU Charleroi, Charleroi, Belgium
| | - Emmanuel Toussaint
- Department of Gastroenterology, CHU Charleroi, Charleroi, Belgium; CHU Brugmann, Department of Gastroenterology, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Axel Hittelet
- Department of Gastroenterology, Hôpital Ambroise Paré, Mons, Belgium
| | - Didier Verset
- Department of Gastroenterology, CH Jolimont, La Louvière, Belgium
| | - Walter Margos
- Department of Gastroenterology, CH Jolimont, La Louvière, Belgium
| | - Olivier Le Moine
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Hassane Njimi
- Intensive Care Unit, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles (ULB) Brussels, Belgium
| | - Wei-Chih Liao
- Department of Internal Medicine, National Taiwan University Hospital, Taiwan
| | - Jacques Devière
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Arnaud Lemmers
- Department of Gastroenterology and Hepatopancreatology, Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
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8
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Rojas-Victoria EJ, Hernández-Ruiz SI, García-Perdomo HA. Effectiveness of the pharmacological therapy to prevent post ERCP acute pancreatitis: a network meta-analysis. Expert Rev Gastroenterol Hepatol 2024; 18:203-215. [PMID: 38725175 DOI: 10.1080/17474124.2024.2345640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 04/17/2024] [Indexed: 05/24/2024]
Abstract
OBJECTIVE To determine the effectiveness of the different pharmacological agents in preventing post-ERCP acute pancreatitis. METHODS We included clinical trials of pharmacological interventions for prophylaxis of acute post-ERCP pancreatitis. The event evaluated was acute pancreatitis. We conducted a search strategy in MEDLINE (OVID), EMBASE, and Cochrane Central Register of Controlled Trials from inception to nowadays. We reported the information in terms of relative risks (RR) with a 95% confidence interval. We assessed the heterogeneity using the I2 test. RESULTS We included 84 studies for analysis (30,463 patients). The mean age was 59.3 years (SD ± 7.01). Heterogeneity between studies was low (I2 = 34.4%) with no inconsistencies (p = 0.2567). Post ERCP pancreatitis was less in prophylaxis with NSAIDs (RR 0.65 95% CI [0.52 to 0.80]), aggressive hydration with Lactate Ringer (RR 0.32 95% CI [0.12-0.86]), NSAIDs + isosorbide dinitrate (RR 0.28 95% CI [0.11-0.71]) and somatostatin and analogues (RR 0.54 [0.43 to 0.68]) compared with placebo. CONCLUSIONS NSAIDs, the Combination of NSAIDs + isosorbide dinitrate, somatostatin and analogues, and aggressive hydration with lactate ringer are pharmacological strategies that can prevent post-ERCP pancreatitis when compared to placebo. More clinical trials are required to determine the effectiveness of these drugs.
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Affiliation(s)
| | | | - Herney Andrés García-Perdomo
- Division of Urology/Urooncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
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Liu KJ, Hu Y, Guo SB. Effect of rectal indomethacin on the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography for choledocholithiasis: a prospective randomized clinical trial. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:20-208. [PMID: 37982566 DOI: 10.17235/reed.2023.9899/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
BACKGROUND AND AIM the aim of this study was to evaluate the efficacy and safety of rectal indomethacin for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in patients with common bile duct (CBD) stones. METHODS a total of 167 patients undergoing ERCP between November 2019 and November 2022 for CBD stones in the First Affiliated Hospital of Dalian Medical University were prospectively analyzed. The patients were divided into an indomethacin group (n = 58) and a control group (n = 109). The primary endpoint was the percent of patients who experienced PEP. RESULTS PEP was observed in a total of 26 patients (15.57 %); four patients (6.90 %) in the indomethacin group and 22 (20.18 %) in the control group (p = 0.042). Mild, moderate and severe PEP was observed in three (5.17 %), one (1.72 %) and zero patients, respectively, in the indomethacin group, and in eleven (10.09 %), nine (8.26 %) and two (1.83 %) patients, respectively, in the control group. There was one case (0.92 %) of death due to PEP in the control group. No cases of moderate or severe bleeding were observed in either group. CONCLUSIONS rectal indomethacin is an effective and safe method to prevent PEP for patients with CBD stones undergoing ERCP.
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Affiliation(s)
- Kai-Ji Liu
- Gastroenterology, The Fifth Affiliated Hospital of Southern Medical University
| | - Yang Hu
- Gastroenterology, The First Affiliated Hospital of Dalian Medical University
| | - Shi-Bin Guo
- Gastroenterology, The First Affiliated Hospital of Dalian Medical University, China
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10
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Tenner S, Vege SS, Sheth SG, Sauer B, Yang A, Conwell DL, Yadlapati RH, Gardner TB. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol 2024; 119:419-437. [PMID: 38857482 DOI: 10.14309/ajg.0000000000002645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/08/2023] [Indexed: 06/12/2024]
Abstract
Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.
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Affiliation(s)
- Scott Tenner
- State University of New York, Health Sciences Center, Brooklyn, New York, USA
| | | | - Sunil G Sheth
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Bryan Sauer
- University of Virginia, Charlottesville, Virginia, USA
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11
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El Kurdi B, Imam Z, Abonofal A, Babar S, Shah P, Pannala R, Papachristou G, Echavarria J, Pisipati S, Jahangir S, Rajalingamgari P, Chang YHH, Singh VP. NSAIDs do not reduce severity among post-ERCP pancreatitis patients. Pancreatology 2024; 24:14-23. [PMID: 37981523 PMCID: PMC11298787 DOI: 10.1016/j.pan.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/05/2023] [Accepted: 11/01/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE Non-steroidal anti-inflammatory drugs (NSAIDs) are the most studied chemoprophylaxis for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). While previous systematic reviews have shown NSAIDs reduce PEP, their impact on moderate to severe PEP (MSPEP) is unclear. We conducted a systematic review and meta-analysis to understand the impact of NSAIDs on MSPEP among patients who developed PEP. We later surveyed physicians' understanding of that impact. DESIGN A systematic search for randomized trials using NSAIDs for PEP prevention was conducted. Pooled-prevalence and Odds-ratio of PEP, MSPEP were compared between treated vs. control groups. Analysis was performed using R software. Random-effects model was used for all variables. Physicians were surveyed via email before and after reviewing our results. RESULTS 7688 patients in 25 trials were included. PEP was significantly reduced to 0.598 (95%CI, 0.47-0.76) in the NSAIDs group. Overall burden of MSPEP was reduced among all patients undergoing ERCP: OR 0.59 (95%CI, 0.42-0.83). However, NSAIDs didn't affect the proportion of MSPEP among those who developed PEP (p = 0.658). Rectal Indomethacin and diclofenac reduced PEP but not MSPEP. Efficacy didn't vary by risk, timing of administration, or bias-risk. Survey revealed a change in the impression of the effect of NSAIDs on MSPEP after reviewing our results. CONCLUSIONS Rectal diclofenac or indomethacin before or after ERCP reduce the overall burden of MSPEP by reducing the pool of PEP from which it can arise. However, the proportion of MSPEP among patients who developed PEP is unaffected. Therefore, NSAIDs prevent initiation of PEP, but do not affect severity among those that develop PEP. Alternative modalities are needed to reduce MSPEP among patients who develop PEP.
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Affiliation(s)
- Bara El Kurdi
- Department of Internal Medicine East Tennessee State University, Johnson City, TN, USA; Division of Gastroenterology and Hepatology, University of Texas Health at San Antonio, TX, USA.
| | - Zaid Imam
- Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Abdulrahman Abonofal
- Department of Internal Medicine East Tennessee State University, Johnson City, TN, USA
| | - Sumbal Babar
- Department of Internal Medicine East Tennessee State University, Johnson City, TN, USA
| | - Pir Shah
- Division of Gastroenterology and Hepatology, University of Texas Health at San Antonio, TX, USA
| | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Georgios Papachristou
- Division of Gastroenterology and Hepatology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Juan Echavarria
- Division of Gastroenterology and Hepatology, University of Texas Health at San Antonio, TX, USA
| | - Sailaja Pisipati
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Sarah Jahangir
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Prasad Rajalingamgari
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Yu-Hui H Chang
- Department of Biostatistics, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Vijay P Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ, USA.
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12
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Thompson DA, Tsaava T, Rishi A, George SJ, Hepler TD, Hide D, Pavlov VA, Brines M, Chavan SS, Tracey KJ. Galantamine ameliorates experimental pancreatitis. Mol Med 2023; 29:149. [PMID: 37907853 PMCID: PMC10617083 DOI: 10.1186/s10020-023-00746-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/19/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Acute pancreatitis is a common and serious inflammatory condition currently lacking disease modifying therapy. The cholinergic anti-inflammatory pathway (CAP) is a potent protective anti-inflammatory response activated by vagus nerve-dependent α7 nicotinic acetylcholine receptor (α7nAChR) signaling using splenic CD4+ T cells as an intermediate. Activating the CAP ameliorates experimental acute pancreatitis. Galantamine is an acetylcholinesterase inhibitor (AChEI) which amplifies the CAP via modulation of central muscarinic ACh receptors (mAChRs). However, as mAChRs also activate pancreatitis, it is currently unknown whether galantamine would be beneficial in acute pancreatitis. METHODS The effect of galantamine (1-6 mg/kg-body weight) on caerulein-induced acute pancreatitis was evaluated in mice. Two hours following 6 hourly doses of caerulein (50 µg/kg-body weight), organ and serum analyses were performed with accompanying pancreatic histology. Experiments utilizing vagotomy, gene knock out (KO) technology and the use of nAChR antagonists were also performed. RESULTS Galantamine attenuated pancreatic histologic injury which was mirrored by a reduction in serum amylase and pancreatic inflammatory cytokines and an increase the anti-inflammatory cytokine IL-10 in the serum. These beneficial effects were not altered by bilateral subdiaphragmatic vagotomy, KO of either choline acetyltransferase+ T cells or α7nAChR, or administration of the nAChR ganglionic blocker mecamylamine or the more selective α7nAChR antagonist methyllycaconitine. CONCLUSION Galantamine improves acute pancreatitis via a mechanism which does not involve previously established physiological and molecular components of the CAP. As galantamine is an approved drug in widespread clinical use with an excellent safety record, our findings are of interest for further evaluating the potential benefits of this drug in patients with acute pancreatitis.
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Affiliation(s)
- Dane A Thompson
- Laboratory of Biomedical Sciences, Institute for Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, 11030, USA
- The Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY, USA
- Department of Surgery, Northshore University Hospital, Northwell Health, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Tea Tsaava
- Laboratory of Biomedical Sciences, Institute for Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, 11030, USA
| | - Arvind Rishi
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Sam J George
- Laboratory of Biomedical Sciences, Institute for Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, 11030, USA
| | - Tyler D Hepler
- Laboratory of Biomedical Sciences, Institute for Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, 11030, USA
| | - Daniel Hide
- Laboratory of Biomedical Sciences, Institute for Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, 11030, USA
| | - Valentin A Pavlov
- Laboratory of Biomedical Sciences, Institute for Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, 11030, USA
- The Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY, USA
| | - Michael Brines
- Laboratory of Biomedical Sciences, Institute for Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, 11030, USA
| | - Sangeeta S Chavan
- Laboratory of Biomedical Sciences, Institute for Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, 11030, USA.
