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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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2
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Saglam-Metiner P, Yildiz-Ozturk E, Tetik-Vardarli A, Cicek C, Goksel O, Goksel T, Tezcanli B, Yesil-Celiktas O. Organotypic lung tissue culture as a preclinical model to study host- influenza A viral infection: A case for repurposing of nafamostat mesylate. Tissue Cell 2024; 87:102319. [PMID: 38359705 DOI: 10.1016/j.tice.2024.102319] [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: 09/18/2023] [Revised: 01/11/2024] [Accepted: 01/29/2024] [Indexed: 02/17/2024]
Abstract
Reliable and effective models for recapitulation of host-pathogen interactions are imperative for the discovery of potential therapeutics. Ex vivo models can fulfill these requirements as the multicellular native environment in the tissue is preserved and be utilized for toxicology, vaccine, infection and drug efficacy studies due to the presence of immune cells. Drug repurposing involves the identification of new applications for already approved drugs that are not related to the prime medical indication and emerged as a strategy to cope with slow pace of drug discovery due to high costs and necessary phases to reach the patients. Within the scope of the study, broad-spectrum serine protease inhibitor nafamostat mesylate was repurposed to inhibit influenza A infection and evaluated by a translational ex vivo organotypic model, in which human organ-level responses can be achieved in preclinical safety studies of potential antiviral agents, along with in in vitro lung airway culture. The safe doses were determined as 10 µM for in vitro, whereas 22 µM for ex vivo to be applied for evaluation of host-pathogen interactions, which reduced virus infectivity, increased cell/tissue viability, and protected total protein content by reducing cell death with the inflammatory response. When the gene expression levels of specific pro-inflammatory, anti-inflammatory and cell surface markers involved in antiviral responses were examined, the significant inflammatory response represented by highly elevated mRNA gene expression levels of cytokines and chemokines combined with CDH5 downregulated by 5.1-fold supported the antiviral efficacy of NM and usability of ex vivo model as a preclinical infection model.
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Affiliation(s)
- Pelin Saglam-Metiner
- Department of Bioengineering, Faculty of Engineering, Ege University, 35100 Izmir, Turkey; Translational Pulmonary Research Center (EgeSAM), Ege University, Izmir 35100, Turkey
| | - Ece Yildiz-Ozturk
- Translational Pulmonary Research Center (EgeSAM), Ege University, Izmir 35100, Turkey; Department of Food Processing, Food Technology Programme, Yasar University, 35100 Izmir, Turkey
| | - Aslı Tetik-Vardarli
- Translational Pulmonary Research Center (EgeSAM), Ege University, Izmir 35100, Turkey; Department of Medical Biology, Faculty of Medicine, Ege University, Izmir 35100, Turkey
| | - Candan Cicek
- Department of Medical Microbiology, Faculty of Medicine, Ege University, Izmir 35100, Turkey
| | - Ozlem Goksel
- Translational Pulmonary Research Center (EgeSAM), Ege University, Izmir 35100, Turkey; Department of Pulmonary Medicine, Division of Allergy and Immunology, Faculty of Medicine, Ege University, Izmir 35100, Turkey
| | - Tuncay Goksel
- Translational Pulmonary Research Center (EgeSAM), Ege University, Izmir 35100, Turkey; Department of Pulmonary Medicine, Division of Allergy and Immunology, Faculty of Medicine, Ege University, Izmir 35100, Turkey
| | | | - Ozlem Yesil-Celiktas
- Department of Bioengineering, Faculty of Engineering, Ege University, 35100 Izmir, Turkey; Translational Pulmonary Research Center (EgeSAM), Ege University, Izmir 35100, Turkey.
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Xie Y, Cheng Z, Deng C, Deng M, Zhang H. Nafamostat mesilate for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis based on prospective, randomized, and controlled trials. Medicine (Baltimore) 2023; 102:e35174. [PMID: 37832051 PMCID: PMC10578773 DOI: 10.1097/md.0000000000035174] [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: 06/23/2023] [Accepted: 08/21/2023] [Indexed: 10/15/2023] Open
Abstract
OBJECTIVES To evaluate the efficacy of nafamostat mesilate in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) by conduct a systematic review and meta-analysis. METHOD We retrieved for all randomized controlled trials (RCTs) about compare nafamostat mesilate with placebo in preventing PEP published before August 23, 2022, in 5 major electronic databases. The primary outcome was PEP rate, and the secondary outcome was post-ERCP hyperamylasemia (PEHA) rate. Subgroup analyses were performed to reveal the factors that may affect the preventive effect of nafamostat. Assessment of the quality of evidence was conducted based on Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. RESULTS According to the search strategy and criteria of inclusion and exclusion, 8 articles with a number of 3210 patients were included. The PEP incidence of the nafamostat group was inferior compared with the placebo group (4.6% vs 8.5%, RR = 0.50, 95% CI: 0.38-0.66). Subgroup analyses revealed that nafamostat had a preventive effect on patients with different risk stratification (High-risk: RR = 0.61, 95% CI: 0.43-0.86, Low-risk: RR = 0.28; 95% CI: 0.17-0.47). Different doses (20 mg: RR = 0.50, 95% CI: 0.36-0.69, 50 mg: RR = 0.45, 95% CI: 0.27-0.74) and duration (<12 hour: RR = 0.55, 95% CI: 0.37-0.81, ≥12 h: RR = 0.44, 95% CI: 0.29-0.66) of administration of nafamostat are adequate for the prevention of PEP, but postoperative administration may not help (preoperative: RR = 0.52, 95% CI: 0.39-0.69, postoperative: RR = 0.54, 95% CI: 0.23-1.23). Nafamostat may not efficacious in preventing severe PEP (Mild: RR = 0.49, 95% CI, 0.35-0.68, Moderate: RR = 0.47, 95% CI: 0.25-0.86, Severe: RR = 0.91, 95% CI, 0.25-3.29) or in low-quality studies (Low-quality: RR = 0.69, 95% CI: 0.13-3.60, High-quality: RR = 0.49, 95% CI: 0.37-0.65). CONCLUSION Preoperative use of nafamostat can effectively prevent PEP in patients with various risk stratification. Nafamostat can prevent mild and moderate PEP, but may not prevent severe PEP and PEHA. There should be more high-quality RCTs in future to strengthen the evidence of nafamostat in preventing PEP.
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Affiliation(s)
- Yu Xie
- Department of Infectious Diseases, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ziyao Cheng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Cunliang Deng
- Department of Infectious Diseases, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Mingming Deng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hailong Zhang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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4
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Akshintala VS, Singh VK. Postendoscopic Retrograde Cholangiopancreatography Pancreatitis Pathophysiology and Prevention. Gastrointest Endosc Clin N Am 2023; 33:771-787. [PMID: 37709410 DOI: 10.1016/j.giec.2023.05.001] [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] [Indexed: 09/16/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreato-biliary disorders. Pancreatitis remains the most frequent complication of the ERCP procedure, and it is, therefore, necessary to recognize the pathophysiology and risk factors contributing to the development of pancreatitis and understand the methods to prevent this complication.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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5
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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: 7] [Impact Index Per Article: 7.0] [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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6
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El Hage Chehade N, Ghoneim S, Shah S, Chahine A, Issak A, Choi AY, Moosvi Z, Chang KJ, Samarasena JB. Combination Topical Epinephrine and Non-steroidal Inflammatory Drugs in the Prevention of Post-ERCP Pancreatitis: A Systematic Review. Dig Dis Sci 2023; 68:957-968. [PMID: 35695971 DOI: 10.1007/s10620-022-07518-4] [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: 01/26/2022] [Accepted: 04/07/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND The utility of combination rectal NSAID and topical epinephrine (EI) or rectal NSAID and normal saline (SI) sprayed on duodenal papilla in the prevention of post-ERCP pancreatitis (PEP) has been studied but results have been conflicting. AIMS To evaluate the benefit of using combination prophylaxis in preventing PEP. METHODS A literature search was performed using Scopus, PubMed/MEDLINE, and Cochrane databases in May 2021. Randomized controlled trials (RCTs) involving adults patients who underwent ERCP and received EI versus SI were eligible for inclusion. The pooled effect was expressed as odds ratio (OR) to assess the rate of PEP, severity of PEP, and specific adverse events. The results were pooled using Reviewer Manager 5.4 software. RESULTS Six RCTs involving 4016 patients were included in the final analysis. The EI group did not demonstrate any significant benefit over SI group in preventing PEP (OR = 1.00, 95% CI [0.68, 1.45], P = 0.98), irrespective of gender or the epinephrine concentration used. The tests for subgroup differences were not statistically significant with P-values of 0.66 and 0.28, respectively. The addition of topical epinephrine to rectal NSAID did not improve the rate of moderate to severe PEP (OR = 0.94, P = 0.86) or PEP in high-risk patients (OR = 1.14, 95%, P = 0.73). The rates of infection, including cholangitis and sepsis (OR = 0.63, P = 0.07), gastrointestinal bleeding (OR = 1.25, P = 0.56) and procedure-related death (OR = 0.71, P = 0.59) were similar between both groups. CONCLUSION The addition of topical epinephrine did not demonstrate any benefit over rectal NSAID alone in preventing PEP or reducing other procedure-related adverse events.
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Affiliation(s)
- Nabil El Hage Chehade
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Sara Ghoneim
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sagar Shah
- Department of Internal Medicine, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Anastasia Chahine
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, 101 The City Drive S, Orange, CA, 92868, USA
| | - Abdulfatah Issak
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Alyssa Y Choi
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, 101 The City Drive S, Orange, CA, 92868, USA
| | - Zain Moosvi
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth J Chang
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, 101 The City Drive S, Orange, CA, 92868, USA
| | - Jason B Samarasena
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, 101 The City Drive S, Orange, CA, 92868, USA.
