Intravenous bolus somatostatin after diagnostic cholangiopancreatography reduces the incidence of pancreatitis associated with therapeutic endoscopic retrograde cholangiopancreatography procedures: a randomised controlled trial

Effectiveness of the pharmacological therapy to prevent post ERCP acute pancreatitis: a network meta-analysis

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.

Incidence, severity, and mortality of post-ERCP pancreatitis: an updated systematic review and meta-analysis of 145 randomized controlled trials

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.

Comparison between transpapillary versus transmural endoscopic ultrasound-guided decompression for biliary obstruction: a meta-analysis

BACKGROUND

Recent advances have led to the development of transmural endoscopic ultrasound guided biliary drainage (EUS-BD) for cases where the duodenal papilla cannot be accessed.

OBJECTIVES

We performed a meta-analysis comparing efficacy and complications of both approaches for biliary drainage.

REVIEW METHODS

English articles were searched in PubMed. Primary outcomes included technical success and complications. Secondary outcomes were clinical success and subsequent stent malfunction. Patient demographics and etiology of obstruction were collected and relative risk ratios and 95% CIs were calculated. P-value <0.05 was considered as statistically significant.

RESULTS

Initial database search yielded 245 studies from which 7 were chosen based upon inclusion criteria for final analysis. There was no statistically different relative risk for technical success when comparing primary EUS-BD to endoscopic retrograde cholangiopancreatography (ERCP) (RR: 1.04) or overall procedural complication rate (RR 1.39). EUS-BD did have increased specific risk of cholangitis (RR: 3.01). Likewise, primary EUS-BD and ERCP had similar RR for clinical success (RR: 1.02) and overall stent malfunction (RR: 1.55), but stent migration was higher in the primary EUS-BD group (RR: 5.06).

CONCLUSIONS

Primary EUS-BD may be considered when the ampulla cannot be accessed, when there is gastric outlet obstruction, or presence of a duodenal stent.

Effect of Adding Intravenous Somatostatin to Rectal Indomethacin on Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis in High-risk Patients: A Double-blind Randomized Placebo-controlled Clinical Trial

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) has an important role in the treatment of pancreaticobiliary disorders.

GOALS

Considering the high prevalence and importance of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) and the controversial findings, we aimed to determine the effect of adding intravenous somatostatin to rectal indomethacin on the incidence of PEP in high-risk patients.

STUDY

In this prospective study, 530 patients underwent ERCP during March 2018 and February 2019. Patients were randomized into 2 groups. The intervention group received a bolus injection of 250 μg somatostatin followed by an infusion of 500 μg of somatostatin for 2 hours. In both groups, 100 mg of pre-ERCP suppository indomethacin was administrated. All patients were screened for PEP symptoms and signs for 24 hours after ERCP (Iranian Registry of Clinical Trials code: IRCT20080921001264N11).

RESULTS

A total of 376 patients were finally analyzed. PEP was the most common adverse event with 50 (13.2%) episodes, including 21 (5.5%) mild, 23 (6.1%) moderate, and 6 (1.2%) severe. The rate of PEP was 15.2% in the control group and 11.4% in the intervention group ( P =0.666). The incidence of post-ERCP hyperamylasemia was 21.7% in the control group and 18.2% in the intervention group ( P =0.395). No death occurred.

CONCLUSIONS

In this study administration of somatostatin plus indomethacin could safely reduce the rate of post-ERCP hyperamylasemia and PEP in the intervention group compared with the control group, but the differences were not significant. Further studies with larger sample sizes are required.

Effect of ice water injection toward the duodenal papilla for preventing post-ERCP pancreatitis: study protocol for a multicenter, single-blinded, randomized controlled trial (EUTOPIA study)

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure in the diagnosis and treatment of biliopancreatic diseases. The most common adverse event of ERCP is post-ERCP pancreatitis (PEP), which can sometimes be severe. Our previous study suggested that injecting ice water at the end of ERCP suppressed PEP, and we decided to investigate this effect in a multicenter randomized controlled trial.