- The Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA.
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY, USA.
| | - Kevin J Tracey
- Laboratory of Biomedical Sciences, Institute for Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, 11030, USA.
- The Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA.
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY, USA.
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13
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Wu Z, Xiao G, Wang G, Xiong L, Qiu P, Tan S. Effects of Somatostatin and Indomethacin Mono or Combination Therapy on High-risk Hyperamylasemia and Post-pancreatitis Endoscopic Retrograde Cholangiopancreatography Patients: A Randomized Study. Surg Laparosc Endosc Percutan Tech 2023; 33:474-479. [PMID: 37523580 PMCID: PMC10545056 DOI: 10.1097/sle.0000000000001202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/17/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive technique widely used to diagnose and treat pancreatic and biliary diseases; however, it is linked with imminent hyperamylasemia and post-ERCP pancreatitis (PEP). Somatostatin and indomethacin are the classic recommended drugs used for PEP prevention. OBJECTIVE To elucidate the effects of somatostatin and indomethacin mono or in combination to prevent hyperamylasemia and PEP in high-risk individuals. METHODS Altogether 1458 patients who underwent ERCP in our hospital from January 2016 to May 2022 were included in this investigation and categorized into 4 groups based on the treatment regimen: placebo, indomethacin, somatostatin, and indomethacin + somatostatin. The pre operation and post operation (at 6, 12, and 24 h) hospitalization cost, length of stay, the occurrence of hyperamylasemia and PEP, levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), IL-8, and VAS pain score were determined in the 4 groups. In all the groups, VAS and IL-6, TNF-α, and IL-8 levels substantially increased in the pretreatment and decreased sequentially from 6 to 24 h post operation. The individuals in the indomethacin revealed substantially reduced hyperamylasemia, VAS, and levels of IL-6, TNF-α, and IL-8, 6 h post operation, whereas the hospitalization fee, length of stay, PEP incidence, VAS, levels of IL-6, TNF-α, and IL-8, 12 and 24 h post operation were not statistically important in comparison with the individuals who received placebo therapy. The somatostatin and the indomethacin + somatostatin groups indicated markedly alleviated hospitalization fee, length of stay, the occurrence of hyperamylasemia and PEP, VAS, and the levels of IL-6, TNF-α, and IL-8 at 6, 12, and 24 h post operation compared with the placebo cohort. Furthermore, compared with the indomethacin group, the above-determined factors notably reduced at 6, 12, and 24 h post operation in somatostatin and indomethacin + somatostatin groups. It was also observed that the indomethacin + somatostatin group has substantially decreased the occurrence of hyperamylasemia, VAS score, and levels of IL-6, TNF-α, and IL-8, 6 hours post operation, while at 12 and 24 h post operation, the hospitalization fee, length of stay and incidence of PEP, VAS, levels of IL-6, TNF-α, and IL-8 were not statistically important compared with the somatostatin group. It is also worth noting that the side effects of both drugs are rare and mild. RESULTS For high-risk PEP patients, indomethacin and somatostatin can efficiently alleviate post-operative hyperamylasemia and improve their life standard within 6 hours and 24 hours, respectively. Indomethacin is suitable for individuals who underwent simple, short-duration ERCP with expected mild post-operative abdominal pain, whereas somatostatin is given to patients with complicated, long-duration ERCP and expected severe post-operative abdominal pain. Their combinational therapy produces a synergistic effect and can reduce the incidence of hyperamylasemia, thereby improving patients' quality of life within 6 h and is also effective against individuals who received a more complicated, longer-duration ERCP and were expected to have severer and longer post-operative abdominal pain.
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Affiliation(s)
- Zaoxuan Wu
- Department of Digestive Internal Medicine, Southern Medical University Pingxiang Hospital, Pingxiang, People’s Republic of China
| | - Gui Xiao
- Department of International School of Nursing, Hainan Medical University, Haikou, People’s Republic of China
| | - Guiliang Wang
- Department of Digestive Internal Medicine, Southern Medical University Pingxiang Hospital, Pingxiang, People’s Republic of China
- Department of Pathophysiology, Laboratory of Shock, Xiangya School of Medicine, Central South University, Changsha, Hunan, People’s Republic of China
| | - Liumei Xiong
- Department of Digestive Internal Medicine, Southern Medical University Pingxiang Hospital, Pingxiang, People’s Republic of China
| | - Ping Qiu
- Department of Digestive Internal Medicine, Southern Medical University Pingxiang Hospital, Pingxiang, People’s Republic of China
| | - Sipin Tan
- Department of Pathophysiology, Laboratory of Shock, Xiangya School of Medicine, Central South University, Changsha, Hunan, People’s Republic of China
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14
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Akshintala VS, Kanthasamy K, Bhullar FA, Sperna Weiland CJ, Kamal A, Kochar B, Gurakar M, Ngamruengphong S, Kumbhari V, Brewer-Gutierrez OI, Kalloo AN, Khashab MA, van Geenen EJM, Singh VK. Incidence, severity, and mortality of post-ERCP pancreatitis: an updated systematic review and meta-analysis of 145 randomized controlled trials. Gastrointest Endosc 2023; 98:1-6.e12. [PMID: 37004815 DOI: 10.1016/j.gie.2023.03.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 03/01/2023] [Accepted: 03/21/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND AND AIMS The incidence, severity, and mortality of post-ERCP pancreatitis (PEP) largely remain unknown with changing trends in ERCP use, indication, and techniques. We sought to determine the incidence, severity, and mortality of PEP in consecutive and high-risk patients based on a systemic review and meta-analysis of patients in placebo and no-stent arms of randomized control trials (RCTs). METHODS The MEDLINE, Embase, and Cochrane databases were searched from the inception of each database to June 2022 to identify full-text RCTs evaluating PEP prophylaxes. The incidence, severity, and mortality of PEP from the placebo or no-stent arms of RCTs were recorded for consecutive and high-risk patients. A random-effects meta-analysis for a proportions model was used to calculate PEP incidence, severity, and mortality. RESULTS One hundred forty-five RCTs were found with 19,038 patients in the placebo or no-stent arms. The overall cumulative incidence of PEP was 10.2% (95% confidence interval [CI], 9.3-11.3), predominantly among the academic centers conducting such RCTs. The cumulative incidences of severe PEP and mortality were .5% (95% CI, .3-.7) and .2% (95% CI, .08-.3), respectively, across 91 RCTs with 14,441 patients. The cumulative incidences of PEP and severe PEP were 14.1% (95% CI, 11.5-17.2) and .8% (95% CI, .4-1.6), respectively, with a mortality rate of .2% (95% CI, 0-.3) across 35 RCTs with 3733 patients at high risk of PEP. The overall trend for the incidence of PEP among patients randomized to placebo or no-stent arms of RCTs has remained unchanged from 1977 to 2022 (P = .48). CONCLUSIONS The overall incidence of PEP is 10.2% but is 14.1% among high-risk patients based on this systematic review of placebo or no-stent arms of 145 RCTs; this rate has not changed between 1977 and 2022. Severe PEP and mortality from PEP are relatively uncommon.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Kavin Kanthasamy
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Furqan A Bhullar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Ayesha Kamal
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Merve Gurakar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Anthony N Kalloo
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Erwin-Jan M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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15
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Gordon SR. Prevention of post-endscopic retrograde cholangiopancreatography pancreatitis: Do we practice what we preach? Gastrointest Endosc 2023; 97:1067-1069. [PMID: 37208040 DOI: 10.1016/j.gie.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 05/21/2023]
Affiliation(s)
- Stuart R Gordon
- Section of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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16
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Agarwal A, Mahapatra SJ, Sethia R, Agarwal S, Elhence A, Mohta S, Gunjan D, Garg PK. Universal prophylactic rectal nonsteroidal anti-inflammatory drugs with a policy of selective pancreatic duct stenting significantly reduce post-endoscopic retrograde cholangiopancreatography pancreatitis. Indian J Gastroenterol 2023; 42:370-378. [PMID: 37160838 DOI: 10.1007/s12664-023-01354-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 02/03/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Although rectal nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be effective for the prevention of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis (PEP) in high-risk patients, the benefit in average-risk patients is unclear. We aimed at assessing the benefit of prophylactic rectal NSAIDs in unselected consecutive patients to prevent PEP. METHODS All patients undergoing index ERCP procedures from January 2018 until March 2020 were included. All patients received prophylactic rectal diclofenac. A prophylactic pancreatic duct (PD) stent was placed if there was repeated PD cannulation, at the discretion of the endoscopist. The frequency of PEP was compared with historical controls. RESULTS Of 769 patients who underwent ERCP, 34 (4.4%) developed PEP (mild in 29 [85.3%], moderate in four [11.8%] and severe in one [2.9%]). Female gender, precut sphincterotomy, inadvertent PD cannulation and procedural time of > 30 minutes predicted PEP in univariate analysis. Inadvertent PD cannulation (OR 4.6, 95% CI: 1.8-11.7; p < 0.001) and procedural time of > 30 minutes (OR 8.5, 95% CI: 3.7-10.1; p < 0.001) were independent risk factors on multivariate analysis. When compared with historical controls, the odds of PEP with prophylactic use of rectal NSAIDs and selective PD stenting was 0.54 (CI: 0.31-0.93, p = 0.027). The number needed to treat (NNT) was 22 to prevent one PEP with prophylactic rectal NSAIDs. CONCLUSION Routine use of prophylactic rectal NSAIDs effectively prevents the occurrence of PEP in unselected consecutive patients in a real-world scenario.
