Botulinum toxin injection after biliary sphincterotomy

Randomized trial of high-dose rectal diclofenac suppository and epinephrine spray on duodenal papilla for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND AND AIMS

High-dose rectal diclofenac suppository and epinephrine spray on duodenal papilla during endoscopic retrograde cholangiopancreatography (ERCP) may reduce the incidence of post-ERCP pancreatitis. We performed randomized trial to compare the effect of combination of rectal diclofenac and epinephrine spray on papilla (group A) vs. combination of rectal diclofenac with saline spray (group B) for prevention of post-ERCP pancreatitis.

METHODS

We performed a double-blind trial at tertiary care center from April 2018 to May 2020 on 882 patients with naive papilla undergoing ERCP. The patients were randomly assigned to groups, A (n=437) or B (n=445). All patients received a single dose of rectal diclofenac 100 mg within 30 minutes before ERCP; 20 mL of diluted epinephrine 0.02% (group A) or saline (group B) was then sprayed on the duodenal papilla at the end of ERCP. The primary outcome was to compare incidence of post-ERCP pancreatitis (PEP) in two groups.

RESULTS

The groups had similar baseline characteristics. PEP developed in 28 patients in group A (6.4%) and 35 patients in group B (7.9%) (relative risk, 1.1; 95% CI, 0.87-1.39; p=0.401).

CONCLUSION

Our study showed that addition of epinephrine spray on duodenal papilla did not reduce the risk of post-ERCP pancreatitis. There is need for further studies to evaluate the role of different concentrations of epinephrine spray on papilla for prevention of post-ERCP pancreatitis.

TRIAL REGISTRATION

Clinical Trials Registry- India (CTRI/2018/04/013396).

Exploring the role of botulinum toxin in critical care

INTRODUCTION

Botulinum neurotoxin (BoNT) is one of the most potent and extensively studied neurotoxins with clinical applications across several different medical specialties. This review article explores the latest evidence for therapeutic applications of BoNT in patients receiving critical management in an intensive care unit (ICU).

AREAS COVERED

The authors did a literature search in PubMed, Google Scholar, and Texas Medical Center Library database for studies describing the use of BoNT in a critical care setting. They extracted information on study design, patient selection, methodology, and results of relevant studies. Based on initial identification of 85 studies and after conducting screening, the authors identified 61 studies to be included in this review. In an ICU setting, BoNT has been used for several neurological and non-neurological indications. However, the supporting evidence is mostly limited to small observational studies.

EXPERT OPINION

The use of BoNT in this setting is largely underutilized due to paucity of well-designed clinical trials and financial barriers. Further research is needed to provide evidence for the safety and efficacy of BoNT and to optimize the dosing and injection techniques for various conditions encountered in this setting.

Gastrointestinal Uses of Botulinum Toxin

Botulinum toxin (BT), one of the most powerful inhibitors that prevents the release of acetylcholine from nerve endings, represents an alternative therapeutic approach for "spastic" disorders of the gastrointestinal tract such as achalasia, gastroparesis, sphincter of Oddi dysfunction, chronic anal fissures, and pelvic floor dyssynergia.BT has proven to be safe and this allows it to be a valid alternative in patients at high risk of invasive procedures but long-term efficacy in many disorders has not been observed, primarily due to its relatively short duration of action. Administration of BT has a low rate of adverse reactions and complications. However, not all patients respond to BT therapy, and large randomized controlled trials are lacking for many conditions commonly treated with BT.The local injection of BT in some conditions becomes a useful tool to decide to switch to more invasive therapies. Since 1980, the toxin has rapidly transformed from lethal poison to a safe therapeutic agent, with a significant impact on the quality of life.

Randomized sham-controlled trials in endoscopy: a systematic review and meta-analysis of adverse events

BACKGROUND AND AIMS

Sham procedures in endoscopy are used with the intention of controlling for placebo response, potentially allowing more precise evaluation of treatment effect. Nevertheless, this type of study may impose significant risk without potential benefit for those in the sham group. The aim of the current study was to systematically review and analyze the endoscopic literature to assess the safety of sham controls.