Methods

This study is being conducted at eight hospitals in Japan starting in April 2022. Patients undergoing ERCP will be randomized to ice water group and control group. In the ice water group, 250 ml of ice water is injected toward the papilla at the end of ERCP. The next morning, a physical examination and blood tests are performed to evaluate for the development of pancreatitis. The goal is to have 440 cases in each group.

Discussion

The main cause of PEP is thought to be papilla edema. Cooling the papilla, as everyone naturally does at the time of a burn, is expected to prevent its inflammation and edema. Various methods to suppress PEP have been reported, but so far none of them are reliable. The method we have devised is very simple, easy, and safe. We hope that our study will change the world's ERCP common practice.

Trial registration:UMIN000047528. Registered 20 April 2022, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000053209

Combination prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients undergoing double-guidewire assisted biliary cannulation: A case-control study with propensity score matching

BACKGROUND AND AIM

Rectal indomethacin and pancreatic duct stenting (PDS) are recommended for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). However, the effects of the combination of the two methods on preventing PEP are controversial. We hypothesized that some group of difficult patients might benefit from the combination of indomethacin plus PDS (IP) compared with indomethacin alone (IN).

METHODS

Patients with native papilla who underwent endoscopic retrograde cholangiopancreatography in eight tertiary hospitals were screened. They were enrolled if the cannulation proved difficult and post-procedure indomethacin was administered. Propensity score matching (PSM) was used to balance the baseline characteristics between IP and IN groups. The primary outcome was PEP.

RESULTS

Among 4456 patients with available cannulation-related data, 1889 (42.4%) patients had difficult cannulation and received indomethacin. After PSM, both IP and IN groups included 332 patients. PEP was comparable between the two groups (12.7% vs 10.2%, P = 0.329). By subgroup analysis, the PEP rate was found to be lower in the IP group than in the IN group (7.3% vs 18.2%, P = 0.026) in patients undergoing double-guidewire technique (DGT). The results of an additional analysis using PSM in DGT patients were consistent with the subgroup analysis results (7.8% vs 19.4%, P = 0.036).

CONCLUSIONS

The current study indicated that the combined prevention of PEP with indomethacin plus PDS was useful in PEP prevention in patients undergoing DGT. Other groups of patients with difficult cannulation may not benefit from the combination strategy.

Emerging Therapies to Prevent Post-ERCP Pancreatitis

PURPOSE OF REVIEW

The aim of this review is to evaluate emerging, novel therapies for the prevention of post-ERCP pancreatitis.

RECENT FINDINGS

Rectal indomethacin reduces the risk of pancreatitis in low- and average-risk patients, who comprise the majority of patients undergoing ERCP. An 8-h protocol of aggressive lactated Ringer's reduces the risk of pancreatitis in average-risk patients. Sublingual nitrate may provide additional benefit to rectal NSAIDs in preventing PEP. A tacrolimus trough > 2.5 ng/mL was recently shown to be associated with a lower risk of PEP in liver transplant patients undergoing ERCP. Routine usage of rectal indomethacin in all patients undergoing ERCP reduces the risk of PEP. Pancreatic-duct stents reduce the risk of PEP in high-risk patients. There is emerging data that aggressive hydration with lactated Ringer's and nitrates may further reduce PEP. Tacrolimus is a promising potential agent to prevent PEP but needs further clinical study.

Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in the Indomethacin Era - A Prospective Study

Background and Aims

Although endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure used to treat conditions affecting the biliopancreatic system, it can lead to several complications. Post-ERCP pancreatitis (PEP) is the most frequent one, with an incidence ranging from 3 to 14%. Our aim was to assess the potential risk factors associated with PEP occurrence in patients undergoing ERCP with indomethacin prophylaxis.