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Affiliation(s)
- Ashish Agarwal
- Department of Gastroenterology, All India Institute of Medical Sciences, Jodhpur, 342 005, India
| | - Soumya Jagannath Mahapatra
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Rahul Sethia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Srikanth Mohta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Pramod Kumar Garg
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
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Keswani RN, Duloy A, Nieto JM, Panganamamula K, Murad MH, Bazerbachi F, Shaukat A, Elmunzer BJ, Day LW. Interventions to improve the performance of ERCP and EUS quality indicators. Gastrointest Endosc 2023; 97:825-838. [PMID: 36967249 DOI: 10.1016/j.gie.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/11/2022] [Indexed: 04/21/2023]
Affiliation(s)
- Rajesh N Keswani
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Anna Duloy
- Division of Gastroenterology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Jose M Nieto
- Digestive Disease Consultants, Jacksonville, Florida, USA
| | - Kashyap Panganamamula
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - M Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St Cloud Hospital, St Cloud, Minnesota, USA
| | - Aasma Shaukat
- Division of Gastroenterology and Hepatology, NYU Grossman School of Medicine, New York, New York, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, Zuckerberg San Francisco General Hospital and University of San Francisco, San Francisco, California, USA
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18
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Park TY, Kang H, Choi GJ, Oh HC. Aggressive hydration for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: trial sequential analysis. Surg Endosc 2023; 37:1366-1375. [PMID: 36508009 DOI: 10.1007/s00464-022-09808-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) have demonstrated that aggressive hydration with lactated Ringer's (LR) solution reduces the frequency and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). In this trial sequential analysis (TSA), we aimed to evaluate the prophylactic effect of aggressive hydration on PEP in specific patient subgroups and to determine the need for additional RCTs. METHODS We conducted a systematic and comprehensive search to identify all randomized controlled studies published through August 2021 that examined the effectiveness of aggressive hydration for preventing PEP. The primary outcome was the frequency of PEP. We also performed TSA to calculate the required information size and assess whether our results were conclusive. RESULTS The analysis included 12 studies involving 2,501 patients. According to the TSA, the overall frequency of PEP was significantly lower in the aggressive hydration group (5.6%; 74 of 1,327 patients) than in the control group (13.1%; 154 of 1,174 patients) (risk ratio [RR]: 0.458; 95% confidence interval [CI]: 0.350-0.599). In the subgroup analysis of patients with average risk, the cumulative Z curve crossed both the conventional test boundary and the trial sequential monitoring boundary. However, in the high-risk group and in patients with moderate-to-severe PEP, the Z curve did not cross the trial sequential monitoring boundary. CONCLUSIONS This TSA indicates that aggressive hydration is effective in the overall prevention of PEP. However, additional RCTs are required to examine the prophylactic effect of aggressive hydration with LR on PEP in high-risk populations.
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Affiliation(s)
- Tae Young Park
- Division of Gastroenterology, Chung-Ang University College of Medicine, 102 Heukseok-ro Dongjak-gu, Seoul, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyoung-Chul Oh
- Division of Gastroenterology, Chung-Ang University College of Medicine, 102 Heukseok-ro Dongjak-gu, Seoul, Korea.
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19
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American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: methodology and review of evidence. Gastrointest Endosc 2023; 97:163-183.e40. [PMID: 36517309 DOI: 10.1016/j.gie.2022.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/26/2022] [Indexed: 01/22/2023]
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20
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American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: summary and recommendations. Gastrointest Endosc 2023; 97:153-162. [PMID: 36517310 DOI: 10.1016/j.gie.2022.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/04/2022] [Indexed: 01/22/2023]
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21
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Sakai H, Iwai N, Sakagami J, Okuda T, Ohara T, Hattori C, Taniguchi M, Oka K, Hara T, Tsuji T, Komaki T, Kagawa K, Dohi O, Yasuda H, Konishi H, Itoh Y. Rectal administration of low-dose diclofenac does not reduce post-endoscopic retrograde cholangiopancreatography pancreatitis: a propensity score matching analysis. Surg Endosc 2022; 37:2698-2705. [PMID: 36443561 DOI: 10.1007/s00464-022-09718-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 10/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a popular technique; however, post-ERCP pancreatitis (PEP) remains a major adverse event. The administration of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) is reportedly effective in preventing PEP. However, the recommended dose varies and the efficacy of low-dose rectal NSAIDs remains unclear. Therefore, we decided to investigate the effectiveness of low-dose rectal diclofenac on PEP prevention, using propensity score matching. METHODS This single-center retrospective study included 401 patients who underwent ERCP between July 2015 and March 2020. After December 2016, we administered rectal diclofenac within 30 min before the ERCP procedure as widely as possible. Patients were divided into those who did (diclofenac group) and did not (control group) receive rectal diclofenac. Patients weighing ≥ 50 kg were administered a 50 mg dose, while those weighing < 50 kg were administered a 25 mg dose. The incidence and severity of PEP in the two groups were assessed by propensity score matching analysis. RESULTS Among 401 patients undergoing ERCP, 367 fulfilled the inclusion criteria. Overall, 187 patients received rectal diclofenac (diclofenac group) and 180 did not (control group). After propensity score matching, 105 pairs were selected for evaluation. Overall, seven (6.7%) patients in the diclofenac group and 10 (9.5%) in the control group developed PEP (P = 0.45). Moderate or severe PEP occurred in four (3.8%) patients in the diclofenac group and six (5.7%) in the control group (P = 0.52). CONCLUSIONS The administration of low-dose rectal diclofenac could not reduce the incidence and severity of PEP.
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Affiliation(s)
- Hiroaki Sakai
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Naoto Iwai
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan.
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Junichi Sakagami
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Takashi Okuda
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Tomoya Ohara
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Chie Hattori
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Masashi Taniguchi
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Kohei Oka
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Tasuku Hara
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Toshifumi Tsuji
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Toshiyuki Komaki
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Keizo Kagawa
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Osamu Dohi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroaki Yasuda
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hideyuki Konishi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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22
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Alavinejad P, Tran NPN, Eslami O, Shaarawy OE, Hormati A, Seiedian SS, Parsi A, Ahmed MH, Behl NS, Abravesh AA, Tran QT, Vignesh S, Salman S, Sakr N, Ara TF, Hajiani E, Hashemi SJ, Patai ÁV, Butt AS, Lee SH. ORAL N-ACETYL CYSTEINE VERSUS RECTAL INDOMETHACIN FOR PREVENTION OF POST ERCP PANCREATITIS: A MULTICENTER MULTINATIONAL RANDOMIZED CONTROLLED TRIAL. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:508-512. [PMID: 36383882 DOI: 10.1590/s0004-2803.202204000-90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/03/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND This multicenter multinational RCT designed to compare the efficacy of suppository indomethacin and NAC for prevention of PEP. METHODS During a 6-month period, all of the ERCP cases in seven referral centers were randomly assigned to receive either 1200 mg oral NAC, indomethacin suppository 100 mg, 1200 mg oral NAC plus indomethacin suppository 100 mg or placebo 2 hours before ERCP. The primary outcomes were the rate and severity of any PEP. RESULTS A total of 432 patients included (41.4% male). They were originally citizens of 6 countries (60.87% Caucasian). They were randomly allocated to receive either NAC (group A, 84 cases), rectal indomethacin (group B, 138 cases), NAC + rectal indomethacin (group C, 115 cases) or placebo (group D, 95 cases). The rate of PEP in groups A, B and C in comparison with placebo were 10.7%, 17.4%, 7.8% vs 20% (P=0.08, 0.614 & 0.01 respectively). The NNT for NAC, indomethacin and NAC + indomethacin was 11, 38 and 8 respectively. CONCLUSION Oral NAC is more effective than rectal indomethacin when compared to placebo for prevention of PEP and the combination of NAC and Indomethacin had the lowest incidence of PEP and may have synergistic effect in preventing of PEP (IRCT20201222049798N1; 29/12/2020).
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Affiliation(s)
- Pezhman Alavinejad
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
- World Endoscopy Organization emerging star group, WEO, Munich, Germany
| | | | - Omid Eslami
- Clinical Research Development Unit, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
- Gastroenterology and Hepatology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Omar El Shaarawy
- Lecturer and consultant of Hepatology, Gastroenterology and Endoscopy, National Liver institute, Menoufia University, Egypt
| | - Ahmad Hormati
- Gastrointestinal and liver Diseases Research Center, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Seied Saeed Seiedian
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
| | - Abazar Parsi
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
| | - Mohammed Hussien Ahmed
- Lecturer Hepatology Gastroenterology and infectious diseases, Faculty of Medicine, Kafrelsheikh University, Cairo, Egypt
| | - Nitin Shanker Behl
- Institute of Gastro and Liver diseases, Fortis Hospital, Ludhiana, India
| | - Ali Akbar Abravesh
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
| | - Quang Trung Tran
- Department of Internal Medicine, University of Medicine and Pharmacy, Hue University, Vietnam
- Department of Internal Medicine A, University Medicine Greifswald, Germany
- World Endoscopy Organization emerging star group, WEO, Munich, Germany
| | - Shivakumar Vignesh
- Division of gastroenterology, Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA
- World Endoscopy Organization emerging star group, WEO, Munich, Germany
| | - Saif Salman
- Hashemite University, Faculty of Medicine, Alzarqa, Jordan
| | - Naemt Sakr
- Assistant Lecturer and specialist of Hepatology and Gastroenterology at the National Liver Institute, Menoufia University, Egypt
| | - Tahmineh Farbod Ara
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
| | - Eskandar Hajiani
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
| | - Seyed Jalal Hashemi
- Alimentary Tract Research Center, Imam Khomeini hospital clinical research development Unit, The school of medicine, Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran
| | - Árpád V Patai
- Gastroenterology Division, Internal Medicine and Hematology Department, Semmelweis University, Budapest, Hungary
- Interdisciplinary Gastroenterology Working Group, Semmelweis University, Budapest, Hungary
| | - Amna Subhan Butt
- World Endoscopy Organization emerging star group, WEO, Munich, Germany
- Consultant Gastroenterologist, Section of Gastroenterology, Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi, Pakistan
| | - Sang Hyub Lee
- World Endoscopy Organization emerging star group, WEO, Munich, Germany
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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23
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Akshintala VS, Husain SZ, Brenner TA, Singh A, Singh VK, Khashab MA, Sperna Weiland CJ, van Geenen EJM, Bush N, Barakat M, Srivastava A, Kochhar R, Talukdar R, Rodge G, Wu CCH, Lakhtakia S, Sinha SK, Goenka MK, Reddy DN. Rectal INdomethacin, oral TacROlimus, or their combination for the prevention of post-ERCP pancreatitis (INTRO Trial): Protocol for a randomized, controlled, double-blinded trial. Pancreatology 2022; 22:887-893. [PMID: 35872074 DOI: 10.1016/j.pan.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/12/2022] [Accepted: 07/14/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute pancreatitis remains the most common and morbid complication of endoscopic retrograde cholangiopancreatography (ERCP). The use of rectal indomethacin and pancreatic duct stenting has been shown to reduce the incidence and severity of post-ERCP pancreatitis (PEP), but these interventions have limitations. Recent clinical and translational evidence suggests a role for calcineurin inhibitors in the prevention of pancreatitis, with multiple retrospective case series showing a reduction in PEP rates in tacrolimus users. METHODS The INTRO trial is a multicenter, international, randomized, double-blinded, controlled trial. A total of 4,874 patients undergoing ERCP will be randomized to receive either oral tacrolimus (5 mg) or oral placebo 1-2 h before ERCP, and followed for 30 days post-procedure. Blood and pancreatic aspirate samples will also be collected in a subset of patients to quantify tacrolimus levels. The primary outcome of the study is the incidence of PEP. Secondary endpoints include the severity of PEP, ERCP-related complications, adverse drug events, length of hospital stay, cost-effectiveness, and the pharmacokinetics, pharmacodynamics, and pharmacogenomics of tacrolimus immune modulation in the pancreas. CONCLUSIONS The INTRO trial will assess the role of calcineurin inhibitors in PEP prophylaxis and develop a foundation for the clinical optimization of this therapeutic strategy from a pharmacologic and economic standpoint. With this clinical trial, we hope to demonstrate a novel approach to PEP prophylaxis using a widely available and well-characterized class of drugs. TRIAL REGISTRATION NCT05252754, registered on February 14, 2022.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.