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7
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Nebiki H, Fujita K, Yazumi S, Takenaka M, Maruo T, Matsumoto K, Asada M, Eguchi T, Matsubara T, Yasumura S, Matsumoto H, Tamura T, Marui S, Hasegawa K, Mitoro A, Masuda A, Takada R, Minami R, Ogura T, Hoki N, Funatsu E, Kurita A, Onoyama T, Tomoda T, Ueki T, Yamasaki T, Sakata Y, Katayama T, Kawamura T, Kawamoto H. Does endoscopic sphincterotomy contribute to the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis after endoscopic biliary stenting for malignant biliary obstruction? A multicenter prospective cohort study. Surg Endosc 2022; 37:3463-3470. [PMID: 36575219 DOI: 10.1007/s00464-022-09823-5] [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: 09/08/2022] [Accepted: 12/05/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND There is no consensus on the necessity of endoscopic sphincterotomy (ES) to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after endoscopic stenting in patients with malignant biliary obstruction. We investigated the incidence of PEP after endoscopic biliary stenting for malignant biliary obstruction with or without ES in a multicenter prospective cohort study. METHODS We enrolled 807 patients who underwent endoscopic biliary stenting for malignant biliary obstruction with a native papilla at 36 hospitals between April 2017 and March 2018. The incidence of PEP in patients with or without ES was compared for subgroups based on stent type, placement method, and patient background. Univariate and multivariate analysis was performed to investigate the incidence of PEP in all stenting patients. RESULTS Plastic and metal stents (MS) were inserted in 598 and 209 patients, respectively. The incidence of PEP in patients with or without ES was 7.9% and 7.4%, respectively among all stenting patients. The incidences of PEP with or without ES in plastic stent insertion patients, patients with MS insertion, stent insertions across the papilla, stent insertions across the papilla in patients without main pancreatic duct obstruction, and fully covered MS insertions across the papilla were compared. There was no overall significant difference in the incidence of PEP between those with or without ES. Multivariate logistic regression analysis for the incidence of PEP in all stenting patients revealed obstruction of the main pancreatic duct at the pancreatic head and epinephrine spraying on the papilla were significant factors; there was no significant difference in the incidence of PEP between patients with or without ES. CONCLUSION Endoscopic sphincterotomy may not contribute to the prevention of PEP after endoscopic biliary stenting for malignant biliary obstruction, even in cases of insertion with a fully covered MS across the papilla.
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Affiliation(s)
- Hiroko Nebiki
- Department of Gastroenterology, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-Ku, Osaka, Japan.
| | - Koichi Fujita
- Department of Gastroenterology and Hepatology, Yodogawa Christian Hospital, Osaka, Japan
| | - Shujiro Yazumi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Toru Maruo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Kazuya Matsumoto
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Masanori Asada
- Department of Gastroenterology and Hepatology, Japanese Red Cross Osaka Hospital, Osaka, Japan
| | - Takaaki Eguchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | | | | | - Hisakazu Matsumoto
- Department of Gastroenterology and Hepatology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Takashi Tamura
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Saiko Marui
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Akira Mitoro
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryoji Takada
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ryuki Minami
- Department of Gastroenterology, Tenri Hospital, Nara, Tenri, Japan
| | - Takeshi Ogura
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Noriyuki Hoki
- Department of Gastroenterology, Bellland General Hospital, Sakai, Japan
| | - Eiji Funatsu
- Department of Gastroenterology, Chibune General Hospital, Osaka, Japan
| | - Akira Kurita
- Department of Gastroenterology and Hepatology, Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Takumi Onoyama
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Takeshi Tomoda
- Department of Gastroenterology, Okayama City Hospital, Okayama, Japan
| | - Toshiharu Ueki
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Tomoaki Yamasaki
- Department of Gastroenterology, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-Ku, Osaka, Japan
| | - Yuhei Sakata
- Department of Gastroenterology, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-Ku, Osaka, Japan
| | - Toshihiro Katayama
- Faculty of Health Sciences Department of Medical Engineering, Morinomiya University of Medical Sciences, Osaka, Japan
| | | | - Hirofumi Kawamoto
- Kawasaki Medical School, General Internal Medicine 2, General Medical Center, Kawasaki Medical School, Okayama, Japan
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Fujita K, Yazumi S, Matsumoto H, Asada M, Nebiki H, Matsumoto K, Maruo T, Takenaka M, Tomoda T, Onoyama T, Kurita A, Ueki T, Katayama T, Kawamura T, Kawamoto H. Multicenter prospective cohort study of adverse events associated with biliary endoscopic retrograde cholangiopancreatography: Incidence of adverse events and preventive measures for post-endoscopic retrograde cholangiopancreatography pancreatitis. Dig Endosc 2022; 34:1198-1204. [PMID: 34963021 PMCID: PMC9540598 DOI: 10.1111/den.14225] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/18/2021] [Accepted: 12/27/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The reported incidence of adverse events (AEs) in endoscopic retrograde cholangiopancreatography (ERCP) varies between 2.5% and 14%. The aim of this study was to evaluate the incidence and severity of AEs in biliary ERCP and to specify the risk factors and preventive measures for post-ERCP pancreatitis (PEP). METHODS Patients with biliary disease with intact papilla were prospectively enrolled at 36 hospitals between April 2017 and March 2018. The primary outcomes were the incidence and severity of AEs. RESULTS A total of 16,032 ERCP procedures were performed at the 36 hospitals during the study period and 3739 patients were enrolled. The overall incidence of AEs was 10.1% and ERCP-related mortality was 0.08%. PEP developed in 258 cases (6.9%), bleeding in 33 (0.9%), instrumental AEs in 17 (0.5%), infections in 37 (1.0%), cardiovascular AEs in eight (0.2%), pulmonary AEs in eight (0.2%), drug reaction AE in one (0.03%), pain in 15 (0.4%), and other AEs in 15 (0.4%). Multivariable analysis showed significant risk factors for PEP were: female of younger age, pancreatic guidewire-assisted biliary cannulation, temporary guidewire insertion into the pancreatic duct, total procedure time >60 min, and post-ERCP administration of non-steroidal anti-inflammatory drugs. Effective preventive measures were prophylactic pancreatic stenting (PPS) and epinephrine spraying onto the papilla. CONCLUSIONS In patients with intact papilla who underwent biliary ERCP, the incidence of AEs was 10.1% and the mortality was 0.08%. PPS and epinephrine spraying may prevent PEP. REGISTRATION This study was registered in the University Hospital Medical Information Network (UMIN000024820).
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Affiliation(s)
- Koichi Fujita
- Department of Gastroenterology and HepatologyYodogawa Christian HospitalOsakaJapan,First Research DepartmentTazuke Kofukai Medical Research InstituteOsakaJapan
| | - Shujiro Yazumi
- Department of Gastroenterology and HepatologyKitano HospitalOsakaJapan
| | - Hisakazu Matsumoto
- Department of GastroenterologyJapanese Red Cross Hospital Wakayama Medical CenterWakayamaJapan
| | - Masanori Asada
- Department of Gastroenterology and HepatologyJapanese Red Cross Osaka HospitalOsakaJapan
| | - Hiroko Nebiki
- Department of GastroenterologyOsaka City General HospitalOsakaJapan
| | - Kazuya Matsumoto
- Division of Gastroenterology and NephrologyDepartment of Multidisciplinary Internal MedicineFaculty of MedicineTottori UniversityTottoriJapan
| | - Toru Maruo
- Department of GastroenterologyFukuoka University Chikushi HospitalFukuokaJapan
| | - Mamoru Takenaka
- Department of Gastroenterology and HepatologyKindai UniversityOsakaJapan
| | - Takeshi Tomoda
- Department of Gastroenterology and HepatologyOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Takumi Onoyama
- Division of Gastroenterology and NephrologyDepartment of Multidisciplinary Internal MedicineFaculty of MedicineTottori UniversityTottoriJapan
| | - Akira Kurita
- Department of Gastroenterology and HepatologyKitano HospitalOsakaJapan
| | - Toshiharu Ueki
- Department of GastroenterologyFukuoka University Chikushi HospitalFukuokaJapan
| | - Toshiro Katayama
- Department of Medical EngineeringFaculty of Health SciencesMorinomiya University of Medical SciencesOsakaJapan,Help Center of Medical ResearchTazuke Kofukai Medical Research InstituteOsakaJapan
| | | | - Hirofumi Kawamoto
- General Internal Medicine 2Kawasaki Medical School General Medical CenterOkayamaJapan
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Yao W, Luo D, Lv Z, Yang Y, Wang L, Ma B, Xue D, Hao C, Zhang Y. The Rabep1-Mediated Endocytosis and Activation of Trypsinogen to Promote Pancreatic Stellate Cell Activation. Biomolecules 2022; 12:biom12081063. [PMID: 36008957 PMCID: PMC9406084 DOI: 10.3390/biom12081063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/26/2022] [Accepted: 07/29/2022] [Indexed: 02/01/2023] Open
Abstract
Background: The pathogenesis of chronic pancreatitis is still unclear. Trypsinogen activation is an active factor in acute pancreatitis that has not been studied in the occurrence of chronic pancreatitis. Methods: Immunofluorescence was used to detect the location and expression of trypsinogen in chronic pancreatitis and normal tissues. Microarray and single-cell RNA-seq (scRNA-seq) were used to screen core genes and pathways in pancreatic stellate cells (PSCs). Western blotting and immunofluorescence were used to verify trypsinogen expression in PSCs after silencing Rabep1. Immunofluorescence and flow cytometry were used to validate trypsinogen activation and PSC activation after intervening in the endocytosis pathway. Results: Endocytosed trypsinogen was found in PSCs in CP clinical samples. Bioinformatic analysis showed that Rabep1 is a core gene that regulates trypsinogen endocytosis through the endocytosis pathway, verified by Western blot and immunofluorescence. Immunofluorescence and flow cytometry analyses confirmed the activation of trypsinogen and PSCs through the endocytosis pathway in PSCs. Conclusion: This study discovered a new mechanism by which trypsinogen affects the activation of PSCs and the occurrence and development of CP. Through communication between pancreatic acinar cells and PSCs, trypsinogen can be endocytosed by PSCs and activated by the Rabep1 gene.
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Affiliation(s)
- Wenchao Yao
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China; (W.Y.); (D.L.); (Z.L.); (Y.Y.); (L.W.); (B.M.); (D.X.)
- Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Dankun Luo
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China; (W.Y.); (D.L.); (Z.L.); (Y.Y.); (L.W.); (B.M.); (D.X.)
- Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Zhenyi Lv
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China; (W.Y.); (D.L.); (Z.L.); (Y.Y.); (L.W.); (B.M.); (D.X.)
- Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Yang Yang
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China; (W.Y.); (D.L.); (Z.L.); (Y.Y.); (L.W.); (B.M.); (D.X.)
- Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Liyi Wang
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China; (W.Y.); (D.L.); (Z.L.); (Y.Y.); (L.W.); (B.M.); (D.X.)
- Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Biao Ma
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China; (W.Y.); (D.L.); (Z.L.); (Y.Y.); (L.W.); (B.M.); (D.X.)
- Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Dongbo Xue
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China; (W.Y.); (D.L.); (Z.L.); (Y.Y.); (L.W.); (B.M.); (D.X.)
- Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Chenjun Hao
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China; (W.Y.); (D.L.); (Z.L.); (Y.Y.); (L.W.); (B.M.); (D.X.)
- Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
- Correspondence: (C.H.); (Y.Z.)
| | - Yingmei Zhang
- Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
- Correspondence: (C.H.); (Y.Z.)
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10
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Akshintala VS, Singh A, Singh VK. Prevention and Management of Complications of Biliary Endoscopy. Gastrointest Endosc Clin N Am 2022; 32:397-409. [PMID: 35691688 DOI: 10.1016/j.giec.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreaticobiliary disorders. ERCP is, however, associated with the risk of complications including pancreatitis, bleeding, perforation, infection, and instrument failure, which can often be fatal. It is, therefore, necessary to recognize the risk of ERCP-associated complications and understand the methods to prevent and treat such complications.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA
| | - Anmol Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA.
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11
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Sperna Weiland CJ, Smeets XJ, Verdonk RC, Poen AC, Bhalla A, Venneman NG, Kievit W, Timmerhuis HC, Umans DS, van Hooft JE, Besselink MG, van Santvoort HC, Fockens P, Bruno MJ, Drenth JP, van Geenen EJ. Optimal timing of rectal diclofenac in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis. Endosc Int Open 2022; 10:E246-E253. [PMID: 35295242 PMCID: PMC8920594 DOI: 10.1055/a-1675-2108] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 09/21/2021] [Indexed: 12/11/2022] Open
Abstract
Background and study aims Rectal nonsteroidal anti-inflammatory drug (NSAID) prophylaxis reduces incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Direct comparisons to the optimal timing of administration, before or after ERCP, are lacking. Therefore, we aimed to assess whether timing of rectal NSAID prophylaxis affects the incidence of post-ERCP pancreatitis. Patients and methods We conducted an analysis of prospectively collected data from a randomized clinical trial. We included patients with a moderate to high risk of developing post-ERCP pancreatitis, all of whom received rectal diclofenac monotherapy 100-mg prophylaxis. Administration was within 30 minutes before or after the ERCP at the discretion of the endoscopist. The primary endpoint was post-ERCP pancreatitis. Secondary endpoints included severity of pancreatitis, length of hospitalization, and Intensive Care Unit (ICU) admittance. Results We included 346 patients who received the rectal NSAID before ERCP and 63 patients who received it after ERCP. No differences in baseline characteristics were observed. Post-ERCP pancreatitis incidence was lower in the group that received pre-procedure rectal NSAIDs (8 %), compared to post-procedure (18 %) (relative risk: 2.32; 95% confidence interval: 1.21 to 4.46, P = 0.02). Hospital stays were significantly longer with post-procedure prophylaxis (1 day; interquartile range [IQR] 1-2 days vs. 1 day; IQR 1-4 days; P = 0.02). Patients from the post-procedure group were more likely to be admitted to the ICU (1 patient [0.3 %] vs. 4 patients [6 %]; P = 0.002). Conclusions Pre-procedure administration of rectal diclofenac is associated with a significant reduction in post-ERCP pancreatitis incidence compared to post-procedure use.
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Affiliation(s)
- Christina J. Sperna Weiland
- Department of Gastroenterology and Hepatology, Radboud Institute for Molecular Life Science, Radboudumc, Nijmegen, the Netherlands,Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Xavier J.N.M. Smeets
- Department of Gastroenterology and Hepatology, Jeroen Bosch ziekenhuis, Den Bosch, the Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Alexander C. Poen
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, Hagaziekenhuis, The Hague, the Netherlands
| | - Niels G. Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Wietske Kievit
- Department for Health evidence, Radboudumc, Nijmegen, the Netherlands
| | - Hester C. Timmerhuis
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Devica S. Umans
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands,Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University medical Centre, Leiden, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands ,Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Joost P.H. Drenth
- Department of Gastroenterology and Hepatology, Radboud Institute for Molecular Life Science, Radboudumc, Nijmegen, the Netherlands
| | - Erwin J.M. van Geenen
- Department of Gastroenterology and Hepatology, Radboud Institute for Molecular Life Science, Radboudumc, Nijmegen, the Netherlands
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12
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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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [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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13
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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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14
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Akshintala VS, Sperna Weiland CJ, Bhullar FA, Kamal A, Kanthasamy K, Kuo A, Tomasetti C, Gurakar M, Drenth JPH, Yadav D, Elmunzer BJ, Reddy DN, Goenka MK, Kochhar R, Kalloo AN, Khashab MA, van Geenen EJM, Singh VK. Non-steroidal anti-inflammatory drugs, intravenous fluids, pancreatic stents, or their combinations for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol 2021; 6:733-742. [PMID: 34214449 DOI: 10.1016/s2468-1253(21)00170-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs), intravenous fluid, pancreatic stents, or combinations of these have been evaluated in randomised controlled trials (RCTs) for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, but the comparative efficacy of these treatments remains unclear. Our aim was to do an exploratory network meta-analysis of previous RCTs to systematically compare the direct and indirect evidence and rank NSAIDs, intravenous fluids, pancreatic stents, or combinations of these to determine the most efficacious method of prophylaxis for post-ERCP pancreatitis. METHODS We searched PubMed, Embase, and the Cochrane Central Register from inception to Nov 15, 2020, for full-text RCTs that evaluated the efficacy of NSAIDs, pancreatic stents, intravenous fluids, or combinations of these for post-ERCP pancreatitis prevention in adult (aged ≥18 years) patients undergoing ERCP. Summary data from intention-to-treat analyses were extracted from published reports. We analysed incidence of post-ERCP pancreatitis across studies using network meta-analysis under the frequentist framework, obtaining pairwise odds ratios (ORs) and 95% CIs. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system for the confidence rating. This study is registered with PROSPERO, CRD42020172606. FINDINGS We identified 1503 studies, of which 55 RCTs evaluating 20 interventions in 17 062 patients were included in the network meta-analysis. The mean incidence of post-ERCP pancreatitis in the placebo or active control group was 12·2% (95% CI 11·4-13·0). Normal saline plus rectal indometacin (OR 0·02, 95% CI 0·00-0·40), intramuscular diclofenac 75 mg (0·24, 0·09-0·69), intravenous high-volume Ringer's lactate plus rectal diclofenac 100 mg (0·30, 0·16-0·55), intravenous high-volume Ringer's lactate (0·31, 0·12-0·78), 5-7 Fr pancreatic stents (0·35, 0·26-0·48), rectal diclofenac 100 mg (0·36, 0·25-0·52), 3 Fr pancreatic stents (0·47, 0·26-0·87), and rectal indometacin 100 mg (0·60, 0·50-0·73) were all more efficacious than placebo for preventing post-ERCP pancreatitis in pairwise comparisons. 5-7 Fr pancreatic stents (0·59, 0·41-0·84), intravenous high-volume Ringer's lactate plus rectal diclofenac 100 mg (0·49, 0·26-0·94), intravenous standard-volume normal saline plus rectal indometacin 100 mg (0·04, 0·00-0·66), and rectal diclofenac 100 mg (0·59, 0·40-0·89) were more efficacious than rectal indometacin 100 mg. The GRADE confidence rating was low to moderate for 98·3% of the pairwise comparisons. INTERPRETATION This systematic review and network meta-analysis summarises the available literature on NSAIDs, pancreatic stents, intravenous fluids, or combinations of these for prophylaxis of post-ERCP pancreatitis. Rectal diclofenac 100 mg is the best performing rectal NSAID in this network meta-analysis. Combinations of prophylaxis might be more effective, but there is little evidence. These findings help to establish prophylaxis of post-ERCP pancreatitis for future research and practice, and could reduce costs and increase adoption of prophylaxis. FUNDING None.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | | | - Furqan A Bhullar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ayesha Kamal
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Kavin Kanthasamy
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Albert Kuo
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Cristian Tomasetti
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of Biostatistics & Bioinformatics, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Merve Gurakar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Dhiraj Yadav
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mahesh K Goenka
- Department of Gastroenterology, Apollo Gleneagles Hospital, Kolkata, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Anthony N Kalloo
- 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
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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15
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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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Romano-Munive AF, García-Correa JJ, García-Contreras LF, Ramírez-García J, Uscanga L, Barbero-Becerra VJ, Moctezuma-Velázquez C, Ochoa-Rubí JA, Toledo-Cuque J, Vázquez-Anaya G, Keil-Ríos D, Grajales-Figueroa G, Ramírez-Luna MÁ, Valdovinos-Andraca F, Zamora-Nava LE, Tellez-Avila F. Can topical epinephrine application to the papilla prevent pancreatitis after endoscopic retrograde cholangiopancreatography? Results from a double blind, multicentre, placebo controlled, randomised clinical trial. BMJ Open Gastroenterol 2021; 8:bmjgast-2020-000562. [PMID: 33558263 PMCID: PMC7871689 DOI: 10.1136/bmjgast-2020-000562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/23/2022] Open
Abstract
Background and study aims Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a complication associated with important morbidity, occasional mortality and high costs. Preventive strategies are suboptimal as PEP continues to affect 4% to 9% of patients. Spraying epinephrine on the papilla may decrease oedema and prevent PEP. This study aimed to compare rectal indomethacin plus epinephrine (EI) versus rectal indomethacin plus sterile water (WI) for the prevention of PEP. Patients and methods This multicentre randomised controlled trial included patients aged >18 years with an indication for ERCP and naive major papilla. All patients received 100 mg of rectal indomethacin and 10 mL of sterile water or a 1:10 000 epinephrine dilution. Patients were asked about PEP symptoms via telephone 24 hours and 7 days after the procedure. The trial was stopped half way through after a new publication reported an increased incidence of PEP among patients receiving epinephrine. Results Of the 3602 patients deemed eligible, 3054 were excluded after screening. The remaining 548 patients were randomised to EI group (n=275) or WI group (n=273). The EI and WI groups had similar baseline characteristics. Patients in the EI group had a similar incidence of PEP to those in the WI group (3.6% (10/275) vs 5.12% (14/273), p=0.41). Pancreatic duct guidewire insertion was identified as a risk factor for PEP (OR 4.38, 95% CI (1.44 to 13.29), p=0.009). Conclusion Spraying epinephrine on the papilla was no more effective than rectal indomethacin alone for the prevention of PEP. Trial registration number This study was registered with ClinicalTrials.gov (NCT02959112).