METHODS

MEDLINE and Embase databases were searched for endoscopic sham procedures for all dates to July 2017. Only randomized controlled trials comparing an endoscopic therapy with a sham were included. Primary outcome was adverse events (AEs) categorized as mild, moderate, or severe. Results were combined using a random-effects model. Heterogeneity was assessed with the I² statistic, and publication bias was assessed with the Egger test and funnel plots.

RESULTS

Data were extracted from 34 publications (1987-2017; 100% full text), with a total of 2492 procedures (1355 treatment/1137 sham). Sham procedures involved upper endoscopy (31 studies) and ERCP (3 studies). Treatment arms included procedures with the following indications: weight loss (38.2%), GI bleeding (26.5%), GERD (20.6%), sphincter of Oddi dysfunction (8.8%), and dysphagia (6.2%). Overall percentage of severe adverse events (SAEs) in the sham group was 1.7% (19/1137). Of these, the most common SAEs in the sham groups were need for surgery/intensive care unit stay (35.3%), post-ERCP pancreatitis (23.5%), and perforation (11.8%). There was no significant difference in the odds of developing an SAE between the treatment group and the sham group (odds ratio, 1.3; 95% confidence interval [CI], 0.7-2.3). The pooled additional risk incurred from being initially randomized to the sham arm and then receiving a cross-over intervention was significant (RR, 1.33; 95% CI, 1.14-1.56; P < .001), compared with patients initially randomized to the study intervention.

CONCLUSION

The frequency of AEs in endoscopic sham procedures is substantial, and patients are subjected to considerable morbidity. These results raise a serious ethical dilemma regarding the use of sham-controlled trials.

Celecoxib Oral Administration for Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Randomized Prospective Trial

OBJECTIVES

Rectal nonsteroidal anti-inflammatory drugs have reported promising prophylactic activity in post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Conversely, cyclooxygenase-2 enzyme has been suggested to contribute to experimental acute pancreatitis. The aim of this study was to evaluate the efficacy of oral administration of celecoxib, a cyclooxygenase-2 inhibitor, for the prevention of PEP.

METHODS

We performed a prospective randomized controlled study. Patients who were scheduled to undergo ERCP were randomized to receive either oral 400-mg celecoxib tablets 1 hour before ERCP and saline infusion (celecoxib group) or saline infusion only (control group). The primary outcome measure was the frequency of PEP.

RESULTS

A total of 170 patients were randomized; 85 patients each in the celecoxib group and control group were analyzed. After the procedure, 23 patients (13.5%) developed PEP. There was no difference in the frequency of PEP between the 2 groups (control group vs celecoxib group, 15.3% (13/85) vs 11.7% (10/85); P = 0.65). The severity of PEP, asymptomatic hyperamylasemia, and post-ERCP pain were not significantly different between the 2 groups. There were no adverse events related to celecoxib treatment.

CONCLUSIONS

Oral administration of celecoxib had no beneficial preventive effect on PEP.

Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Medications and Techniques

Over the past 2 decades, it increasingly has been recognized that endoscopic retrograde cholangiopancreatography (ERCP) is the most predictable provocateur of acute pancreatitis, with an incidence of more than 15% in high-risk patients. For this reason, there has been considerable interest in the effect of periprocedural drug administration as well as different ERCP techniques on both the incidence and severity of post-ERCP pancreatitis. Although many agents and techniques have shown promise in small clinical studies, the majority of these have failed to yield consistent benefit in larger randomized patient groups. This review summarizes the data on medications and ERCP techniques that have been studied for the prevention of post-ERCP pancreatitis.