| | - Sohail Z Husain
- Division of Pediatric Gastroenterology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Todd A Brenner
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Anmol Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nikhil Bush
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Monique Barakat
- Division of Pediatric Gastroenterology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Ananta Srivastava
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Gajanan Rodge
- Department of Gastroenterology, Apollo Multispecialty Hospitals, Kolkata, India
| | - Clement C H Wu
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Mahesh K Goenka
- Department of Gastroenterology, Apollo Multispecialty Hospitals, Kolkata, India
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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24
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Thiruvengadam NR, Kouanda A, Kalluri A, Schaubel D, Saumoy M, Forde K, Song J, Faggen A, Davis BG, Onwugaje KC, Cote G, Arain MA, Kochman ML. A Prospective Cohort Study Evaluating PAN-PROMISE, a Patient-reported Outcome Measure to Detect Post-ERCP Morbidity. Clin Gastroenterol Hepatol 2022; 21:1233-1242.e14. [PMID: 36075501 DOI: 10.1016/j.cgh.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The Cotton Consensus (CC) criteria for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) may not capture post-ERCP morbidity. PAN-PROMISE, a patient-reported outcome measure (PROM), was developed to quantify acute pancreatitis-related morbidity. This study aims to determine the value of PAN-PROMISE in independently defining ERCP-related morbidity. METHODS We conducted a prospective cohort study of patients undergoing ERCP at 2 academic centers from September 2021 to August 2022. We administered PAN-PROMISE and assessed quality of life and work productivity at baseline, 48 to 72 hours, 7 days, and 30 days following ERCP. PEP was defined by a 3-physician committee using the CC criteria. We defined high morbidity following ERCP (elevated PROM) by an increase of PAN-PROMISE score of >7 at 7 days post-procedure. The McNemar test assessed discordance between PEP and elevated-PROM. RESULTS A total of 679 patients were enrolled. Choledocholithiasis (30%) and malignant biliary obstruction (29%) were the main indications for ERCP. Thirty-two patients (4.7%) developed PEP. One hundred forty-seven patients (21.6%) had an elevated PROM, whereas only 20 of them (13.4%) had PEP by the CC criteria (P < .001 for discordance). An elevated PROM strongly correlated with lower physical quality of life and increased direct and indirect health care costs ($80 and $25 per point increase in PAN-PROMISE, respectively). Patients with pancreatic cancer (odds ratio, 4.52; 95% confidence interval, 1.68-10.74) and primary sclerosing cholangitis (odds ratio, 1.79; 95% confidence interval, 1.29-2.45) had the highest odds of elevated PROM. CONCLUSIONS A substantial number of patients experience significant morbidity after ERCP despite not developing PEP or other adverse events. Future studies are needed to characterize better the reasons behind this increase in symptoms and potential interventions to reduce the symptom burden post-ERCP. CLINICALTRIALS gov number, NCT05310409.
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Affiliation(s)
- Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California; Division of Gastroenterology and Hepatology, Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Endoscopic Innovation, Research and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Abdul Kouanda
- Division of Gastroenterology and Hepatology, UCSF Medical Center, San Francisco, California
| | - Anita Kalluri
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Douglas Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Monica Saumoy
- Center for Digestive Health, Penn Medicine Princeton Medical Center, Plainsboro, New Jersey
| | - Kimberly Forde
- Department of Gastroenterology and Hepatology, Temple University, Philadelphia, Pennsylvania
| | - Jun Song
- Department of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Alec Faggen
- Division of Gastroenterology and Hepatology, UCSF Medical Center, San Francisco, California
| | - Brenton G Davis
- Division of Gastroenterology and Hepatology, UCSF Medical Center, San Francisco, California
| | - Kenechukwu Chudy Onwugaje
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Gregory Cote
- Division of Gastroenterology and Hepatology, Oregon Health Sciences University, Portland, Oregon
| | - Mustafa A Arain
- Division of Gastroenterology and Hepatology, UCSF Medical Center, San Francisco, California; Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - Michael L Kochman
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Endoscopic Innovation, Research and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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25
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A review of the rationale for the testing of the calcineurin inhibitor tacrolimus for post-ERCP pancreatitis prevention. Pancreatology 2022; 22:678-682. [PMID: 35872075 DOI: 10.1016/j.pan.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 12/11/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is commonly performed for the management of pancreaticobiliary disorders. The most troublesome ERCP-associated adverse event is post-ERCP pancreatitis (PEP), which occurs in up to 15% of all patients undergoing ERCP. A substantial body of preclinical data support a mechanistic rationale for calcineurin inhibitors in preventing PEP. The findings are coupled with recent clinical data suggesting lower rates of PEP in patients who concurrently use the calcineurin inhibitor tacrolimus (e.g., solid organ transplant recipients). In this review, we will firstly summarize data in support of testing the use of tacrolimus for PEP prophylaxis, either in combination with rectal indomethacin or by itself. Secondly, we propose that administering tacrolimus through the rectal route could be favorable for PEP prophylaxis over other routes of administration.
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26
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Shi QQ, Huang GX, Li W, Yang JR, Ning XY. Rectal nonsteroidal anti-inflammatory drugs, glyceryl trinitrate, or combinations for prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis: A network meta-analysis. World J Clin Cases 2022; 10:7859-7871. [PMID: 36158503 PMCID: PMC9372852 DOI: 10.12998/wjcc.v10.i22.7859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/04/2021] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute pancreatitis is the most common and severe complication of endoscopic retrograde cholangiopancreatography (ERCP). Recent evidence suggests that combinations based on rectal nonsteroidal anti-inflammatory drugs (NSAIDs) are more beneficial in preventing post-ERCP pancreatitis (PEP). Randomized controlled trials (RCTs) have also demonstrated the efficacy of glyceryl trinitrate (GTN). We conducted a network meta-analysis to compare NSAIDs and GTN for prevention of PEP and to determine whether they are better in combination.
AIM To compare NSAIDs and GTN for prevention of PEP and to determine whether they are better in combination.
METHODS A systematic search was done for full-text RCTs of PEP in PubMed, Embase, Science Citation Index, and the Cochrane Controlled Trials database. Inclusion and exclusion criteria were used to screen for eligible RCTs. The major data were extracted by two independent reviewers. The frequentist model was used to conduct this network meta-analysis and obtain the pairwise OR and 95%CI. The data were then extracted and assessed on the basis of the Reference Citation Analysis (https://www.referencecitationanalysis.com/).
RESULTS Twenty-four eligible RCTs were selected, evaluating seven preventive strategies in 9416 patients. Rectal indomethacin 100 mg plus sublingual GTN (OR: 0.21, 95%CI: 0.09–0.50), rectal diclofenac 100 mg (0.34, 0.18–0.65), sublingual GTN (0.34, 0.12–0.97), and rectal indomethacin 100 mg (0.49, 0.33–0.73) were all more efficacious than placebo in preventing PEP. The combination of rectal indomethacin and sublingual GTN had the highest surface under the cumulative ranking curves (SUCRA) probability of (92.2%) and was the best preventive strategy for moderate-to-severe PEP with a SUCRA probability of (89.2%).
CONCLUSION Combination of rectal indomethacin 100 mg with sublingual GTN offered better prevention of PEP than when used alone and could alleviate the severity of PEP.
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Affiliation(s)
- Qing-Qing Shi
- Department of Health Management Center, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Guo-Xiu Huang
- Department of Health Management Center, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Wei Li
- Department of Health Management Center, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Jian-Rong Yang
- Department of Hepatobiliary, Pancreas and Spleen Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Xiao-Yi Ning
- Department of Hematology, The Frist People’s Hospital of Nanning, Nanning 530021, Guangxi Zhuang Autonomous Region, China
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27
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Continuous Infusion of Fluid Hydration Over 24 Hours Does Not Prevent Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Dig Dis Sci 2022; 67:4122-4130. [PMID: 34655014 DOI: 10.1007/s10620-021-07256-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 09/16/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Aggressive intravenous fluid hydration, by administering 3500 mL of lactated Ringer's solution (LRS) in 9 h with a peri-procedural bolus, reduces post-ERCP pancreatitis (PEP) incidence. A concern of this strategy is adverse events related to volume overload; however, the impact of fluid hydration over an extended period without a bolus on PEP is unknown. AIM To assess the effect of continuous infusion of high-volume fluid at a constant rate over 24 h on PEP incidence and severity. METHODS Two-hundred patients were randomly assigned (1:1) to receive either 3600 mL of LRS in 24 h starting 2 h before the ERCP (high-volume group) or maintenance fluid hydration calculated by the Holliday-Segar method (control group). RESULTS The mean age of the patients was 50.6 ± 11.6 years. The predominant indications were choledocholithiasis (48%) and malignancies (32%). Patient demographics and PEP risk factors were similar in both groups. Patients in the high-volume group received significantly more fluid than the control group (3600 vs. 2413 ml, P < 0.001). PEP incidence was not different between the high-volume and the control group (14% vs. 15%; relative risk 0.93: 95% CI 0.48-1.83, P = 0.84). There were no differences in moderate to severe PEP (3% vs. 4%; relative risk 0.75: 95% CI, 0.17-3.27, P = 1.00). Subgroup analysis did not show a benefit in high-risk patients. Only one patient in the control group developed peripheral edema. CONCLUSIONS An infusion of high-volume hydration over 24 h is not sufficient to provide optimal hydration for PEP prevention. CLINICAL TRIAL REGISTRY NUMBER No. NCT02821546.
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Koshitani T, Konaka Y, Ohishi T, Yasuda T, Morinushi T, Mita M, Masuda M, Nakano K, Fuki S, Nakagawa S. Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Using Temporary Pancreatic Stents Versus Rectal Nonsteroidal Anti-inflammatory Drugs: A Randomized Controlled Trial. Pancreas 2022; 51:663-670. [PMID: 36099496 DOI: 10.1097/mpa.0000000000002090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Both pancreatic stenting and rectal nonsteroidal anti-inflammatory drugs (NSAIDs) prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. The aim of the study was to compare post-ERCP pancreatitis (PEP) prophylaxis using pancreatic stents and/or rectal NSAIDs prospectively. METHODS A total of 321 patients undergoing ERCP were studied. Each patient was randomly allocated to receive pancreatic stent placement (PS), 50 mg of rectal diclofenac (NSAID), or both (PS + NSAID) for PEP prophylaxis. The primary outcome was the occurrence rate of PEP, and secondary outcomes included the severity of PEP and serum pancreatic amylase and lipase levels on the day after ERCP. RESULTS Five patients (PS: 2/101, NSAID: 1/106, PS + NSAID: 2/102) developed PEP, and the overall occurrence rate of PEP was 1.6% (5/309). The occurrence rates of PEP in the PS, NSAID, and PS + NSAID groups were statistically equivalent with an equivalent margin of 10%. The severity of PEP was mild in all 5 patients. Median serum pancreatic amylase and lipase levels in the NSAID group were significantly lower than those in the PS and PS + NSAID groups. CONCLUSIONS Rectal administration of 50 mg of diclofenac may become a first-line therapy for PEP prophylaxis in our country.