Methods

Prospective, single-center, real-world observational study (January to December 2015) with inclusion of patients submitted to ERCP, where relevant patient-related and procedure-related data had been collected. Patients had to have been admitted for a minimum of 24 h in order to establish the presence of early complications. All patients were submitted to PEP prophylaxis with 1 or 2 methods: rectal indomethacin and pancreatic duct (PD) stenting.

Results

A total of 188 patients who had undergone ERCP were included (52.7% women; mean age 69.2 ± 16.0 years) and PEP was diagnosed in 13 (6.9%). PEP prophylaxis consisted of indomethacin in all cases (100%) and PD stenting in 7.4%. The pancreatitis was mild in 11 patients (84.6%) and severe in the other 2. One of them died (0.5%). None of the patient-related risk factors were associated with changes in PEP probability. Of all patients, 33.0% had 2 or more procedure-related risk factors. A higher number of synchronous procedure-related risk factors showed a statistically significant correlation with PEP occurrence, p = 0.040.

Conclusions

The 6.9% PEP rate is considered acceptable since 33.0% patients had a medium-high risk for PEP due to challenging biliary cannulation. The total number of procedure-related risk factors seems to play a critical role in the development of PEP despite indomethacin prophylaxis.

Effect of somatostatin on prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis and hyperamylasemia: A systematic review and meta-analysis

OBJECTIVE

To perform a meta-analysis of all available studies on the effect of prophylactic somatostatin administration on prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and post-ERCP hyperamylasemia (PEHA).

METHODS

Electronic databases, including PubMed, EMBASE, the Cochrane library, and the Science Citation Index were searched to retrieve relevant trials. Randomized, placebo-controlled trials in adult patients that compared somatostatin versus placebo in prevention of PEP were included. Meta-analysis was performed using a random-effects model to assess the ratios of PEP, PEHA and post-ERCP abdominal pain.

RESULTS

Total ratio of PEP of somatostatin group was significantly lower than that of placebo group. For the short-term injection or bolus injection there were no heterogeneity and no significance between the ratio of PEP of somatostatin group and placebo group. For the long-term injection subgroup there was heterogeneity, and the ratio of PEP of somatostatin group was significantly lower than that of placebo group. There was no significance between the ratio of PEP of somatostatin group and placebo group for the low-risk PEP subgroup, while the ratio of PEP of somatostatin group was significantly lower than that of placebo group for the high-risk PEP subgroup. The ratio of PEP of somatostatin group was significantly lower than that of placebo group for the long-term injection high-risk PEP subgroup. There was no significance between the ratio of PEHA of somatostatin group and placebo group for the short-term injection subgroup or bolus injection subgroup. The ratio of PEHA of somatostatin group was significantly lower than that of placebo group for the long-term injection subgroup. The total ratio of post-ERCP abdominal pain of somatostatin group was significantly lower than that of placebo group. The funnel plot of incidence of PEP and PEHA showed no asymmetry with a negative slope.

CONCLUSION

Prophylactic use of long-term injection of somatostatin can significantly reduce the incidence of PEP, PEHA and post-ERCP abdominal pain for the high-risk PEP patients, while it is not necessary to be used for the low-risk PEP patients.

Utility of serum phosphate as a marker for predicting the severity of post-endoscopic retrograde cholangiopancreatography pancreatitis

Background

To date, no reliable marker for predicting the severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis exists. A previous animal study reported a correlation between serum phosphate level and the severity of acute pancreatitis.

Objective

The purpose of this study was to evaluate the feasibility of serum phosphate as a marker for predicting the severity of post-ERCP pancreatitis in humans.

Methods

A cohort of patients that were diagnosed with post-ERCP pancreatitis between January 2005 and December 2016 was queried. In addition to serum phosphate levels measured between 12 and 24 hours after ERCP, several candidates deemed suitable for accurately predicting the severity of post-ERCP pancreatitis were also explored.