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Affiliation(s)
| | | | | | | | - Luis Uscanga
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | | | | | - Jorge A Ochoa-Rubí
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Julio Toledo-Cuque
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Gerardo Vázquez-Anaya
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Daniel Keil-Ríos
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | | | | | | | | | - Felix Tellez-Avila
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
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17
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Efficacy of Epinephrine Injection in Preventing Post-ERCP Pancreatitis. Surg Laparosc Endosc Percutan Tech 2020; 31:208-214. [PMID: 33048897 DOI: 10.1097/sle.0000000000000867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/14/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Rectal indomethacin or a topical spray of epinephrine to the papilla of Vater has each shown efficacy alone in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). We supposed that a submucosal epinephrine injection would be more effective and longer acting than a topical epinephrine spray and therefore would further reduce the incidence of PEP. PATIENTS AND METHODS A retrospective analysis was conducted of 412 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2017 and December 2019. These patients were divided into 2 groups: the indomethacin group and the indomethacin plus the submucosal epinephrine injection group. The incidence rates and severity of PEP, post-ERCP hyperamylasemia, other outcomes, and any other adverse events were compared between the groups. RESULTS Baseline demographic and clinical characteristics and procedure-related parameters were similar between the 2 groups. The incidence of PEP was 0.4% in the epinephrine group compared with 5.1% in the indomethacin group (P<0.001). Post-ERCP hyperamylasemia occurred in 24.6% of patients in the indomethacin group, whereas 7.6% of patients in the epinephrine group developed this condition; the difference was significant (P<0.001). Postsphincterotomy bleeding occurred in 5 patients, all of whom were in the indomethacin group (P<0.001). Other adverse events, including arrhythmias, acute coronary events, stroke, or hypertension were not significantly different between the 2 groups. CONCLUSION Addition of a submucosal epinephrine injection in conjunction with rectal indomethacin significantly reduced the incidence of PEP, post-ERCP hyperamylasemia, and postsphincterotomy bleeding.
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Toussaint E, Dumonceau JM. Should we incorporate topical epinephrine in the ESGE guideline on prevention of post-ERCP pancreatitis? Endosc Int Open 2020; 8:E1068-E1069. [PMID: 32744535 PMCID: PMC7373662 DOI: 10.1055/a-1196-1458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- E Toussaint
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
| | - J-M Dumonceau
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
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Boškoski I, Costamagna G. How to Prevent Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastroenterology 2020; 158:2037-2040. [PMID: 32197979 DOI: 10.1053/j.gastro.2020.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS; and Centre for Endoscopic Research, Therapeutics and Training (CERTT), Catholic University of Rome, Rome, Italy.
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS; and Centre for Endoscopic Research, Therapeutics and Training (CERTT), Catholic University of Rome, Rome, Italy
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20
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Park TY, Oh HC, Fogel EL, Lehman GA. Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis with rectal non-steroidal anti-inflammatory drugs. Korean J Intern Med 2020; 35:535-543. [PMID: 32392660 PMCID: PMC7214369 DOI: 10.3904/kjim.2020.069] [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: 02/24/2020] [Accepted: 03/25/2020] [Indexed: 12/29/2022] Open
Abstract
Acute pancreatitis is the most common and feared adverse event associated with performance of endoscopic retrograde cholangiopancreatography (ERCP). Unremitting effort has been made for over 40 years to minimize the frequency and severity of this complication. Recently, the use of rectal non-steroidal anti-inflammatory drugs (NSAIDs) have opened a new era for its prevention. This review focuses on the role of NSAIDs in pancreatitis, the pharmacokinetics of these agents, and summarizes the results of clinical trials with rectal NSAIDs alone and combination regimens in the prevention of post-ERCP pancreatitis.
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Affiliation(s)
- Tae Young Park
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Hyoung-Chul Oh
- Division of Gastroenterology, Chung-Ang University College of Medicine, Seoul, Korea
- Correspondence to Hyoung-Chul Oh, M.D. Division of Gastroenterology, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea Tel: +82-2-6299-3149 Fax: +82-2-6299-3119 E-mail:
| | - Evan L. Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Glen A. Lehman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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Aziz M, Ghanim M, Sheikh T, Sharma S, Ghazaleh S, Fatima R, Khan Z, Lee-Smith W, Nawras A. Rectal indomethacin with topical epinephrine versus indomethacin alone for preventing Post-ERCP pancreatitis - A systematic review and meta-analysis. Pancreatology 2020; 20:356-361. [PMID: 32107191 DOI: 10.1016/j.pan.2020.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/04/2020] [Accepted: 02/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recent studies have compared the utility of rectal indomethacin with topical epinephrine (IE) sprayed on duodenal papilla and rectal indomethacin alone (IS) to prevent post-ERCP pancreatitis (PEP) with conflicting results. We performed a systematic review and meta-analysis to evaluate the benefit of using the combination prophylaxis as oppose to rectal indomethacin alone. METHODS The following database were searched for our systematic review: PubMed∖Medline, Embase, Cochrane, and Web of Science. We included both randomized controlled trials (RCTs) and cohort studies. Primary outcome was incidence of PEP and secondary outcomes were adverse events and mortality. RESULTS A total of 3 studies (all RCTs) with 2244 patients (1132 in IS and 1112 in IE group) were included. The IE group did not demonstrate any significant benefit over IS group in preventing PEP (RR: 1.15, 95% CI 0.62-2.2), mortality (RR: 0.85, 95% CI 0.22-3.24) or overall adverse events (RR: 1.3, 95% CI 0.93-1.7). CONCLUSION The combination of rectal indomethacin and topical epinephrine failed to demonstrate any benefit over indomethacin alone in preventing PEP, decreasing mortality and overall adverse events.
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Affiliation(s)
- Muhammad Aziz
- Department of Internal Medicine, University of Toledo Medical Center, 3000 Arlington Ave, Toledo, OH, 43614, United States.
| | - Marcel Ghanim
- Department of Internal Medicine, University of Toledo Medical Center, 3000 Arlington Ave, Toledo, OH, 43614, United States.
| | - Taha Sheikh
- Department of Internal Medicine, University of Toledo Medical Center, 3000 Arlington Ave, Toledo, OH, 43614, United States.
| | - Sachit Sharma
- Department of Internal Medicine, University of Toledo Medical Center, 3000 Arlington Ave, Toledo, OH, 43614, United States.
| | - Sami Ghazaleh
- Department of Internal Medicine, University of Toledo Medical Center, 3000 Arlington Ave, Toledo, OH, 43614, United States.
| | - Rawish Fatima
- Department of Internal Medicine, University of Toledo Medical Center, 3000 Arlington Ave, Toledo, OH, 43614, United States.
| | - Zubair Khan
- Department of Gastroenterology, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin St, Houston, TX, 77030, United States.
| | - Wade Lee-Smith
- University of Toledo Libraries, 3000 Arlington Ave, Toledo, OH, 43614, United States.
| | - Ali Nawras
- Department of Gastroenterology, University of Toledo Medical Center, 3000 Arlington Ave, Toledo, OH, 43614, United States.
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Comparison between length of stay criteria and the revised Atlanta classification in identifying severe postendoscopic retrograde cholangiopancreatography pancreatitis. Eur J Gastroenterol Hepatol 2019; 31:1072-1073. [PMID: 31268901 DOI: 10.1097/meg.0000000000001465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Luo H, Wang X, Zhang R, Liang S, Kang X, Zhang X, Lou Q, Xiong K, Yang J, Si L, Liu W, Liu Y, Zhou Y, Wang S, Yang M, Chen W, Han Y, Shang G, Yang X, He Y, Zou Q, Guo W, Dai Y, Zeng W, Zhu X, Gong R, Li X, Nie Z, Wang Q, Wang L, Pan Y, Guo X, Fan D. Rectal Indomethacin and Spraying of Duodenal Papilla With Epinephrine Increases Risk of Pancreatitis Following Endoscopic Retrograde Cholangiopancreatography. Clin Gastroenterol Hepatol 2019; 17:1597-1606.e5. [PMID: 30391434 DOI: 10.1016/j.cgh.2018.10.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/24/2018] [Accepted: 10/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Rectal indomethacin and spraying of the duodenal papilla with epinephrine might reduce the incidence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). We performed a randomized trial to compare the effects of the combination of indomethacin and epinephrine (IE) vs indomethacin plus saline (IS) in prophylaxis of post-ERCP pancreatitis (PEP). METHODS We performed a double-blind trial at 10 centers in China, from February 2017 to October 2017, of 1158 patients with native papilla undergoing ERCP. The patients were assigned randomly to groups given IE (n = 576) or IS (n = 582). All patients received a single dose of rectal indomethacin within 30 minutes before ERCP; 20 mL of dilute epinephrine (IE group) or saline (IS group) then was sprayed on the duodenal papilla at the end of ERCP. The primary outcome was the incidence of overall PEP. Data were analyzed on an intention-to-treat principle. RESULTS The study was terminated at the interim analysis for safety concerns and futility. The groups had similar baseline characteristics. PEP developed in 49 patients in the IE group (8.5%) and in 31 patients in the IS group (5.3%) (relative risk, 1.60, 95% CI, 1.03-2.47; P = .033). There were no significant differences between groups in proportions of patients with postsphincterotomy bleeding (2.1% in the IE group and 1.5% in the IS group) and biliary infection (1.2% in the IE group and 2.2% in the IS group). CONCLUSIONS In a randomized trial, we found the combination of rectal indomethacin with papillary epinephrine spraying increased the risk of PEP compared with indomethacin alone. Spray epinephrine should not be used with rectal indomethacin for prevention of post-ERCP pancreatitis. ClincialTrials.gov no: NCT03057769.
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Affiliation(s)
- Hui Luo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiangping Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Rongchun Zhang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shuhui Liang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiaoyu Kang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiaofeng Zhang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qifeng Lou
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kangwei Xiong
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jing Yang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lijuan Si
- Department of Gastroenterology, Zhongshan Hospital of Xiamen University, Xiamen, China
| | - Wenming Liu
- Department of Gastroenterology, Zhongshan Hospital of Xiamen University, Xiamen, China
| | - Yunpeng Liu
- Department of Gastroenterology, Zhongshan Hospital of Xiamen University, Xiamen, China
| | - Yi Zhou
- Department of Gastroenterology, No 451 Military Hospital, Xi'an, China
| | - Suli Wang
- Department of Gastroenterology, No 451 Military Hospital, Xi'an, China
| | - Mei Yang
- Department of Gastroenterology, No 451 Military Hospital, Xi'an, China
| | - Wei Chen
- Department of Gastroenterology, The First Affiliated Hospital of the Medical College, Shihezi University, Shihezi, China
| | - Yanzhi Han
- Department of Gastroenterology, The First Affiliated Hospital of the Medical College, Shihezi University, Shihezi, China
| | - Guochen Shang
- Department of Gastroenterology, The First Affiliated Hospital of the Medical College, Shihezi University, Shihezi, China
| | - Xiaocui Yang
- Endoscopy Center, Ankang Central Hospital, Ankang, China
| | - Yongfeng He
- Endoscopy Center, Ankang Central Hospital, Ankang, China
| | - Qiang Zou
- Endoscopy Center, Ankang Central Hospital, Ankang, China
| | - Wenwei Guo
- Endoscopy Center, Ankang Central Hospital, Ankang, China
| | - Yichen Dai
- Department of Gastroenterology, Chenggong Hospital of Xiamen University, Xiamen, China
| | - Wei Zeng
- Department of Gastroenterology, Chenggong Hospital of Xiamen University, Xiamen, China
| | - Xiaosan Zhu
- Department of Gastroenterology, Chenggong Hospital of Xiamen University, Xiamen, China
| | - Rongqing Gong
- Department of Gastroenterology, Chenggong Hospital of Xiamen University, Xiamen, China
| | - Xun Li
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Zhanguo Nie
- Department of Gastroenterology, Urumqi General Hospital of Lanzhou Military Region, Urumqi, China
| | - Qi Wang
- Department of Hepatobiliary Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Ling Wang
- Department of Health Statistics, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China.
| | - Xuegang Guo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China.