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Affiliation(s)
- Tatsuya Koshitani
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Yoshitomo Konaka
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Takashi Ohishi
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Tomoyo Yasuda
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Tatsuo Morinushi
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Masaki Mita
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Masataka Masuda
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Keimei Nakano
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Shuichi Fuki
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
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Chong B, Cote GA. Hurdles in ERCP Trials: Do We Need to Change the Diagnostic Criteria for Post-ERCP Pancreatitis? Clin Gastroenterol Hepatol 2022; 20:1218-1219. [PMID: 34673255 DOI: 10.1016/j.cgh.2021.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 10/09/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Bradford Chong
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Gregory A Cote
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
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Takada T, Isaji S, Mayumi T, Yoshida M, Takeyama Y, Itoi T, Sano K, Iizawa Y, Masamune A, Hirota M, Okamoto K, Inoue D, Kitamura N, Mori Y, Mukai S, Kiriyama S, Shirai K, Tsuchiya A, Higuchi R, Hirashita T. JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:1057-1083. [PMID: 35388634 DOI: 10.1002/jhbp.1146] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 11/09/2022]
Abstract
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. Base on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast-enhanced 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 was 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 hours 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 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.
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Affiliation(s)
- Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Shuji Isaji
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, School of Medicine, International University of Health & Welfare, Chiba, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Takao Itoi
- Department. of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yusuke Iizawa
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Fukuoka, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Hospital, Ishikawa, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Chiba, Japan
| | - Yasuhisa Mori
- Department of Surgery I, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Shuntaro Mukai
- Department. of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, Gifu, Japan
| | - Kunihiro Shirai
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
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Radadiya D, Brahmbhatt B, Reddy C, Devani K. Efficacy of Combining Aggressive Hydration With Rectal Indomethacin in Preventing Post-ERCP Pancreatitis: A Systematic Review and Network Meta-Analysis. J Clin Gastroenterol 2022; 56:e239-e249. [PMID: 33769395 DOI: 10.1097/mcg.0000000000001523] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
| | - Bhaumik Brahmbhatt
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL
| | - Chakradhar Reddy
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, East Tennessee State University, Johnson City, TN
| | - Kalpit Devani
- Department of Internal Medicine, Division of Gastroenterology and Liver Disease, Prisma Health, School of Medicine, University of South Carolina, Greenville, SC
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Park TY, Kang H, Choi GJ, Oh HC. Rectal NSAIDs-based combination modalities are superior to single modalities for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a network meta-analysis. Korean J Intern Med 2022; 37:322-339. [PMID: 35168302 PMCID: PMC8925947 DOI: 10.3904/kjim.2021.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/15/2021] [Accepted: 11/03/2021] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Tae Young Park
- Division of Gastroenterology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
| | - Hyoung-Chul Oh
- Division of Gastroenterology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
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Zeng C, Zhang Y, Yang H, Hong J. Prevention of pancreatitis after stent implantation for distal malignant biliary strictures: systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2022; 16:141-154. [PMID: 35020545 DOI: 10.1080/17474124.2022.2027239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Biliary stent placement remains a palliative treatment for patients with unresectable distal malignant biliary strictures (DMBS). The incidence of post-ERCP-pancreatitis (PEP) significantly increases in patients receiving fully covered self-expandable metal stents (FCSEMS) who undergo endoscopic retrograde cholangiopancreatography (ERCP). AREAS COVERED This review provides an overview of prevention of PEP after stent implantation for DMBSs. The following operational variables were evaluated: (1) stent type (plastic or metal stent); (2) stent location (above or across the sphincter of Oddi); (3) prophylactic pancreatic duct stent placement; (4) endoscopic sphincterotomy (EST). PubMed, EMBASE, and Cochrane database were searched to identify eligible studies up to October 2021. The odds ratio (OR) with 95% confidence intervals (CI) were pooled using fixed- or random- effects models. EXPERT OPINION 1. PEP occurs more frequently in DMBS patients with self-expandable metal stents (SEMS) compared to that plastic stent (PS). 2. The PEP incidence is higher in covered stents than that in uncovered self-expandable metal stents (USEMS), but not significantly. 3. PEP incidence increases in patients receiving transpapillary FCSEMS placement, particularly when there is an absence of pancreatic duct dilation, and prophylactic pancreatic stenting is recommended for these patients. 4. Limited studies with small sample indicate that there is no significant difference in PEP incidence between transpapillary and suprapapillary stents placement for DMBS. 5. Limited studies indicate that EST does not significantly affect the incidence of pancreatitis in DMBS patients.
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Affiliation(s)
- Chuanfei Zeng
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China.,Medical College of Nanchang University, Nanchang, China
| | - Yiling Zhang
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China.,Medical College of Nanchang University, Nanchang, China
| | - Hui Yang
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China.,Medical College of Nanchang University, Nanchang, China
| | - Junbo Hong
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
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Wu ZX, Wang GL, Qiu P, Gong M, Li X, Wen JB. Selective indications of indomethacin and somatostatin, alone or in combination, and their preventive effects in patients at high risk for post-ERCP pancreatitis. Shijie Huaren Xiaohua Zazhi 2021; 29:1222-1229. [DOI: 10.11569/wcjd.v29.i21.1222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used minimally invasive technique for the diagnosis and treatment of biliary and pancreatic disorders. However, some patients may suffer post-ERCP pancreatitis (PEP). Somatostatin and indomethacin are the classical drugs for the prevention of PEP. There is still controversy over the use of somatostatin and indomethacin, alone or in combination, in this context.
AIM To investigate the selective indications of indomethacin and somatostatin, alone or in combination, and their preventive effects in patients at high risk for PEP.
METHODS A prospective analysis was performed on 729 patients at high risk for PEP at our hospital from January 2017 to December 2020. They were randomly divided into four groups according to factorial design: Placebo group, indomethacin group, somatostatin group, and indomethacin + somatostatin group. Hyperamylasemia, PEP, visual analogue scale (VAS) score, tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6), and IL-8 concentrations, and the incidence of side effects were compared among the four groups.
RESULTS Compared with the placebo group, the incidence of PEP, hospitalization cost, and length of hospital stay showed no significant difference, but the incidence of hyperamylasemia, VAS score within 6 h after operation, and the TNF-α, IL-6 and IL-8 concentrations significantly decreased in the indomethacin group. Compared with the placebo group or indomethacin group, hospitalization cost, hospitalization time, the incidence of hyperamylasemia, the incidence of PEP, VAS score at 6 h, 12 h, and 24 h after operation, and the TNF-α, IL-6, and IL-8 concentrations after operation significantly decreased in the somatostatin group. Compared with the indomethacin + somatostatin group, the cost of hospitalization, length of hospitalization, incidence of hyperamylase blood, incidence of PEP, VAS score at 6 h, 12 h and 24 h after operation, and the TNF-α, IL-6 and IL-8 concentrations after operation significantly decreased in the indomethacin + somatostatin group. Compared with the somatostatin group, the incidence of PEP, hospitalization cost, and length of hospital stay in the indomethacin + somatostatin group showed no significant difference, but the incidence of hyperamylasemia, VAS score, and TNF-α, IL-6, and IL-8 concentrations within 6 h after operation significantly decreased. The VAS and TNF-α, IL-6, and IL-8 concentrations at 12 h to 24 h after operation showed no statistically significant differences.
CONCLUSION For patients at high risk for PEP, indomethacin can reduce the incidence of postoperative hyperamylasemia and improve the quality of life of patients in a short period of time. It is suitable for patients undergoing simple, short-duration ERCP procedure with expected mild postoperative abdominal pain. Somatostatin can reduce the incidence of postoperative hyperamylasemia, improve the patients' quality of life and the incidence of PEP over a long period of time, and reduce the cost of hospitalization. It is suitable for patients with complicated, long-duration ERCP operation with expected severe postoperative abdominal pain. The combination of indomethacin and somatostatin has a synergistic effect in reducing the incidence of hyperamylasemia and improving patients' quality of life within 6 h after operation, and it is suitable for patients with more complicated, longer-duration ERCP operation with expected severe and longer postoperative abdominal pain.
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Affiliation(s)
- Zao-Xuan Wu
- Department of Gastroenterology, Southern Medical University Affiliated Pingxiang Hospital, Pingxiang 337000, Jiangxi Province, China
| | - Gui-Liang Wang
- Department of Gastroenterology, Southern Medical University Affiliated Pingxiang Hospital, Pingxiang 337000, Jiangxi Province, China
| | - Ping Qiu
- Department of Gastroenterology, Southern Medical University Affiliated Pingxiang Hospital, Pingxiang 337000, Jiangxi Province, China
| | - Min Gong
- Department of Gastroenterology, Southern Medical University Affiliated Pingxiang Hospital, Pingxiang 337000, Jiangxi Province, China
| | - Xing Li
- Department of Gastroenterology, Southern Medical University Affiliated Pingxiang Hospital, Pingxiang 337000, Jiangxi Province, China
| | - Jian-Bo Wen
- Department of Gastroenterology, Southern Medical University Affiliated Pingxiang Hospital, Pingxiang 337000, Jiangxi Province, China
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Paez LF, Cury MDS, Mello MPM, Campos DND, Rodrigues BER. POST ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PANCREATITIS PROPHYLAXIS: EVALUATION OF TWO DIFFERENT NSAID REGIMENS. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:270-275. [PMID: 34705958 DOI: 10.1590/s0004-2803.202100000-47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 04/26/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography is a widely used therapeutic modality for the pancreaticobiliary tree. However, it is responsible for the highest rates of complications among the endoscopic procedures, especially post-endoscopic retrograde cholangiopancreatography pancreatitis. The preventive methods include mechanical and pharmacological approaches, such as the use of non-steroidal anti-inflammatory drugs. OBJECTIVE To compare the efficacy of two different strategies using non-steroidal anti-inflammatory drugs for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis, and to clarify the uncertainty about the route of administration of non-steroidal anti-inflammatory drugs in the prevention of this complication. METHODS This was a prospective trial. Two therapeutic groups were compared with a control group that was composed of patients who underwent endoscopic retrograde cholangiopancreatography, performed in the same service and by the same team in the period preceding the study (historical series), without the administration of any type of prophylaxis. The first group received 100 mg rectal diclofenac. The second group received 100 mg intravenous ketoprofen. Both groups were compared, separately and jointly, with the control group. RESULTS Post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in 4.39% (12/273) of the participants. In the group without prophylaxis, the incidence was 6.89% (10/145). Among those who received intravenous ketoprofen, the incidence was 2.56% (2/78). No cases of acute post-procedural pancreatitis were observed in the group that received rectal diclofenac (0/52). Although there was no statistical difference between the therapeutic groups when they were separately analyzed, a statistical difference in the prevention of post-procedural pancreatitis was observed when they were analyzed together (P=0.037). CONCLUSION This study provides evidence for the efficacy of non-steroidal anti-inflammatory drugs in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis.