Treatment of gastrointestinal sphincters spasms with botulinum toxin A

Botulinum toxin A inhibits neuromuscular transmission. It has become a drug with many indications. The range of clinical applications has grown to encompass several neurological and non-neurological conditions. One of the most recent achievements in the field is the observation that botulinum toxin A provides benefit in diseases of the gastrointestinal tract. Although toxin blocks cholinergic nerve endings in the autonomic nervous system, it has also been shown that it does not block non-adrenergic non-cholinergic responses mediated by nitric oxide. This has promoted further interest in using botulinum toxin A as a treatment for overactive smooth muscles and sphincters. The introduction of this therapy has made the treatment of several clinical conditions easier, in the outpatient setting, at a lower cost and without permanent complications. This review presents current data on the use of botulinum toxin A in the treatment of pathological conditions of the gastrointestinal tract.

Prevention and treatment of post-ERCP pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) is widely used in the diagnosis and treatment of cholangiopancreatic diseases, and pancreatitis remains the most common and severe complication. It is therefore important to minimize the incidence and severity of pancreatitis. This paper discusses the recent progress in the prevention and treatment of post-ERCP pancreatitis.

A randomized trial of rectal indomethacin and sublingual nitrates to prevent post-ERCP pancreatitis

OBJECTIVES

Acute pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography (ERCP). Recent data suggest that indomethacin can reduce the risk of post-ERCP pancreatitis (PEP) in high-risk individuals. However, whether the combination of indomethacin and sublingual nitrates is superior to indomethacin alone is unknown. Therefore, we aimed to evaluate the efficacy of rectally administered indomethacin plus sublingual nitrate compared with indomethacin alone to prevent PEP.

METHODS

During a 17-month period, all eligible patients who underwent ERCP were enrolled in this study. We excluded patients who had undergone a prior endoscopic sphincterotomy. In a double-blind controlled randomized trial, patients received a suppository containing 100 mg of indomethacin, plus 5 mg of sublingual nitrate (group A), or a suppository containing 100 mg of indomethacin, plus sublingual placebo (group B), before ERCP. Serum amylase levels and clinically pertinent evaluations were measured in all patients after ERCP.

RESULTS

Of the 300 enrolled patients, 150 received indomethacin plus nitrate. Thirty-three patients developed pancreatitis: 10 (6.7%) in group A and 23 (15.3%) in group B (P=0.016, risk ratio=0.39, 95% confidence intervals (CI): 0.18-0.86). More than 80% of the patients were at high risk of developing pancreatitis after ERCP. Absolute risk reduction, relative risk reduction, and number needed to treat for the prevention of PEP were 8.6% (95% CI: 4.7-14.5), 56.2% (95% CI: 50.6-60.8), and 12 (95% CI: 7-22), respectively.

CONCLUSIONS

Combination of rectal indomethacin and sublingual nitrate given before ERCP was significantly more likely to reduce the incidence of PEP than indomethacin suppository alone. Multicenter trials to confirm these promising findings are needed.

Can patient and pain characteristics predict manometric sphincter of Oddi dysfunction in patients with clinically suspected sphincter of Oddi dysfunction?

BACKGROUND

Biliopancreatic-type postcholecystectomy pain, without significant abnormalities on imaging and laboratory test results, has been categorized as "suspected" sphincter of Oddi dysfunction (SOD) type III. Clinical predictors of "manometric" SOD are important to avoid unnecessary ERCP, but are unknown.

OBJECTIVE

To assess which clinical factors are associated with abnormal sphincter of Oddi manometry (SOM).

DESIGN

Prospective, cross-sectional.

SETTING

Tertiary.

PATIENTS

A total of 214 patients with suspected SOD type III underwent ERCP and pancreatic SOM (pSOM; 85% dual SOM), at 7 U.S. centers (from August 2008 to March 2012) as part of a randomized trial.

INTERVENTIONS

Pain and gallbladder descriptors, psychosocial/functional disorder questionnaires.

MAIN OUTCOME MEASUREMENTS

Abnormal SOM findings. Univariate and multivariate analyses assessed associations between clinical characteristics and outcome.