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
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Shih HY, Hsu WH, Kuo CH. Postendoscopic retrograde cholangiopancreatography pancreatitis. Kaohsiung J Med Sci 2019; 35:195-201. [PMID: 30887733 DOI: 10.1002/kjm2.12040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 01/09/2019] [Indexed: 12/11/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has been a mainstay examination to clarify the biliary and pancreatic system. Not just diagnostic purpose, it could achieve therapeutic goal. Under the trend of more and more procedures about ERCP being interventional, the rate of adverse events after the procedure is increasing. Among them, post-ERCP pancreatitis (PEP) is the most common and sometimes tremendous complication. This mini-review will overview the PEP from definition, pathogenesis, and risk factors to prevention.
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Affiliation(s)
- Hsiang-Yao Shih
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chao-Hung Kuo
- Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
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Pavel L, Bălan GG, Nicorescu A, Gîlcă-Blanariu GE, Sfarti C, Chiriac Ș, Diaconescu S, Drug VL, Bălan G, Ștefănescu G. Split-dose or hybrid nonsteroidal anti-inflammatory drugs and N-acetylcysteine therapy for prevention of post-retrograde cholangiopancreatography pancreatitis. World J Clin Cases 2019; 7:300-310. [PMID: 30746371 PMCID: PMC6369386 DOI: 10.12998/wjcc.v7.i3.300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/18/2018] [Accepted: 12/24/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Despite significant technical and training improvements, the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has not significantly dropped. Although many studies have evaluated the efficacy of various agents, e.g. nonsteroidal anti-inflammatory drugs, octreotide, antioxidants, administered via various dosages, routes (oral, intrarectal or parenteral), and schedules (before or after the procedure), the results have been conflicting.
AIM To evaluate efficacy of three pharmacologic prophylactic methods for prevention of PEP.
METHODS In this prospective, single-center randomized trial, patients who underwent first-time ERCP for choledocholithiasis were randomly assigned to three groups. The first group received 600 mg N-acetylcysteine 15 min prior to ERCP, and per-rectum administration of 50 mg indomethacin both prior to and after completion of the ERCP. The second group was administered only the 50 mg indomethacin per-rectum both prior to and after the ERCP. The third group was administered per-rectum 100 mg indomethacin only after the ERCP, representing the control group given the guideline-recommended regimen. The primary end-point was PEP prevention.
RESULTS Among the total 211 patients evaluated during the study, 186 fulfilled the inclusion criteria and completed the protocol. The percentages of patients who developed PEP in each of the three groups were not significantly different (χ2 = 2.793, P = 0.247). Among the acute PEP cases, for all groups, 14 patients developed mild pancreatitis (77.77%) and 4 moderate. No severe cases of PEP occurred, and in all PEP cases the resolution was favorable. No adverse events related to the medications (digestive hemorrhage, rectal irritation, or allergies) occurred.
CONCLUSION The efficacies of split-dose indomethacin and combined administration (N-acetylcysteine with indomethacin) for preventing PEP were similar to that of the standard regimen.
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Affiliation(s)
- Laura Pavel
- Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași 700115, România
| | - Gheorghe Gh Bălan
- Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași 700115, România
| | - Alexandra Nicorescu
- Endocrinology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași 700115, România
| | | | - Cătălin Sfarti
- Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași 700115, România
| | - Ștefan Chiriac
- Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași 700115, România
| | - Smaranda Diaconescu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iași 700115, România
| | - Vasile Liviu Drug
- Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași 700115, România
| | - Gheorghe Bălan
- Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași 700115, România
| | - Gabriela Ștefănescu
- Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași 700115, România
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A Randomized Trial of Topical Epinephrine and Rectal Indomethacin for Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in High-Risk Patients. Am J Gastroenterol 2019; 114:339-347. [PMID: 30730860 DOI: 10.14309/ajg.0000000000000049] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Rectal indomethacin and topical spray of epinephrine have separately shown efficacy in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) in randomized controlled trials. We hypothesized that the combination of indomethacin and topical spray of epinephrine on the duodenal papillae would further reduce PEP than when indomethacin was used alone. METHODS We conducted a comparative effectiveness, multicenter, double-blinded, randomized trial of rectal indomethacin alone vs a combination of rectal indomethacin and topical spray of epinephrine for the prevention of PEP in high-risk patients. The primary outcome was the incidence of PEP and the secondary outcome was the severity of PEP. A 2-tailed Fisher's exact test was used to analyze the difference in the proportion of patients with PEP in the indomethacin alone vs the combination group. RESULTS A total of 960 patients (mean age 52.33 ± 14.96 years; 551 [57.4%] females) were randomized and 959 completed follow-up. The baseline demographic and clinical characteristics were similar between the 2 groups. Women <50 years of age (25.4%) and difficult cannulation (84.9%) were the most common PEP risk factors. The incidence of PEP was 6.4% in the indomethacin alone group (n = 482) compared to 6.7% in the combination group (n = 477; P = 0.87). Severe PEP was found in 5 (12%) and 7 (16%) patients in the indomethacin alone and combination groups, respectively (P = 0.88). The overall mortality was 0.6%, which was unrelated to the primary outcome. CONCLUSIONS The combination of rectal indomethacin and topical spray of epinephrine does not reduce the incidence of PEP compared to rectal indomethacin alone in high-risk patients; https://clinicaltrials.gov/ct2/show/NCT02116309.
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Faghih M, Sinha A, Moran RA, Afghani E, Patel YA, Storm AC, Kamal A, Akshintala VS, Zaheer A, Kalloo AN, Kumbhari V, Khashab MA, Singh VK. Length of stay overestimates severity of post-ERCP pancreatitis: Is it time to revise the consensus definition? Endosc Int Open 2018; 6:E838-E843. [PMID: 29978003 PMCID: PMC6031441 DOI: 10.1055/a-0624-2491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/25/2018] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Length of stay (LOS) is an important determinant of the severity of post-ERCP pancreatitis (PEP) in the consensus definition. The aim of our study was to evaluate and compare severity of PEP based on the revised Atlanta classification (RAC) and the consensus definition. PATIENTS AND METHODS Between 1/2000 and 12/2011, all adult patients admitted with suspicion of PEP after outpatient ERCP were evaluated. PEP was defined using the RAC, but the severity of PEP was defined using both revised Atlanta and consensus definitions. RESULTS A total of 341 patients (mean age 49 years and 75 % females) were diagnosed with PEP. The consensus definition classified 57 %, 37 %, and 8 % of patients with mild, moderate, and severe PEP, respectively. The RAC diagnosed 94 %, 6 %, and 0 % with mild, moderate, and severe acute pancreatitis, respectively. Of the patients diagnosed with moderate-severe PEP by consensus definition, only 12.5 % had clinical parameters of pancreatitis severity, such as acute fluid collection(s), pancreatic necrosis, transient organ failure and/or required percutaneous or surgical drainage, while 87.5 % were classified only based on a LOS ≥ 4 days. The most common reason for increased LOS was persistent post-procedural abdominal pain in 47 % of patients, followed by other reasons not related to pancreatitis in 17 %. CONCLUSION The consensus definition overestimates the rates of severe PEP when compared to the RAC. The majority of PEP patients classified as moderate-severe PEP have extended LOS, due to post-procedural abdominal pain rather than complications of PEP.
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Affiliation(s)
- Mahya Faghih
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Amitasha Sinha
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Robert A. Moran
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Elham Afghani
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Yuval A. Patel
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Andrew C. Storm
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Ayesha Kamal
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Venkata S. Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Atif Zaheer
- Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Anthony N. Kalloo
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States,Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Vikesh K. Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States,Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States,Corresponding author Vikesh K. Singh, MD, MSc Johns Hopkins HospitalDivision of Gastroenterology1830 E. Monument Street, Room 428Baltimore, MD 21205+1-410-614-7631
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Hatami B, Kashfi SMH, Abbasinazari M, Nazemalhosseini Mojarad E, Pourhoseingholi MA, Zali MR, Mohammad Alizadeh AH. Epinephrine in the Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Preliminary Study. Case Rep Gastroenterol 2018; 12:125-136. [PMID: 29805355 PMCID: PMC5968254 DOI: 10.1159/000479494] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/10/2017] [Indexed: 01/01/2023] Open
Abstract
Background Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The incidence of post-ERCP pancreatitis (PEP) ranges between 15 and 20% among patients at high risk of developing PEP. The efficacy of indomethacin administration in the prevention of PEP is rather debatable. In the present randomized trial study, we evaluated whether or not the combination of indomethacin and epinephrine in comparison to the single administration of indomethacin differs in the pathogenesis and prevention of post-ERCP pancreatitis. Patients and Methods One hundred and ninety-two patients were randomized in a double-blinded manner into 3 groups: the epinephrine group (group A), the indomethacin group (group B), and the combined epinephrine and indomethacin group (group C). After the procedure, patients were evaluated for the PEP development. Results During the procedure, 66 patients were randomized to the epinephrine group (group A), 68 cases to the indomethacin group (group B), and 58 individuals to the indomethacin-epinephrine group (group C). The mean age of patients in the epinephrine group was 59.59 ± 15.680 years, in the indomethacin group it was 58.06 ± 17.125 years, and in the combination group it was 59.62 ± 15.369 years. In the present study, we did not observe a significant difference between the 3 groups in sex, age, pre-ERCP amylase, lipase, and patient and procedure risk factors including pancreatic duct (PD) dilation (p = 0.404), PD cannulation (p = 0.329), and difficult cannulation (p = 0.076) among others. PEP developed in 7 of the 192 individuals (3.6%), 6 PEP cases occurred in the indomethacin group and 1 in the epinephrine group (p = 0.016). Univariate analysis of risk factors for PEP in patients with and without pancreatitis revealed no significant difference between the pancreatitis group and the non-pancreatitis group. Conclusion In comparison to the administration of indomethacin alone, a single application of epinephrine and the combination of epinephrine and indomethacin seem to be effective in reducing the cases of PEP. A further randomized clinical trial with a larger sample size is required to confirm the efficacy of our medication in the prevention of pancreatitis after ERCP.