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Affiliation(s)
- Loyna Flores Paez
- Universidade Federal de Mato Grosso do Sul, Faculdade de Medicina, Campo Grande, MS, Brasil
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Márta K, Gede N, Szakács Z, Solymár M, Hegyi PJ, Tél B, Erőss B, Vincze Á, Arvanitakis M, Boškoski I, Bruno MJ, Hegyi P. Combined use of indomethacin and hydration is the best conservative approach for post-ERCP pancreatitis prevention: A network meta-analysis. Pancreatology 2021; 21:1247-1255. [PMID: 34353727 DOI: 10.1016/j.pan.2021.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Post-ERCP pancreatitis (PEP) is a life-threatening complication. Given the lack of a causative treatment for pancreatitis, it is of vital importance to minimize this risk of PEP. Multi-target preventive therapy may be the best choice for PEP prevention as disease development is multifactorial. AIM We aimed to assess the efficacy of a combination of indomethacin and hydration - type and amount - for PEP prevention via a network meta-analysis. METHODS Through a systematic search in three databases, we searched all randomized controlled trials involving hydration and indomethacin and ranked the PEP preventive efficacy with a Bayesian network meta-analysis using the PRISMA for Network Meta-Analyses (PRISMA-NMA) guideline. The RoB2 tool was used for risk of bias assessment, surface under the cumulative ranking curve (SUCRA) for ranking and PROSPERO for the study protocol [reg. no. CRD42018112698]. We used risk ratios (RR) for dichotomous data with 95% credible intervals (95% CrI). RESULTS The quantitative analysis included 7559 patients from 24 randomized controlled trials. Based on the SUCRA values, a combination of lactated Ringer's and indomethacin is more effective than single therapy with a 94% certainty. The percent relative risk ratios estimate preventive efficacy 70-99% higher for combinations than single therapies. Aggressive hydration with indomethacin (SUCRA 100%) is also significantly more effective than all other interventions (percent relative effect 94.3-98.1%). CONCLUSIONS A one-hit-on-each-target therapeutic approach is recommended in PEP prevention with an easily accessible combination of indomethacin and aggressive hydration for all average and high-risk patients without contraindication.
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Affiliation(s)
- Katalin Márta
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Noémi Gede
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Margit Solymár
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Jenő Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Tél
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Áron Vincze
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Marianna Arvanitakis
- Gastroenterology Department, Gastrointestinal Cancer Unit, Erasme Hospital University, Brussels, Belgium
| | - Ivo Boškoski
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Italy
| | - Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, University Medical Center Rotterdam, the Netherlands
| | - Péter Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Centre for Translational Medicine, Semmelweis University, Budapest, Hungary.
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Yu S, Shen X, Li L, Bi X, Chen P, Wu W. Rectal indomethacin and diclofenac are equally efficient in preventing pancreatitis following endoscopic retrograde cholangiopancreatography in average-risk patients. JGH Open 2021; 5:1119-1126. [PMID: 34621996 PMCID: PMC8485396 DOI: 10.1002/jgh3.12643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/04/2021] [Indexed: 11/22/2022]
Abstract
Rectal indomethacin and diclofenac are promising drugs for prevention of post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, their prophylactic effect on PEP in average‐risk patients remains controversial. We performed a systematic review and meta‐analysis to assess the efficacy and safety of rectal indomethacin and diclofenac in average‐risk patients, and to indirectly compare the prophylactic effect of the two drugs. A comprehensive search of the PubMed, EMBASE, and Cochrane Library databases was performed to identify randomized controlled trials (RCTs) on rectal indomethacin or diclofenac for prophylaxis against PEP. Fixed‐ and random‐effects models weighted by the Mantel–Haenszel method were used for direct comparisons. The adjusted indirect treatment comparison method was used to indirectly compare the efficacy of indomethacin and diclofenac. A total of 10 RCTs, including 2928 patients, met our inclusion criteria. No significant publication bias was identified. Pooled estimates showed that rectal indomethacin and diclofenac were associated with a significant reduction in the overall risk of PEP compared with control intervention [relative risk (RR) = 0.62; 95% confidence interval (CI): 0.46–0.83] in average‐risk patients. Subgroup analyses showed that both rectal indomethacin (RR = 0.67; 95% CI: 0.49–0.94) and diclofenac (RR = 0.42; 95% CI: 0.23–0.75) were effective in the prevention of PEP. Indirect comparison showed no significant difference between the effectiveness of the two drugs in the prevention of PEP (RR = 1.607; 95% CI: 0.824–3.136). The updated meta‐analysis suggests that both drugs provide equivalent protection against PEP in average‐risk patients.
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Affiliation(s)
- Shuang Yu
- Department of Gastroenterology Chongqing University Three Gorges Hospital Chongqing China
| | - Xumu Shen
- Department of Gastroenterology Chongqing University Three Gorges Hospital Chongqing China
| | - Liang Li
- Department of Gastroenterology Chongqing University Three Gorges Hospital Chongqing China
| | - Xiaofei Bi
- Department of Gastroenterology Chongqing University Three Gorges Hospital Chongqing China
| | - Ping Chen
- Department of Gastroenterology Chongqing University Three Gorges Hospital Chongqing China
| | - Wei Wu
- Department of Gastroenterology Chongqing University Three Gorges Hospital Chongqing China
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Takaori A, Ikeura T, Hori Y, Ito T, Nakamaru K, Masuda M, Mitsuyama T, Miyoshi H, Shimatani M, Takaoka M, Okazaki K, Naganuma M. Rectally Administered Low-Dose Diclofenac Has No Effect on Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Propensity Score Analysis. Pancreas 2021; 50:1024-1029. [PMID: 34629455 DOI: 10.1097/mpa.0000000000001877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We evaluated the preventive effect of low-dose diclofenac (25-50 mg) on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) by propensity score matching analysis. METHODS We retrospectively analyzed the data of 515 patients who underwent ERCP for the first time with or without the rectal administration of low-dose diclofenac before the procedure. For the purpose of minimization of the intrinsic selection bias, we compared the incidence rate of PEP between the diclofenac and control group after propensity score matching. RESULTS Post-ERCP pancreatitis developed in 15 patients (2.9%). There was no significant difference in the incidence of PEP between the diclofenac (2.4%) and control group (3.3%) (P = 0.608). One hundred ninety matched pairs were generated by propensity score matching and analyzed; however, the incidence rate of PEP was the same in both groups (2.1%, P = 1.000). In the subgroup analysis using data of patients with high-risk factors for developing PEP, the incidence rate of PEP was comparable between the diclofenac (3.8%) and control groups (4.0%) (P = 0.917). CONCLUSIONS In our propensity score analysis, rectal administration of low-dose diclofenac was not shown to be useful in preventing PEP.
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Affiliation(s)
- Ayaka Takaori
- From the Third Department of Internal Medicine, Kansai Medical University
| | - Tsukasa Ikeura
- From the Third Department of Internal Medicine, Kansai Medical University
| | - Yuichi Hori
- From the Third Department of Internal Medicine, Kansai Medical University
| | - Takashi Ito
- From the Third Department of Internal Medicine, Kansai Medical University
| | - Koh Nakamaru
- From the Third Department of Internal Medicine, Kansai Medical University
| | - Masataka Masuda
- From the Third Department of Internal Medicine, Kansai Medical University
| | | | - Hideaki Miyoshi
- From the Third Department of Internal Medicine, Kansai Medical University
| | - Masaaki Shimatani
- From the Third Department of Internal Medicine, Kansai Medical University
| | - Makoto Takaoka
- From the Third Department of Internal Medicine, Kansai Medical University
| | | | - Makoto Naganuma
- From the Third Department of Internal Medicine, Kansai Medical University
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Oh HC, Kang H, Park TY, Choi GJ, Lehman GA. Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis with a combination of pharmacological agents based on rectal non-steroidal anti-inflammatory drugs: A systematic review and network meta-analysis. J Gastroenterol Hepatol 2021; 36:1403-1413. [PMID: 33068012 DOI: 10.1111/jgh.15303] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/08/2020] [Accepted: 10/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Rectally administered non-steroidal anti-inflammatory drugs (NSAIDs) are effective but suboptimal in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis or PEP. New trials with the combination of rectal NSAIDs and other pharmacological agents have been conducted. This network meta-analysis (NMA) aimed to determine the relative efficacy of combination regimens and identify an optimal regimen for preventing PEP. METHODS We performed a systematic and comprehensive search to identify and analyze all the randomized controlled studies published until October 15, 2019, examining rectal NSAIDs and their combination with other pharmacological agents for the prevention of PEP. The primary outcome was the frequency of PEP. We conducted an NMA to combine the direct and indirect comparisons of rectal NSAIDs and their combination with other pharmacological agents. RESULTS The NMA included 24 studies evaluating 14 regimens in 11 321 patients. According to predictive interval plot and surface under the cumulative ranking curve values, indomethacin + lactated Ringer's solution, followed by diclofenac + nitrate and indomethacin + normal saline, is the most efficacious combination of pharmacological agents for the overall prevention of PEP. Rectal indomethacin alone is the most efficacious agent for prevention of moderate to severe PEP, and rectal diclofenac is the most useful agent for prevention of PEP among the high-risk group. CONCLUSIONS Rectal indomethacin with intravenous hydration and rectal diclofenac with sublingual nitrate are the most efficacious combination regimens for the overall prevention of PEP.