RESULTS

The cohort was 92% female with a mean age of 38 years. Baseline pancreatic enzymes were increased in 5%; 9% had minor liver enzyme abnormalities. Pain was in the right upper quadrant (RUQ) in 90% (48% also epigastric); 51% reported daily abdominal discomfort. Fifty-six took narcotics an average of 33 days (of the past 90 days). Less than 10% experienced depression or anxiety. Functional disorders were common. At ERCP, 64% had abnormal pSOM findings (34% both sphincters, 21% biliary normal), 36% had normal pSOM findings, and 75% had at least abnormal 1 sphincter. Demographic factors, gallbladder pathology, increased pancreatobiliary enzymes, functional disorders, and pain patterns did not predict abnormal SOM findings. Anxiety, depression, and poorer coping were more common in patients with normal SOM findings (not significant on multivariate analysis).

LIMITATIONS

Generalizability.

CONCLUSIONS

Patient and pain factors and psychological comorbidity do not predict SOM results at ERCP in suspected type III SOD. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00688662.).

The diagnosis and management of Sphincter of Oddi dysfunction: a systematic review

OBJECTIVES

Sphincter of Oddi dysfunction (SOD) is a benign pathological syndrome. The clinical manifestations may be a consequence of an anatomical stenosis or sphincter dysmotility. Manometry is invasive and has an associated morbidity. Non-invasive investigations have been evaluated to ameliorate risk but have unknown efficacy. The review aims to critically appraise current evidence for the diagnosis and management of SOD.

METHODS

A systematic review of articles containing relevant search terms was performed.

RESULTS

Manometry is the current gold standard in selecting which patients are likely to benefit from endoscopic sphincterotomy (ES). It can, however, be misleading. Several non-invasive investigations were identified. These have poor sensitivities and specificities compared to manometry. There is a paucity of data examining the investigation's specific ability to select patients for ES. Outcomes of ES for Type I SOD are favourable irrespective of manometry. Types II and III SOD may respond to an initial trial of medical therapy. Manometry may predict response to ES in Type II SOD, but not in Type III.

CONCLUSIONS

Non-invasive investigations currently lack sufficient sensitivities and specificities for routine use in diagnosing SOD. Type I SOD should be treated with ES without manometry. Manometry may be useful for Type II SOD. However, whilst data is lacking a therapeutic trial of Botox(TM) or trial stenting may bean alternative. Careful and thorough patient counselling is essential. Type III SOD is associated with high complications from manometry and poor outcomes from ES. Alternative diagnoses should be thoroughly sought and its management should be medical.

The Size of the Papilla of Vater and Its Relation to Its Height in Comparison with the Visibility of the Sphincter of Oddi before and after Cholecystectomy

This study investigated the changes in the surface area and height of the papilla of Vater (PV) and the visibility of the sphincter of Oddi complex (SOK) using endoscopic ultrasound (EUS) examinations of 80 patients with symptomatic gallstones before and at 3 and 6 months after cholecystectomy. Following surgery, 50 patients experienced early atypical symptoms characteristic of postcholecystectomy syndrome (PCS) and 30 patients were asymptomatic. The PV measurements were greater in all patients compared with normal reference values and increased significantly from before surgery to 3 months postsurgery. At 6 months postsurgery, both the surface area and height of the PV had significantly decreased to preoperative values but remained higher than normal. The proportion of patients with a visible SOK had increased by 3 months postsurgery but had reduced again by 6 months. There were no significant differences between symptomatic and asymptomatic patients, suggesting that the changes observed in the PV and SOK do not explain the presence of the atypical symptoms of PCS.