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Affiliation(s)
- Behzad Hatami
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Hossein Kashfi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Abbasinazari
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ehsan Nazemalhosseini Mojarad
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Pourhoseingholi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Houshang Mohammad Alizadeh
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Homma S, Hayashi K, Yoshida K, Sagawa Y, Kamata Y, Ito M. Nafamostat mesilate, a serine protease inhibitor, suppresses interferon-gamma-induced up-regulation of programmed cell death ligand 1 in human cancer cells. Int Immunopharmacol 2018; 54:39-45. [DOI: 10.1016/j.intimp.2017.10.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 10/10/2017] [Accepted: 10/16/2017] [Indexed: 01/01/2023]
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Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2018; 66:159-176. [PMID: 29280782 PMCID: PMC5755713 DOI: 10.1097/mpg.0000000000001715] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the incidence of acute pancreatitis (AP) in children is increasing, management recommendations rely on adult published guidelines. Pediatric-specific recommendations are needed. METHODS The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas committee performed a MEDLINE review using several preselected key terms relating to management considerations in adult and pediatric AP. The literature was summarized, quality of evidence reviewed, and statements of recommendations developed. The authorship met to discuss the evidence, statements, and voted on recommendations. A consensus of at least 75% was required to approve a recommendation. RESULTS The diagnosis of pediatric AP should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions (by meeting at least 2 out of 3 criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times upper limits of normal, (3) imaging findings consistent with AP). Adequate fluid resuscitation with crystalloid appears key especially within the first 24 hours. Analgesia may include opioid medications when opioid-sparing measures are inadequate. Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours. Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route. Little evidence supports the use of prophylactic antibiotics, antioxidants, probiotics, and protease inhibitors. Esophago-gastro-duodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have limited roles in diagnosis and management. Children should be carefully followed for development of early or late complications and recurrent attacks of AP. CONCLUSIONS This clinical report represents the first English-language recommendations for the management of pediatric AP. Future aims should include prospective multicenter pediatric studies to further validate these recommendations and optimize care for children with AP.
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Mine T, Morizane T, Kawaguchi Y, Akashi R, Hanada K, Ito T, Kanno A, Kida M, Miyagawa H, Yamaguchi T, Mayumi T, Takeyama Y, Shimosegawa T. Clinical practice guideline for post-ERCP pancreatitis. J Gastroenterol 2017; 52:1013-1022. [PMID: 28653082 DOI: 10.1007/s00535-017-1359-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/04/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERPC) is used for the diagnosis and treatment of pancreatic and biliary diseases. Post-ERCP pancreatitis (PEP) is a complication which needs special care and clinical practice guideline for this morbidity is also needed. METHODS The key clinical issues of diagnosis and treatment of PEP were listed and checked, and then the clinical questions were formulated. PubMed (MEDLINE) and Ichushi-web (Japanese medical literature) were used as databases. For the study of diagnostic test accuracy, items similar to QUADAS-2, i.e., random selection from a population to which the diagnostic test is applied, blinding of index tests and reference tests, completeness of reference standard, completeness of test implementations, the same timing of tests, and missing data were assessed as well as the indirectness of the study subjects, index tests, reference standard, and outcomes. Grading of recommendations was determined as strong or weak. In clinical practice, the judgment of attending doctors should be more important than recommendations described in clinical practice guidelines. Gastroenterologists are the target users of this clinical practice guideline. General practitioners or general citizens are not supposed to use this guideline. The guideline committee has decided to include wide clinical issues such as etiological information, techniques of ERCP, the diagnosis, treatments, and monitoring of PEP in this guideline. RESULTS In this concise report, we described ten clinical questions, recommendations, and explanations pertaining to risk factors, diagnosis, prognostic factors, treatments, and preventive interventions in the medical practice for PEP. CONCLUSIONS We reported here the essence of the clinical practice guideline for PEP.
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Affiliation(s)
- Tetsuya Mine
- Tokai University, School of Medicine, Isehara, Japan.
| | | | | | - Ryukichi Akashi
- Kumamoto City Medical Association Health Care Center, Kumamoto, Japan
| | | | - Tetsuhide Ito
- Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Atsushi Kanno
- Department of Gastroenterology, Tohoku University, Sendai, Japan
| | - Mitsuhiro Kida
- Kitasato University School of Medicine, Sagamihara, Japan
| | | | | | - Toshihiko Mayumi
- University of Occupational and Environmental Health, Kitakyushu, Japan
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Li L, Han Z, Yuan H, Zhang G, Jia Y, He C. Nonsteroidal anti-inflammatory drugs reduce the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:520-529. [PMID: 28681997 DOI: 10.1002/jhbp.489] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Several recent studies suggested that nonsteroidal anti-inflammation drugs (NSAIDs) could prevent the pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, the routes of administration, the dosages of NSAIDs and the potential efficacy in reducing the severity of pancreatitis remain controversial. The aim of this meta-analysis was to evaluate the efficacy of NSAIDs for post-ERCP pancreatitis (PEP) prophylaxis. METHODS We systematically searched PubMed, Embase, EBSCO, Elsevier and Web of Science databases up to 1 October 2016 for relevant studies. RESULTS A total of 24 studies met the inclusion criteria. Compared to the controls, the risk of pancreatitis was much lower in the NSAIDs group (OR = 0.57, 95% CI: 0.48-0.67, P < 0.0001). However, NSAIDs were not effective in reducing the risk of moderate to severe pancreatitis compared with placebo (OR = 0.75, 95% CI: 0.57-1.00). In the subanalyses, rectal administration was the only effective route (OR = 0.51, 95% CI: 0.42-0.62), and the risk of PEP was reduced in both randomized controlled trials (RCTs) (OR = 0.63, 95% CI: 0.52-0.76) and case-control articles (C-Cs) (OR = 0.40, 95% CI: 0.28-0.58). CONCLUSIONS Prophylactic administration of NSAIDs reduced the incidence of PEP in both RCTs and C-Cs, especially when rectally administered, but was not effective in reducing the risk of moderate to severe pancreatitis.
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Affiliation(s)
- Lin Li
- Department of Gastroenterology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Zhen Han
- Department of Gastroenterology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Heming Yuan
- Department of Gastroenterology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Guozheng Zhang
- Department of Gastroenterology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Yuliang Jia
- Department of Gastroenterology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Chiyi He
- Department of Gastroenterology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
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Patai Á, Solymosi N, Mohácsi L, Patai ÁV. Indomethacin and diclofenac in the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis of prospective controlled trials. Gastrointest Endosc 2017; 85:1144-1156.e1. [PMID: 28167118 DOI: 10.1016/j.gie.2017.01.033] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/16/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Diclofenac and indomethacin are the most studied drugs for preventing post-ERCP pancreatitis (PEP). However, there are no prospective, randomized multicenter trials with a sufficient number of patients for correct evaluation of their efficacy. Our aim was to evaluate all prospective trials published in full text that studied the efficacy of diclofenac or indomethacin and were controlled with placebo or non-treatment for the prevention of PEP in adult patients undergoing ERCP. METHODS Systematic search of databases (PubMed, Scopus, Web of Science, Cochrane) for relevant studies published from inception to 30 June 2016. RESULTS Our meta-analysis of 4741 patients from 17 trials showed that diclofenac or indomethacin significantly decreased the risk ratio (RR) of PEP to 0.60 (95% confidence interval [CI], 0.46-0.78; P = .0001), number needed to treat (NNT) was 20, and the reduction of RR of moderate to severe PEP was 0.64 (95% CI, 0.43-0.97; P = .0339). The efficacy of indomethacin compared with diclofenac was similar (P = .98). The efficacy of indomethacin or diclofenac did not differ according to timing (P = .99) or between patients with average-risk and high-risk for PEP (P = .6923). The effect of non-rectal administration of indomethacin or diclofenac was not significant (P = .1507), but the rectal route was very effective (P = .0005) with an NNT of 19. The administration of indomethacin or diclofenac was avoided in patients with renal failure. Substantial adverse events were not detected. CONCLUSIONS The use of rectally administered diclofenac or indomethacin before or closely after ERCP is inexpensive and safe and is recommended in every patient (without renal failure) undergoing ERCP. (Registration number: CRD42016042726, http://www.crd.york.ac.uk/prospero/.).
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Affiliation(s)
- Árpád Patai
- Department of Gastroenterology and Medicine, Markusovszky University Teaching Hospital, Szombathely, Hungary
| | - Norbert Solymosi
- Biometeorology Research Group, University of Veterinary Medicine, Budapest, Hungary
| | - László Mohácsi
- Department of Computer Science, Corvinus University of Budapest, Budapest, Hungary
| | - Árpád V Patai
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
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Wang C, Li Q, Ye P, Zeng S, Li GH, Chen YX, Zhou XJ, Lv NH. Value of Raw Rhubarb Solution in the Precaution of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis in Patients with High-Risk Factors: A Predictive Random Compared Research in One Center. Dig Dis Sci 2017; 62:1043-1050. [PMID: 28194668 DOI: 10.1007/s10620-017-4464-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 01/16/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Post-ERCP pancreatitis and hyperamylasemia are common complications of endoscopic retrograde cholangiopancreatography (ERCP), especially in high-risk patients. The aim of this study is to evaluate whether a raw rhubarb solution can reduce the incidence of PEP and post-ERCP hyperamylasemia. METHODS From October 2012 to October 2013, 2100 patients received ERCP in our Endoscopic Center. Five hundred patients with high-risk factors were enrolled randomly into the raw rhubarb group (RG, 250 cases drank a raw rhubarb soak solution per 3 h until defecation after ERCP) and the control group (CG, 250 cases drank water after ERCP) in the study. The serum amylase concentration was measured. The abdominal pain, purge time and symptoms of patients were observed in the two groups. RESULTS There were no differences in patient demographics, medical history, ERCP procedure, and patient- and procedure-related high-risk factors between the two groups. PEP incidence was 2% (5/250) in the RG group, which was lower than that in the CG group (7.6%, 19/250) (P < 0.01). The rate of post-ERCP hyperamylasemia was 5.2% (13/250) and 16.8% (42/250) in the RG group and CG group, respectively. The incidence of hyperamylasemia in the RG group was significantly lower than that in the CG group (P < 0.01). The incidence of abdominal pain 24 h after ERCP in the RG group was lower than that in the CG group (P < 0.01). No side effects were observed for raw rhubarb solution. CONCLUSIONS A raw rhubarb solution is safe and effective in preventing the incidence of PEP and hyperamylasemia in high-risk patients.