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Affiliation(s)
- Hyoung-Chul Oh
- Division of Gastroenterology, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Tae Young Park
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, Republic of Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Glen A Lehman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Dubravcsik Z, Hritz I, Keczer B, Novák P, Lovász BD, Madácsy L. Network meta-analysis of prophylactic pancreatic stents and non-steroidal anti-inflammatory drugs in the prevention of moderate-to-severe post-ERCP pancreatitis. Pancreatology 2021; 21:704-713. [PMID: 33926821 DOI: 10.1016/j.pan.2021.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/30/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Zsolt Dubravcsik
- Department of Gastroenterology, BKM Hospital, Kecskemét, Hungary.
| | - István Hritz
- Center for Therapeutic Endoscopy, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Bánk Keczer
- Center for Therapeutic Endoscopy, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Péter Novák
- Department of Gastroenterology, BKM Hospital, Kecskemét, Hungary
| | | | - László Madácsy
- Department of Gastroenterology, BKM Hospital, Kecskemét, Hungary; Endo-kapszula Private Medical Center, Székesfehérvár, Hungary
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Cárdenas-Jaén K, Archibugi L, Poropat G, Korpela T, Maisonneuve P, Aparicio JR, Udd M, Stimac D, Arcidiacono PG, De Pretis N, Valente R, Di Giulio E, Casellas JA, Kylänpää L, Hauser G, Mariani A, Gabbrielli A, Löhr M, Vanella G, Rainio M, Brozzi L, Arnelo U, Fagerström N, Capurso G, de-Madaria E. Chronic use of statins and acetylsalicylic acid and incidence of post-endoscopic retrograde cholangiopancreatography acute pancreatitis: A multicenter, prospective, cohort study. Dig Endosc 2021; 33:639-647. [PMID: 32713065 DOI: 10.1111/den.13801] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Post-endoscopic retrograde cholangiopancreatography (ERCP) acute pancreatitis (PEP) is a frequent complication of this endoscopic procedure. Chronic statin intake has been linked to lower incidence and severity of acute pancreatitis (AP). Periprocedural rectal administration of non-steroidal anti-inflammatory drugs is protective against PEP, but the role of chronic acetylsalicylic acid (ASA) treatment is unclear. We aimed to investigate whether statins and chronic ASA intake are associated with lower risk of PEP. METHODS An international, multicenter, prospective cohort study. Consecutive patients undergoing ERCP in seven European centers were included. Patients were followed-up to detect those with PEP. Multivariate analysis by means of binary logistic regression was performed, and adjusted odds ratios (aORs) were calculated. RESULTS A total of 1150 patients were included, and 70 (6.1%) patients developed PEP. Among statins users, 8.1% developed PEP vs. 5.4% among non-users (P = 0.09). Multivariate analysis showed no association between statin use and PEP incidence (aOR 1.68 (95% CI 0.94-2.99, P = 0.08)). Statin use had no effect on severity of PEP, being mild in 92.0% of statin users vs. 82.2% in non-statin users (P = 0.31). Chronic ASA use was not associated with PEP either (aOR 1.02 (95% CI 0.49-2.13), P = 0.96). Abuse of alcohol and previous endoscopic biliary sphincterotomy were protective factors against PEP, while >1 pancreatic guidewire passage, normal bilirubin values, and duration of the procedure >20 minutes, were risk factors. CONCLUSIONS The use of statins or ASA is not associated with a lower risk or a milder course of PEP.
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Affiliation(s)
- Karina Cárdenas-Jaén
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Goran Poropat
- Department of Gastroenterology, Faculty of Medicine, Clinical Hospital Center of Rijeka, University of Rijeka, Rijeka, Croatia
| | - Taija Korpela
- Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Jose R Aparicio
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Marianne Udd
- Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Davor Stimac
- Department of Gastroenterology, Faculty of Medicine, Clinical Hospital Center of Rijeka, University of Rijeka, Rijeka, Croatia
| | - Paolo G Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Niccolò De Pretis
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Roberto Valente
- Gastrocentrum, Karolinska University Hospital, Stockholm, Sweden
| | - Emilio Di Giulio
- Digestive and Liver Disease Unit, S. Andrea Hospital, Sapienza University, Rome, Italy
| | - Juan A Casellas
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Leena Kylänpää
- Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Goran Hauser
- Department of Gastroenterology, Faculty of Medicine, Clinical Hospital Center of Rijeka, University of Rijeka, Rijeka, Croatia
| | - Alberto Mariani
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Armando Gabbrielli
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Matthias Löhr
- Gastrocentrum, Karolinska University Hospital, Stockholm, Sweden
| | - Giuseppe Vanella
- Digestive and Liver Disease Unit, S. Andrea Hospital, Sapienza University, Rome, Italy
| | - Mia Rainio
- Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Lorenzo Brozzi
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Urban Arnelo
- Gastrocentrum, Karolinska University Hospital, Stockholm, Sweden
| | | | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy.,Digestive and Liver Disease Unit, S. Andrea Hospital, Sapienza University, Rome, Italy
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
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Ahmed A, Kahlam A, Pai S, Ahlawat S. Clinical outcomes and resource utilization analysis in patients with rheumatoid arthritis undergoing endoscopic retrograde cholangiopancreatography. JGH Open 2021; 5:396-400. [PMID: 33732888 PMCID: PMC7936620 DOI: 10.1002/jgh3.12510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIM The literature is lacking on associations of endoscopic retrograde cholangiopancreatography (ERCP) related outcomes in rheumatoid arthritis (RA) patients. The aim of this study is to evaluate the effects of RA on clinical outcomes and hospital resource utilization in patients undergoing ERCP. METHODS The National Inpatient Sample database was used to identify hospitalized patients who had underwent an ERCP study from 2012 to 2014 using International Classification of Diseases-Ninth Edition (ICD-9) codes. Primary outcomes were mortality, hospital charges, and length of stay. Secondary outcomes were ERCP-related complications. Chi-squared tests for categorical data and independent t-test for continuous data were utilized. Multivariate analysis was performed to assess the primary outcomes. RESULTS There was 83 890 ERCP procedures performed, of which 970 patients had RA. In patients with RA, 74.2% were female, and the average age was 65.7 years. RA primary outcomes of mortality rate and hospital cost were lower and statistically significant. There was no statistically significant difference in secondary outcomes except for lower cholecystectomy rates in RA patients. CONCLUSION With a high inflammatory state, it was hypothesized that RA would be associated with worse outcomes after ERCP. Yet, the primary outcomes of mortality and hospital cost were found to be lower than controls, with no difference in secondary outcomes. We posit that immunosuppressants used to treat RA provides a protective effect to overall complications with ERCP.
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Affiliation(s)
- Ahmed Ahmed
- Department of MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Aaron Kahlam
- Department of MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Suraj Pai
- Department of MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Sushil Ahlawat
- Department of Gastroenterology and HepatologyRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
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Han S, Attwell AR, Tatman P, Edmundowicz SA, Hammad HT, Wagh MS, Wani S, Shah RJ. Adverse Events Associated With Therapeutic Endoscopic Retrograde Pancreatography. Pancreas 2021; 50:378-385. [PMID: 33835969 PMCID: PMC8041157 DOI: 10.1097/mpa.0000000000001769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Data regarding the safety of endoscopic retrograde pancreatography (ERP) are limited compared with biliary endoscopic retrograde cholangiopancreatography. The aim of this study was to determine adverse events (AEs) associated with therapeutic ERP. METHODS This single-center retrospective study examined consecutive therapeutic ERPs with the primary intention of cannulating the pancreatic duct. Multivariate logistic regression was performed to identify risk factors for AEs. RESULTS A total of 3023 ERPs were performed in 1288 patients (mean age, 50.3 years; 57.8% female) from January 2000 to January 2017. Overall AE rate was 18.9% with abdominal pain requiring admission (9.8%) and post-ERP pancreatitis (5.7%) being most common. On multivariate analysis, female sex (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.9-2.9), acute recurrent pancreatitis (aOR, 5.0; 95% CI, 1.7-15.3), chronic pancreatitis (aOR, 1.8; 95% CI, 1.3-2.6), and pancreatic sphincter of Oddi dysfunction (aOR, 2.1; 95% CI, 1.4-3.3) were associated with an increased risk of overall AEs. Pancreatic sphincterotomy (aOR, 1.9; 95% CI, 1.5-2.4) and therapeutic stenting (aOR, 1.6; 95% CI, 1.2-2.2) also increased the risk of AEs. CONCLUSIONS Nearly 1 in 5 patients who undergo therapeutic ERP will experience an AE; however, the rates of major AEs, including post-ERP pancreatitis, bleeding, and perforation, are low.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Augustin R. Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Philip Tatman
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Steven A. Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Hazem T. Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Mihir S. Wagh
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Raj J. Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
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Facciorusso A, Crinò SF, Tacelli M, Antonini F, Fantin A, Barresi L. Chronic use of statins and risk of post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2021; 15:195-202. [PMID: 32993442 DOI: 10.1080/17474124.2021.1829471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There is limited evidence on the role of chronic statin therapy in the prevention of acute pancreatitis after ERCP. The aim of this meta-analysis was to evaluate the efficacy of statins in the prophylaxis of post-ERCP pancreatitis. RESEARCH DESIGN AND METHODS Bibliographic search was performed through May 2020. The primary outcome was post-ERCP pancreatitis rate. An additional endpoint was the rate of severe pancreatitis. RESULTS Nine studies, of which 1 prospective and 8 retrospective series, with 9374 patients were included. Baseline clinical and technical features were well balanced between the two study groups. Overall, pooled rate of post-ERCP pancreatitis was 4.8% (3.2%-6.4%) in the statin group and 7.1% (5.9%-8.3%) in the control group, with no difference in terms of pancreatitis rate (odds ratio 0.66, 95% confidence interval 0.43-1.02). This finding was confirmed in the multivariate analysis adjusted for several clinical and technical characteristics (adjusted odds ratio 0.68, 0.40-1.15). No difference was observed between the two study groups in terms of severe pancreatitis rate (odds ratio 1.07, 0.61-1.89). CONCLUSIONS Our meta-analysis seems to suggest the non-superiority of chronic statin therapy in preventing post-ERCP pancreatitis.
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Affiliation(s)
- Antonio Facciorusso
- Department of Medical Sciences, Section of Gastroenterology, University of Foggia , Foggia, Italy
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, the Pancreas Institute, University Hospital of Verona , Verona, Italy
| | - Matteo Tacelli
- Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS , Milan, Italy
| | - Filippo Antonini
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, Augusto Murri Hospital , Fermo, Italy
| | - Alberto Fantin
- Gastroenterology Unit, Istituto Oncologico Veneto IOV-IRCCS , Padova, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione , Palermo, Italy
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Serrano JPR, Jukemura J, Romanini SG, Aguilar PFG, Castro JSLD, Torres IT, Pulla JAS, Neto OM, Taglieri E, Ardengh JC. Nonsteroidal anti-inflammatory drug effectivity in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis. World J Gastrointest Endosc 2020; 12:469-487. [PMID: 33269056 PMCID: PMC7677884 DOI: 10.4253/wjge.v12.i11.469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/24/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is the primary therapeutic procedure for the treatment of diseases affecting the biliary tree and pancreatic duct. Although the therapeutic success rate of ERCP is high, the procedure can cause complications, such as acute pancreatitis [post-ERCP pancreatitis (PEP)], bleeding and perforation.
AIM To assess the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) in preventing PEP during follow-up.
METHODS Databases such as MEDLINE, EMBASE and Cochrane Central Library were searched. Only randomized controlled trials (RCTs) comparing the efficacy of NSAIDs and placebo for the prevention of PEP were included. Outcomes evaluated included the incidence of PEP, severity of pancreatitis, route of administration, types, dose, and timing of administration of NSAIDs.