Endoscopic retrograde cholangiopancreatography associated pancreatitis: A 15-year review

The aim of this article is to review the literature regarding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. We searched for and evaluated all articles describing the diagnosis, epidemiology, pathophysiology, morbidity, mortality and prevention of post-ERCP pancreatitis (PEP) in adult patients using the PubMed database. Search terms included endoscopic retrograde cholangiopancreatography, pancreatitis, ampulla of vater, endoscopic sphincterotomy, balloon dilatation, cholangiography, adverse events, standards and utilization. We limited our review of articles to those published between January 1, 1994 and August 15, 2009 regarding human adults and written in the English language. Publications from the reference sections were reviewed and included if they were salient and fell into the time period of interest. Between the dates queried, seventeen large (> 500 patients) prospective and four large retrospective trials were conducted. PEP occurred in 1%-15% in the prospective trials and in 1%-4% in the retrospective trials. PEP was also reduced with pancreatic duct stent placement and outcomes were improved with endoscopic sphincterotomy compared to balloon sphincter dilation in the setting of choledocholithiasis. Approximately 34 pharmacologic agents have been evaluated for the prevention of PEP over the last fifteen years in 63 trials. Although 22 of 63 trials published during our period of review suggested a reduction in PEP, no pharmacologic therapy has been widely accepted in clinical use in decreasing the development of PEP. In conclusion, PEP is a well-recognized complication of ERCP. Medical treatment for prevention has been disappointing. Proper patient selection and pancreatic duct stenting have been shown to reduce the complication rate in randomized clinical trials.

Evaluation of recombinant platelet-activating factor acetylhydrolase for reducing the incidence and severity of post-ERCP acute pancreatitis

BACKGROUND

Pancreatitis is the most common major complication of diagnostic and therapeutic ERCP. Platelet-activating factor (PAF) has been implicated in the pathophysiologic events associated with acute pancreatitis. Animal and human studies suggested that recombinant PAF acetylhydrolase (rPAF-AH) might ameliorate the severity of acute pancreatitis.

OBJECTIVE

Our purpose was to determine whether prophylactic rPAF-AH administration reduces the frequency or severity of post-ERCP pancreatitis in high-risk patients.

DESIGN

Randomized, multicenter, double-blind, placebo-controlled study.

INTERVENTIONS

Patients received rPAF-AH at a dose of either 1 or 5 mg/kg or placebo. Patients were administered a single intravenous infusion over 10 minutes of study drug or placebo <1 hour before ERCP.

MAIN OUTCOME MEASUREMENTS

Standardized criteria were used to diagnose and grade the severity of post-ERCP pancreatitis. Adverse events were prospectively recorded.

RESULTS

A total of 600 patients were enrolled. There were no statistically significant differences among the treatment groups with respect to patient demographics, ERCP indications, and patient and procedure risk factors for post-ERCP pancreatitis with the following exceptions: the rPAF-AH 5 mg/kg group had significantly fewer patients younger than 40 years old and scheduled to undergo a therapeutic ERCP involving the pancreatic sphincter or duct. Post-ERCP pancreatitis occurred in 17.5%, 15.9%, and 19.6% of patients receiving rPAF-AH (1 mg/kg), rPAF-AH (5 mg/kg), and placebo, respectively (P = .59 for rPAF-AH 1 mg/kg vs placebo and P = .337 for rPAF-AH 5 mg/kg vs placebo). There was no statistically significant difference between the groups with regard to the severity of pancreatitis, frequency of amylase/lipase elevation more than 3 times normal, or abdominal pain.

CONCLUSIONS

There was no apparent benefit of rPAF-AH treatment compared with placebo in reducing the incidence of post-ERCP pancreatitis in subjects at increased risk.

Effects in the control of edema of the papilla of Vater by epinephrine saline irrigation after endoscopic retrograde cholangiopancreatography in an endoscopy center in Japan, 2003 to 2007: exploratory retrospective analysis to evaluate the characteristics of eligible patients with a focus on serum amylase levels

OBJECTIVE

To evaluate the effects of localized irrigation with epinephrine saline after endoscopic retrograde cholangiopancreatography (ERCP).

PATIENTS AND METHODS

One hundred and fourteen patients who underwent ERCP in our institute were treated with or without irrigation using epinephrine diluted in saline after ERCP to prevent post-ERCP pancreatitis. The serum amylase levels, white blood cell counts, and urine amylase levels were measured at 24 and 48 hours after ERCP.