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Affiliation(s)
- Chong Wang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Qirui Li
- Medical College of Nanchang University, Nanchang, Jiangxi Province, China
| | - Peng Ye
- Department of Gastroenterology, The People Hospital of Ganzhou City, Ganzhou, Jiangxi Province, China
| | - Sheng Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Guo-Hua Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China.
| | - You-Xiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xiao-Jiang Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Nong-Hua Lv
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China.
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Wan J, Ren Y, Zhu Z, Xia L, Lu N. How to select patients and timing for rectal indomethacin to prevent post-ERCP pancreatitis: a systematic review and meta-analysis. BMC Gastroenterol 2017; 17:43. [PMID: 28298192 PMCID: PMC5353805 DOI: 10.1186/s12876-017-0599-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/08/2017] [Indexed: 12/29/2022] Open
Abstract
Background Acute pancreatitis is a severe complication of endoscopic retrograde cholangiopancreatography (ERCP). Previous meta-analyses have shown that indomethacin effectively prevents this complication; however, the data are limited. We performed a systematic review and meta-analysis to clarify the applications for rectal indomethacin. Methods A systematic search was performed in June 2016. Human prospective, randomized, placebo-controlled trials that compared rectally administered indomethacin with a placebo for the prevention of post-ERCP pancreatitis (PEP) were included. A meta-analysis was performed using a random-effects model to assess the outcomes (PEP) using Review Manager 5.0. Results Seven randomized controlled trials met the inclusion criteria (n = 3013). The overall incidence of PEP was significantly lower after prophylactic administration of rectal indomethacin than after administration of the placebo (RR, 0.58, 95% CI, 0.40–0.83; P = 0.004). A subgroup analysis was performed for rectal indomethacin administration compared to a placebo in high-risk patients (RR, 0.46; 95% CI, 0.32–0.65; P < 0.00001) and average-risk patients (RR, 0.75; 95% CI, 0.46–1.22; P = 0.25) and for administration before ERCP (RR, 0.56; 95% CI, 0.39–0.79; P = 0.001) and after the procedure (RR, 0.61; 95% CI, 0.26–1.44; P = 0.26). Conclusions This meta-analysis indicated that prophylactic rectal indomethacin is not suitable for all patients undergoing ERCP but it is safe and effective to prevent PEP in high-risk patients. In addition, rectal indomethacin administration before ERCP is superior to its administration after ERCP for the prevention of PEP. Electronic supplementary material The online version of this article (doi:10.1186/s12876-017-0599-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jianhua Wan
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Yuping Ren
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Zhenhua Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Liang Xia
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China.
| | - Nonghua Lu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China
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Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, Bruining DH, Eloubeidi MA, Fanelli RD, Faulx AL, Gurudu SR, Kothari S, Lightdale JR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85:32-47. [PMID: 27546389 DOI: 10.1016/j.gie.2016.06.051] [Citation(s) in RCA: 438] [Impact Index Per Article: 62.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 02/07/2023]
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Talukdar R. Complications of ERCP. Best Pract Res Clin Gastroenterol 2016; 30:793-805. [PMID: 27931637 DOI: 10.1016/j.bpg.2016.10.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 10/11/2016] [Accepted: 10/21/2016] [Indexed: 01/31/2023]
Abstract
Even though considered safe, endoscopic retrograde cholangiopancreatography (ERCP) is among the endoscopic procedures associated with the highest rate of complications. Post ERCP pancreatitis (PEP) is the most common complication of ERCP. Several independent risk factors have been associated with PEP. Prophylactic PD stenting has been shown to be highly effective in preventing PEP. More recent studies have suggested that NSAIDs, especially rectal indomethacin, could by itself be effective in preventing PEP. However, head to head RCTs comparing PD stents with NSAIDs would be required to confirm this. Other complications include ERCP induced bleeding, perforation, and cholangitis. Bleeding is related to morphological, procedural, and patient related factors. Early identification and correction of the risk factors are of paramount importance in preventing bleeding. Risk of infection is particularly high during ERCP. It is important to ensure complete drainage of obstructed biliary system in order to reduce the risk of post-ERCP cholangitis.
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Affiliation(s)
- Rupjyoti Talukdar
- Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad, 500082, Telangana, India; Asian Healthcare Foundation, 6-3-661 Somajiguda, Hyderabad, 500082, Telangana, India.
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A Randomized Comparative Study of 24- and 6-Hour Infusion of Nafamostat Mesilate for the Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Prospective Randomized Comparison Trial. Pancreas 2016; 45:1179-83. [PMID: 27253231 DOI: 10.1097/mpa.0000000000000625] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Although prolonged intravenous infusion (24 hours) of nafamostat mesilate is effective for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, it requires hospitalization and is expensive. The aim of this study was to compare the efficacy of 24- versus 6-hour intravenous infusion of 20 mg nafamostat mesilate for the prevention of post-ERCP pancreatitis (PEP). METHODS A total of 382 patients who underwent ERCP were randomly assigned into 2 groups: 24 hours or 6 hours. In both groups, nafamostat mesilate (20 mg) infusion was initiated up to an hour before ERCP and continued for either 24 or 6 hours. RESULTS The overall incidence of pancreatitis was 2.4% (9/371). The rates of PEP following 24- and 6-hour infusion were 2.8% (5/179) and 2.1% (4/192), respectively (P = 0.744). No significant difference was observed in the severity of pancreatitis between the groups. On multivariate analysis, increasing pancreatic duct cannulations (odds ratio, 1.685; 95% confidence interval, 1.036-2.741; P = 0.036) was identified as a statistically significant risk factor of PEP. CONCLUSIONS No difference was found in the incidence of PEP regardless of the duration of nafamostat mesilate infusion. Therefore, 6-hour infusion of 20 mg nafamostat mesilate may be useful for the prevention of PEP in an outpatient setting.
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Smeets XJNM, da Costa DW, Besselink MG, Bruno MJ, Fockens P, Mulder CJJ, van der Hulst RW, Vleggaar FP, Timmer R, Drenth JPH, van Geenen EJM. Systematic review: periprocedural hydration in the prevention of post-ERCP pancreatitis. Aliment Pharmacol Ther 2016; 44:541-53. [PMID: 27444408 DOI: 10.1111/apt.13744] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 06/06/2016] [Accepted: 07/06/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND With an overall incidence of 3.5%, pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Periprocedural hydration may prevent post-ERCP pancreatitis by maintaining pancreatic microperfusion, thereby inhibiting the pancreatic inflammatory response. However, the evidence for periprocedural hydration as a preventive measure is unclear. AIM To conduct a systematic review to assess the evidence regarding periprocedural hydration as a preventive measure for post-ERCP pancreatitis. METHODS We searched PubMed and EMBASE databases and adhered to the PRISMA guidelines. We included studies addressing periprocedural hydration as a preventive measure to reduce frequency and severity of post-ERCP pancreatitis. Study quality was assessed by using the MINORS and Cochrane Collaboration's tool. RESULTS Six studies with a total of 1102 patients were included. Two randomised controlled trials reported a decreased incidence of post-ERCP pancreatitis after hydration: 0% vs. 17% (P = 0.016) and 5.3% vs. 22.7% (P = 0.002). A third trial and two case-controls studies did not report significant differences. Two retrospective studies found that patients with mild post-ERCP pancreatitis had received significantly more fluids during (mean 940 mL vs. 810 mL; P = 0.031) or after ERCP (median 2834 mL vs. 2044 mL; P < 0.02) compared to patients with moderate/severe disease. Adverse events of periprocedural hydration were not reported in any of the included studies. The different methodologies of the included studies precluded a formal data synthesis. CONCLUSIONS There is some evidence to suggest that hydration affords protection against post-ERCP pancreatitis, but study heterogeneity precludes firm conclusions. Adequately powered randomised trials are needed to evaluate the preventive effect of periprocedural hydration.
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Affiliation(s)
- X J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
| | - D W da Costa
- Department of Radiology, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - M G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, Noord-Holland, The Netherlands
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - P Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Noord-Holland, The Netherlands
| | - C J J Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, Noord-Holland, The Netherlands
| | - R W van der Hulst
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, Noord-Holland, The Netherlands
| | - F P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - J P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
| | - E J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
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Leerhøy B, Nordholm-Carstensen A, Novovic S, Hansen MB, Jørgensen LN. Effect of body weight on fixed dose of diclofenac for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Scand J Gastroenterol 2016; 51:1007-12. [PMID: 27160512 DOI: 10.3109/00365521.2016.1172338] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to assess the influence of patient body weight on the clinical effect of 100 mg diclofenac administered as a single dose for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). MATERIALS AND METHODS All patients subjected to endoscopic retrograde cholangiopancreatography (ERCP) from 2009 to 2014 were evaluated for inclusion. In total, 772 patients were included of whom 378 (49%) received diclofenac prophylaxis. RESULTS In the diclofenac prophylaxis group, body weight was higher in patients with PEP (mean ± SD: 82 ± 18 kg) than in patients without PEP (74 ± 18 kg) (p = 0.029). In patients not receiving prophylaxis, body weight was not associated with the occurrence of PEP (mean ± SD: 77 ± 18 vs 75 ± 18 kg, respectively, p = 0.450). In an adjusted analysis, higher patient body weight was inversely associated with the clinical effect of 100 mg diclofenac for the prophylaxis of PEP. CONCLUSIONS High patient body weight was associated with a reduced effect of 100 mg diclofenac for prophylaxis of PEP.