RESULTS Twenty-six RCTs were considered eligible with a total of 8143 patients analyzed. Overall, 4020 patients used NSAIDs before ERCP and 4123 did not use NSAIDs (control group). Ultimately, 298 cases of post-ERCP acute pancreatitis were diagnosed in the NSAID group and 484 cases in the placebo group. The risk of PEP was lower in the NSAID group risk difference (RD): -0.04; 95% confidence interval (CI): -0.07 to - 0.03; number needed to treat (NNT), 25; P < 0.05. NSAID use effectively prevented mild pancreatitis compared to placebo use (2.5% vs 4.1%; 95%CI: -0.05 to -0.01; NNT, 33; P < 0.05), but information on moderate PEP and severe PEP could not be fully elucidated. Only rectal administration reduced the incidence of PEP with RD: -0.06; 95%CI: -0.08 to -0.04; NNT, 17; P < 0.05). Furthermore, only the use of diclofenac or indomethacin was effective in preventing PEP, at a dose of 100 mg, which must be administered before performing ERCP.
CONCLUSION Rectal administration of diclofenac and indomethacin significantly reduced the risk of developing mild PEP. Additional RCTs are needed to compare the efficacy between NSAID routes of administration in preventing PEP.
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Affiliation(s)
| | - José Jukemura
- Department of Gastroenterology, University of Sao Paulo, São Paulo 05403-000, São Paulo, Brazil
| | - Samuel Galante Romanini
- Department of Gastrointestinal Endoscopy Service, Hospital 9 de Julho, São Paulo 01409002, São Paulo, Brazil
| | | | | | - Isabela Trindade Torres
- Department of Gastrointestinal Endoscopy Service, Hospital 9 de Julho, São Paulo 01409002, São Paulo, Brazil
| | | | - Otavio Micelli Neto
- Department of Gastrointestinal Endoscopy Service, Hospital 9 de Julho, São Paulo 01409002, São Paulo, Brazil
| | - Eloy Taglieri
- Department of Gastrointestinal Endoscopy Service, Hospital 9 de Julho, São Paulo 01409002, São Paulo, Brazil
| | - José Celso Ardengh
- Department of Gastroenterology, University of Sao Paulo, São Paulo 05403-000, São Paulo, Brazil
- Department of Gastrointestinal Endoscopy Service, Hospital 9 de Julho, São Paulo 01409002, São Paulo, Brazil
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Thiruvengadam NR, Kochman ML. Emerging Therapies to Prevent Post-ERCP Pancreatitis. Curr Gastroenterol Rep 2020; 22:59. [PMID: 33188441 DOI: 10.1007/s11894-020-00796-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to evaluate emerging, novel therapies for the prevention of post-ERCP pancreatitis. RECENT FINDINGS Rectal indomethacin reduces the risk of pancreatitis in low- and average-risk patients, who comprise the majority of patients undergoing ERCP. An 8-h protocol of aggressive lactated Ringer's reduces the risk of pancreatitis in average-risk patients. Sublingual nitrate may provide additional benefit to rectal NSAIDs in preventing PEP. A tacrolimus trough > 2.5 ng/mL was recently shown to be associated with a lower risk of PEP in liver transplant patients undergoing ERCP. Routine usage of rectal indomethacin in all patients undergoing ERCP reduces the risk of PEP. Pancreatic-duct stents reduce the risk of PEP in high-risk patients. There is emerging data that aggressive hydration with lactated Ringer's and nitrates may further reduce PEP. Tacrolimus is a promising potential agent to prevent PEP but needs further clinical study.
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Affiliation(s)
- Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, University of California San Francisco, 513 Parnassus Avenue, S-357, Box 0538, San Francisco, CA, 94143-0538, USA. .,Gastroenterology Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Michael L Kochman
- Gastroenterology Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Endoscopic Innovation, Research and Training, Perelman School of Medicine, Philadelphia, PA, USA
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Oh HC, Easler JJ, El Hajj II, Watkins J, Fogel EL, McHenry L, Sherman S, Kang H, Lehman GA. Effect of calcineurin inhibitor on post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with liver transplantation: a propensity-matched cohort study. Korean J Intern Med 2020; 35:1364-1370. [PMID: 32066219 PMCID: PMC7652662 DOI: 10.3904/kjim.2019.444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 01/04/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND/AIMS A calcineurin inhibitor may alter pancreatic function and inflammatory reaction. This study aimed to determine the possible pharmacologic effect of the calcineurin inhibitor, tacrolimus, on pancreatic function, and to determine its preventive effect on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in liver transplantation (LT) patients. METHODS The serum amylase and lipase values before and after LT were compared. The frequency of post-ERCP pancreatitis was compared between non-LT and LT patients, using propensity score matching method. RESULTS Median serum amylase values (normal range, 19 to 86 U/L) were 49.0 U/L (38.0 to 68.0) before LT and 27.0 U/L (19.3 to 36.8) after LT, and median serum lipase values (normal range, 7 to 59 U/L) were 40.0 U/L (26.5 to 54.0) before LT and 10.5 U/L (6.0 to 21.0) after LT. Both serum amylase and lipase values significantly decreased after LT (p < 0.001), and to a level comparable to chronic pancreatitis. There was a marginal significant difference between the non-LT and LT groups before the propensity score matching with respect to frequency of post-ERCP pancreatitis (16 [3.2%] in non-LT group vs. 2 [0.9%] in LT group, p = 0.069). After propensity score matching, a marginal significant difference still existed with respect to frequency of post-ERCP pancreatitis (7 [4.8%] in non-LT group vs. 1 [0.7%] in LT group, p = 0.067). CONCLUSION The immunosuppression with calcineurin inhibitor may reduce not only the pancreatic enzyme dynamics but also inciting inflammatory event including post-ERCP pancreatitis.
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Affiliation(s)
- Hyoung-Chul Oh
- Division of Gastroenterology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jeffrey J. Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ihab I. El Hajj
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - James Watkins
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Evan L. Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lee McHenry
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Glen A. Lehman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
- Correspondence to Glen A. Lehman, M.D. Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 N. University Boulvard, Suite 1634, Indianapolis, IN 46202, USA Tel: +1-317-944-0925 Fax: +1-317-968-1265 E-mail:
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48
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Regular Statin Use and Incidence of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis. J Clin Gastroenterol 2020; 54:905-910. [PMID: 31895166 DOI: 10.1097/mcg.0000000000001312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
GOALS AND BACKGROUND Endoscopic retrograde cholangiopancreatography is widely utilized to diagnose and treat various pancreaticobiliary diseases, but postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) can be a fatal adverse event. Evidence suggests that statins may exhibit suppressive effects on inflammation in the pancreas. We carried out an observational cohort study to examine the protective effect of statins on PEP. STUDY We retrospectively identified consecutive patients who underwent endoscopic retrograde cholangiopancreatography at a tertiary care center in Japan between January 2010 and January 2019. The incidences of PEP were compared between regular and nonregular statin users. Using the multivariable logistic regression model, we examined the association of regular statin use with the incidence of PEP controlling for potential risk factors for PEP. RESULTS We included 2664 patients (328 regular statin users and 2336 nonregular users). The incidence of PEP did not differ by statin use status (P=0.52): 8.8% in regular statin users and 7.9% in nonregular users. The multivariable-adjusted odds ratio for PEP comparing regular statin use with nonregular use was 1.08 (95% confidence interval, 0.67-1.72; P=0.76). When we examined specific statin types (hydrophilic and lipophilic statins), we consistently observed the null association: 6.8% of 132 hydrophilic statin users and 10% of 196 lipophilic statin users (P=0.74 and 0.27, respectively, compared with nonregular users). CONCLUSIONS Regular statin use was not shown to be protective against PEP. A further investigation is warranted before this medication is tested in prospective randomized trials.
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Shou-xin Y, Shuai H, Fan-guo K, Xing-yuan D, Jia-guo H, Tao P, Lin Q, Yan-sheng S, Ting-ting Y, Jing Z, Fang L, Hao-liang Q, Man L. Rectal nonsteroidal anti-inflammatory drugs and pancreatic stents in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: A network meta-analysis. Medicine (Baltimore) 2020; 99:e22672. [PMID: 33080710 PMCID: PMC7571888 DOI: 10.1097/md.0000000000022672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
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.
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50
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Mansour-Ghanaei F, Joukar F, Khalesi AA, Naghipour M, Sepehrimanesh M, Mojtahedi K, Yeganeh S, Saedi HS, Asl SF. Naproxen, isosorbide dinitrate and co-administration cannot prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: Randomized controlled trial. Ann Hepatobiliary Pancreat Surg 2020; 24:259-268. [PMID: 32843590 PMCID: PMC7452799 DOI: 10.14701/ahbps.2020.24.3.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Acute pancreatitis is the most widespread complication of endoscopic retrograde cholangiopancreatography. Here, we investigated the efficacy of rectal suppository naproxen, sublingual isosorbide dinitrate and their co-administration in the prevention of post-ERCP pancreatitis. Methods This double-blind randomized clinical trial carried out from June 2015 to February 2016 at the Gastrointestinal and Liver Diseases Research Center in Rasht, Iran. A total of 585 patients were selected from candidates for diagnostic or therapeutic ERCP by using the simple sampling method. Patients divided into three groups. Group A received 500 mg naproxen, group B took 5 mg isosorbide dinitrate, and group C was co-administrated both agents before ERCP. The primary outcome measure was the development of pancreatitis onset of pain in the upper abdomen and increase of serum amylase activity more than 3 times over the upper normal limit (60-100 IU/L) within first the 24 h post-ERCP. Results Totally, 80 patients developed PEP included 29 (4.9%), 24 (4.1%), and 27 (4.6%) patients in groups A, B, and C, respectively (p=0.845). Longer ERCP time (p=0.041), using diazepam (p=0.033), a higher number of pancreatic ducts cannulation (p<0.001), pancreatic duct injection (p=0.013), and using pancreatic stent (p=0.004) were the predisposing factors for PEP. Conclusions Our findings indicated that prophylactic naproxen suppository or isosorbide dinitrate sublingually or co-administration had no significant difference in the prevention and severity of PEP, however, enhancing the endoscopist’s skills can be effective. Departments and educational hospitals should develop their assessment and quality assurance measures for the training of fellows’ not only technical training but also an understanding of the diagnostic and therapeutic roles of the procedure.
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Affiliation(s)
- Fariborz Mansour-Ghanaei
- GI Cancer Screening and Prevention Research Center, Rasht, Iran.,Caspian Digestive Disease Research Center, Rasht, Iran
| | - Farahnaz Joukar
- GI Cancer Screening and Prevention Research Center, Rasht, Iran.,Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | | | | | - Masood Sepehrimanesh
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran.,New Iberia Research Center, University of Louisiana, Lafayette, LA, USA
| | - Kourosh Mojtahedi
- Caspian Digestive Disease Research Center, Rasht, Iran.,Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Sara Yeganeh
- GI Cancer Screening and Prevention Research Center, Rasht, Iran.,Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
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