RESULTS

The treatment resulted in improvements in all items. A univariate analysis of the explanatory variables between the treatment and untreated groups revealed the treatment to be effective, but not statistically significant. Gender and cannulation of the pancreatic duct were the only variables with significant partial regression coefficients in the multiple regression model with all explanatory variables (p=0.045). When a stratified analysis was conducted using gender as a moderator variable, the treatment became a significant preventive factor (p=0.038), and cannulation of the pancreatic duct was a significant risk factor (p=0.027) in female patients.

CONCLUSION

We suggest that irrigating with epinephrine saline into the papilla may be effective for preventing pancreatitis in female patients who received ERCP with cannulation of their pancreatic duct.

Early successes and late failures in the prevention of post endoscopic retrograde cholangiopancreatography

Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The only way to prevent this complication is to avoid an ERCP all together. Because of the risks involved, a careful consideration should be given to the indication for ERCP and the potential risk/benefit ratio of the test. Once a decision to perform an ERCP is made, the procedure should be carried out with meticulous care by an experienced endoscopist, and with a minimum of pancreatic duct opacification. Several pharmacologic agents have been tested, but to date the most important method of reducing post ERCP pancreatitis is the placement of pancreatic stent. Pancreatic stents should be placed in all patients at high risk of this complication such as those undergoing pancreatic sphincterotomy, pancreatic duct manipulation and intervention, and patients with suspected sphincter of Oddi dysfunction. Pancreatic stents should be also considered in patients requiring precut sphincterotomy to gain biliary access.

Sphincter of Oddi dysfunction: managing the patient with chronic biliary pain

Sphincter of Oddi dysfunction (SOD) is a syndrome of chronic biliary pain or recurrent pancreatitis due to functional obstruction of pancreaticobiliary flow at the level of the sphincter of Oddi. The Milwaukee classification stratifies patients according to their clinical picture based on elevated liver enzymes, dilated common bile duct and presence of abdominal pain. Type I patients have pain as well as abnormal liver enzymes and a dilated common bile duct. Type II SOD consists of pain and only one objective finding, and Type III consists of biliary pain only. This classification is useful to guide diagnosis and management of sphincter of Oddi dysfunction. The current gold standard for diagnosis is manometry to detect elevated sphincter pressure, which correlates with outcome to sphincterotomy. However, manometry is not widely available and is an invasive procedure with a risk of pancreatitis. Non-invasive testing methods, including fatty meal ultrasonography and scintigraphy, have shown limited correlation with manometric findings but may be useful in predicting outcome to sphincterotomy. Endoscopic injection of botulinum toxin appears to predict subsequent outcome to sphincterotomy, and could be useful in selection of patients for therapy, especially in the setting where manometry is unavailable.

Update on biliary endoscopy

PURPOSE OF REVIEW

Since the introduction of endoscopic retrograde cholangiopancreatography, there have been great improvements in the technique, equipment, and clinical utility of biliary endoscopy. In many cases, therapeutic endoscopic retrograde cholangiopancreatography can take the place of invasive surgery, including common bile duct exploration, thereby decreasing the patient's morbidity and recuperation time. Even with advances, such as stent placement for biliary strictures in a patient after liver transplantation, there is still room for improvement.

RECENT FINDINGS

Research over the past year has been focused on areas including improved imaging and tissue sampling of the biliary tree through endoscopic ultrasound techniques, better identification of patients at risk for pancreatitis after endoscopic retrograde cholangiopancreatography, and refinements in photodynamic therapy for the treatment of cholangiocarcinoma. International research has continued to emphasize biliary sphincterotomy compared with balloon dilation for the management of choledocholithiasis. Further developments in other fields, such as living related liver transplantation, provide challenges for the biliary endoscopist.

SUMMARY

This review focuses on some of the work being performed in the field of biliary endoscopy. The key studies were chosen to highlight some of the areas currently being investigated as well as to indicate certain fields that need further development.