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Affiliation(s)
- Bonna Leerhøy
- a Digestive Disease Center, Bispebjerg Hospital , University of Copenhagen , Copenhagen , Denmark
| | | | - Srdan Novovic
- b Department of Gastroenterology and Gastrointestinal Surgery , Hvidovre Hospital, University of Copenhagen , Copenhagen , Denmark
| | - Mark Berner Hansen
- a Digestive Disease Center, Bispebjerg Hospital , University of Copenhagen , Copenhagen , Denmark ;,c AstraZeneca, Research and Development , Gothenburg , Sweden
| | - Lars Nannestad Jørgensen
- a Digestive Disease Center, Bispebjerg Hospital , University of Copenhagen , Copenhagen , Denmark
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Diclofenac sodium versus ceftazidime for preventing pancreatitis after endoscopic retrograde cholangiopancreatography: a prospective, randomized, controlled trial. Surg Endosc 2016; 31:602-610. [PMID: 27317032 DOI: 10.1007/s00464-016-5004-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 05/23/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS We aimed to compare the efficacy of prophylactic, parenterally administered ceftazidime and rectally applied diclofenac sodium for the prophylaxis of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). METHODS We prospectively enrolled patients who underwent ERCP. In a double-blind, randomized, controlled trial, patients received a suppository containing diclofenac sodium rectally (100 mg) and placebo intravenously (group A) or ceftazidime intravenously (1 g) and placebo rectally (group B) immediately before the procedure. The serum and urine amylase levels were recorded and the patients were clinically evaluated after ERCP. RESULTS Of the 272 patients enrolled (group A: 129; group B: 143), 32 developed pancreatitis (group A: 11 [8.5 %]; group B: 21 [14.7 %]; P = 0.17; relative risk = 1.72; 95 % confidence interval [CI] = 0.86-3.43). The severity of the pancreatitis or complications did not significantly differ between the groups. A serum amylase level of ≥560 U/L and urine amylase level of ≥1150 U/L indicated a positive likelihood ratio for post-ERCP pancreatitis of ≥10. Moreover, the threshold visual analog scale score of ≤5 for abdominal pain after ERCP had excellent diagnostic potential for predicting the presence or absence of post-ERCP pancreatitis. CONCLUSIONS The PEP incidence did not differ between the ceftazidime and diclofenac sodium groups. In patients with nonsteroidal anti-inflammatory drug contraindications, antibiotics can be considered a safe alternative to diclofenac sodium for PEP prevention. Moreover, the visual analog scale for abdominal pain has excellent diagnostic value for predicting PEP. CLINICAL TRIALS. GOV NUMBER NCT 01784445.
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Cotton PB, Elta GH, Carter CR, Pasricha PJ, Corazziari ES. Rome IV. Gallbladder and Sphincter of Oddi Disorders. Gastroenterology 2016; 150:S0016-5085(16)00224-9. [PMID: 27144629 DOI: 10.1053/j.gastro.2016.02.033] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 12/19/2022]
Abstract
The concept that motor disorders of the gallbladder, cystic duct and sphincter of Oddi can cause painful syndromes is attractive and popular, at least in the USA. However, the results of commonly performed ablative treatments (cholecystectomy and sphincterotomy) are not uniformly good. The predictive value of tests that are often used to diagnose dysfunction (dynamic gallbladder scintigraphy and sphincter manometry) is controversial. Evaluation and management of these patients is made difficult by the fluctuating symptoms and the placebo effect of invasive interventions. A recent stringent study has shown that sphincterotomy is no better than sham treatment in patients with post-cholecystectomy pain and little or no objective abnormalities on investigation, so that the old concept of sphincter of Oddi dysfunction (SOD) type III is discarded. ERCP approaches are no longer appropriate in that context. There is a pressing need for similar prospective studies to provide better guidance for clinicians dealing with these patients. We need to clarify the indications for cholecystectomy in patients with Functional Gallbladder Disorder (FGBD) and the relevance of sphincter dysfunction in patients with some evidence for biliary obstruction (previously SOD type II, now called "Functional Biliary Sphincter Disorder - FBSD") and with idiopathic acute recurrent pancreatitis.
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Affiliation(s)
- P B Cotton
- Medical University of South Carolina, Charleston, SC, USA.
| | - G H Elta
- University of Michigan, Ann Arbor, MI, USA
| | | | - P J Pasricha
- Johns Hopkins School of Medicine, Baltimore, MD, USA
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Hegade VS, Krawczyk M, Kremer AE, Kuczka J, Gaouar F, Kuiper EMM, van Buuren HR, Lammert F, Corpechot C, Jones DEJ. The safety and efficacy of nasobiliary drainage in the treatment of refractory cholestatic pruritus: a multicentre European study. Aliment Pharmacol Ther 2016; 43:294-302. [PMID: 26526892 DOI: 10.1111/apt.13449] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 09/08/2015] [Accepted: 10/07/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Pruritus is a common symptom associated with cholestatic liver diseases. To date only small single centre case series have suggested efficacy of nasobiliary drainage in relieving cholestatic pruritus. AIM To perform a multicentre study to evaluate the safety and efficacy of nasobiliary drainage in cholestatic pruritus. METHODS This was a retrospective study of all patients treated with nasobiliary drainage for refractory cholestatic pruritus between 2006 and 2015 at five European centres. Pruritus was quantified using a visual analogue scale (VAS) and liver enzymes, serum bilirubin and total serum bile salts (TBS) were measured before (pre-NBD) and after nasobiliary drainage (post-NBD). We analysed the duration of treatment response and associated complications. RESULTS In total, 27 patients (59% females) underwent 29 nasobiliary drainage procedures. The median duration of NBD was 7 days. NBD decreased pruritus in 89.6% of cases (VAS from 10.0 to 0.3, P < 0.0001). The median percentage decline in pruritus VAS was 94% and 33% of patients were free of pruritus within 24 h of starting drainage. The duration of treatment response was independent of duration of drainage (P = 0.12) and bile output. Significant improvements were seen in the median levels of serum alkaline phosphatase (P = 0.001) and serum bilirubin (P = 0.03) but not in serum TBS (P = 0.07). Mild post-endoscopic retrograde cholangiopancreatography pancreatitis (31%) was the most frequent complication. CONCLUSIONS Nasobiliary drainage is effective in relieving cholestatic pruritus in most patients and has favourable effect on biomarkers of cholestasis. Nasobiliary drainage may be associated with high risk of adverse events, especially pancreatitis. Prospective studies are needed to confirm our findings.
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Affiliation(s)
- V S Hegade
- Freeman Hospital, The Newcastle upon Tyne NHS Foundation Trust and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - M Krawczyk
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany.,Laboratory of Metabolic Liver Diseases, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - A E Kremer
- Department of Medicine I, Friedrich-Alexander-University of Erlangen, Erlangen, Germany
| | - J Kuczka
- Department of Medicine I, Friedrich-Alexander-University of Erlangen, Erlangen, Germany
| | - F Gaouar
- Service d'Hépatologie, Centre de référence des Maladies Inflammatoires des voies biliaires, Hôpital Saint-Antoine, Paris, France
| | - E M M Kuiper
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - H R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - F Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - C Corpechot
- Service d'Hépatologie, Centre de référence des Maladies Inflammatoires des voies biliaires, Hôpital Saint-Antoine, Paris, France
| | - D E J Jones
- Freeman Hospital, The Newcastle upon Tyne NHS Foundation Trust and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Abstract
The medical treatment of acute pancreatitis continues to focus on supportive care, including fluid therapy, nutrition, and antibiotics, all of which will be critically reviewed. Pharmacologic agents that were previously studied were found to be ineffective likely due to a combination of their targets and flaws in trial design. Potential future pharmacologic agents, particularly those that target intracellular calcium signaling, as well as considerations for trial design will be discussed. As the incidence of acute pancreatitis continues to increase, greater efforts will be needed to prevent hospitalization, readmission and excessive imaging in order to reduce overall healthcare costs. Primary prevention continues to focus on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and secondary prevention on cholecystectomy for biliary pancreatitis as well as alcohol and smoking abstinence.
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Affiliation(s)
- Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Yu G, Li S, Wan R, Wang X, Hu G. Nafamostat mesilate for prevention of post-ERCP pancreatitis: a meta-analysis of prospective, randomized, controlled trials. Pancreas 2015; 44:561-9. [PMID: 25822153 DOI: 10.1097/mpa.0000000000000310] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We aimed to evaluate the efficacy of nafamostat on the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). METHODS Medline, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were searched until April 18, 2014. RESULTS Seven randomized controlled trials and 2956 patients met the search criteria. When compared with nonnafamostat, the incidence of PEP was reduced to 53% in the patients who received nafamostat (risk ratio [RR], 0.47; 95% confidence interval [CI], 0.34-0.63). Further analyses were conducted based on the different risk classifications (n = 641 in patients with high risks: RR, 0.54; 95% CI, 0.30-0.96 and n = 944 with low risks: RR, 0.31; 95% CI, 0.17-0.56), PEP severities (n = 1654: RR, 0.38; 95% CI, 0.25-0.59 for mild; RR, 0.37; 95% CI, 0.15-0.96 for moderate; RR, 0.92; 95% CI, 0.13-6.38 for severe), and nafamostat doses (n = 1902: RR, 0.42; 95% CI, 0.28-0.63 for 20 mg; n = 1150: RR, 0.40; 95% CI, 0.25-0.63 for 50 mg). However, there was no reduction of the incidence of post-ERCP hyperamylasemia (n = 1585; 95% CI, 0.68-1.45) or cannulation difficulty (n = 1585; 95% CI, 0.91-1.23). CONCLUSIONS Pooled analyses from current randomized controlled trials support the effectiveness of nafamostat for prophylaxis of PEP.
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Affiliation(s)
- Ge Yu
- From the *Department of Gastroenterology, Shanghai First People's Hospital, Shanghai Jiaotong University School of Medicine; and †Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
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Randomized controlled trial for efficacy of nafamostat mesilate in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreas 2015; 44:415-21. [PMID: 25479585 DOI: 10.1097/mpa.0000000000000278] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The objective of this study was to investigate whether prophylactic administration of nafamostat mesilate reduces the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), its efficacy, and risk factors for PEP. METHODS Potential subjects comprised 876 patients who underwent ERCP between September 2008 and February 2011. Of these, 58 patients were excluded after meeting exclusion criteria, and 818 patients were randomized. Patients in the nafamostat mesilate group were administered 20 mg of nafamostat mesilate dissolved in 500 mL of 5% glucose solution, whereas the control group received 500 mL of 5% glucose solution alone, over 2 hours from the start of ERCP. RESULTS Post-ERCP pancreatitis occurred in 5.1% (41 patients) overall, with a significantly lower frequency in the nafamostat mesilate group (3.5%) than in the control group (6.7%; P = 0.0349). Analysis of the 322 patients who had undergone ERCP for the first time (n = 158 in the nafamostat mesilate group; n = 164 in the control group) found that PEP again significantly less frequently occurred in the nafamostat mesilate group (5.7%) than in the control group (13.4%; P = 0.0172). CONCLUSIONS Our randomized controlled study suggested that short-term administration of nafamostat mesilate 20 mg may reduce the incidence of PEP.
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