Results

A total of 191 patients with severe (n = 42, 22.0%) and mild-to-moderate (n = 149, 78.0%) post-ERCP pancreatitis were included. Several factors for predicting severe post-ERCP pancreatitis were identified in the multivariate analysis: malignancy as the primary indication for ERCP (odds ratio (OR) 2.65, P = 0.038), systemic inflammatory response syndrome (OR 4.49, P = 0.016) and serum phosphate level (OR 1.97, P = 0.040). In the receiver operating characteristic analysis, the area under the curve of serum phosphate level for severe post-ERCP pancreatitis was 0.65 (95% confidence interval, 0.56-0.75). The optimal cut-off value of serum phosphate level for prediction of severe post-ERCP pancreatitis was 3.35 mg/dL (sensitivity, 0.62; specificity, 0.73).

Conclusions

Serum phosphate level after ERCP can be used as a reliable prognostic marker in predicting the severity of post-ERCP pancreatitis. Future prospective studies would be the cogent next step in validating its value.

Rectal NSAIDs in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in unselected patients: Systematic review and meta-analysis

BACKGROUND AND AIM

Efficacy of rectal non-steroidal anti-inflammatory drugs (NSAIDs) for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prophylaxis in unselected patients remained controversial. The aim of the present study was to evaluate the efficacy of rectal NSAIDs in the prevention of PEP in unselected patients.

METHODS

An electronic literature search in the Cochrane Library, Embase, and PubMed was carried out for randomized controlled trials comparing rectal indomethacin or diclofenac with placebo in the prevention of PEP in unselected patients. Cochrane risk of bias tool was used to evaluate methodological quality. The data were carried out in forest plots using fixed-effect methods, and random-effect methods were used when heterogeneity was significant.

RESULTS

A total of nine trials were included in our final analysis. Rectal NSAIDs were effective to reduce the incidence of PEP in unselected patients (RR, 0.61; 95% CI, 0.46-0.79), especially for moderate-to-severe PEP (RR, 0.37; 95% CI, 0.17-0.79). Both indomethacin (RR, 0.67; 95% CI, 0.50-0.88) and diclofenac (RR, 0.29; 95% CI, 0.12-0.69) were significantly efficacious. Rectal NSAIDs given pre-ERCP showed significant efficacy (RR, 0.53; 95% CI, 0.39-0.71), whether when given within 30 min pre-ERCP (RR, 0.62; 95% CI, 0.42-0.92) or not (RR, 0.43; 95% CI, 0.28-0.67).

CONCLUSION

Rectal NSAIDs are effective in the prevention of PEP in unselected patients.

Role of Somatostatin in Preventing Post-endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis: An Update Meta-analysis

Background: Acute pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP). Although, somatostatin (SOM) has been used in the prevention of post-ERCP pancreatitis (PEP), the efficacy of SOM remains inconsistent.

Methods: Electronic databases, including PubMed/MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), and the Science Citation Index were searched to retrieve relevant studies. Details of the study population, including patients’ characteristics, sample size, regimen of drug administration and incidence of PEP, hyperamylasemia and abdominal pain were extracted by two investigators. Data were analyzed with Review Manager 5.3 software.

Results: Eleven randomized controlled trials, enrolling a total of 4192 patients, were included in the meta-analysis. After data were pooled, we observed decreased incidence of ERCP-induced outcomes, such as PEP (RR = 0.63, 95% CI: 0.40, 0.98; P = 0.04) and hyperamylasemia (RR = 0.75, 95% CI: 0.66, 0.84; P < 0.001) in patients treated with SOM than those with placebo. Subgroup analysis by ethnicity found decreased incidence of PEP and hyperamylasemia in Asia only. Subgroup analysis by treatment schedule and dosage revealed decreased incidence of PEP and hyperamylasemia when SOM were treated with a single bolus or long-term infusion, or at dose above 3000 μg. We did not observed efficacy of SOM on abdominal pain in pooled or subgroup analysis.

Conclusion: This meta-analysis of patients undergoing ERCP showed reduced incidence of PEP and hyperamylasemia when SOM was administrated with single bolus, long-term infusion, or high dosage. More data are needed to confirm our findings.

Endoscopic and pharmacological treatment for prophylaxis against postendoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis and systematic review

BACKGROUND AND AIM

Postendoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP) is the most common complication following ERCP. We carried out a systematic review and meta-analysis of the global literature on PEP prevention to provide clinical guidance and a framework for future research in this important field.

METHODS

PubMed, Embase, Science Citation Index, Ovid, and the Cochrane Controlled Trials Register were searched by two independent reviewers to identify full-length, prospective, randomized controlled trials (RCTs) published up until March 2016 investigating the use of pancreatic duct stents and pharmacological agents to prevent PEP.

RESULTS

Twelve RCTs comparing the risk of PEP after pancreatic duct stent placement (1369 patients) and 30 RCTs comparing pharmacological agents over placebo (10251 patients) fulfilled the inclusion criteria and were selected for final review and analysis. Meta-analysis showed that prophylactic pancreatic stents significantly decreased the odds of post-ERCP pancreatitis [odds ratio (OR), 0.28; 95% confidence interval (CI), 0.18-0.42]. Significant OR reduction of PEP was also observed in relation to rectal administration of diclofenac (OR, 0.24; 95% CI, 0.12-0.48) and rectal administration of indometacin (OR, 0.59; 95% CI, 0.44-0.79) compared with placebo. Subgroup analysis showed a significant reduction with bolus-administered somatostatin (OR, 0.23; 95% CI, 0.11-0.49). Subgroup analysis showed a significant reduction with bolus-administered somatostatin (OR, 0.23; 95% CI, 0.11-0.49).

CONCLUSION

Pancreatic stent placement, rectal diclofenac, and bolus administration of somatostatin appear to be most effective in preventing post-ERCP pancreatitis.

Routine pre-procedural rectal indometacin versus selective post-procedural rectal indometacin to prevent pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography: a multicentre, single-blinded, randomised controlled trial

BACKGROUND

Rectal indometacin decreases the occurrence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, the population most at risk and the optimal timing of administration require further investigation. We aimed to assess whether pre-procedural administration of rectal indometacin in all patients is more effective than post-procedural use in only high-risk patients to prevent post-ERCP pancreatitis.

METHODS

We did a multicentre, single-blinded, randomised controlled trial at six centres in China. Eligible patients with native papilla undergoing ERCP were randomly assigned in a 1:1 ratio (with a computer-generated list) to universal pre-procedural indometacin or post-procedural indometacin in only high-risk patients, with stratification by trial centres and block size of ten. In the universal indometacin group, all patients received a single dose (100 mg) of rectal indometacin within 30 min before ERCP. In the risk-stratified, post-procedural indometacin group, only patients at predicted high risk received rectal indometacin, immediately after ERCP. Investigators, but not patients, were masked to group allocation. The primary outcome was overall ocurrence of post-ERCP pancreatitis. The analysis followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT02002650.

FINDINGS

Between Dec 15, 2013, and Sept 21, 2015, 2600 patients were randomly assigned to universal, pre-procedural indometacin (n=1297) or risk-stratified, post-procedural indometacin (n=1303). Overall, post-ERCP pancreatitis occurred in 47 (4%) of 1297 patients assigned to universal indometacin and 100 (8%) of 1303 patients assigned to risk-stratified indometacin (relative risk 0·47; 95% CI 0·34-0·66; p<0·0001). Post-ERCP pancreatitis occurred in 18 (6%) of 305 high-risk patients in the universal group and 35 (12%) of 281 high-risk patients in the risk-stratified group (p=0·0057). Post-ERCP pancreatitis was also less frequent in average-risk patients in the universal group (3% [29/992]), in which they received indometacin, than in the risk-stratified group (6% [65/1022]), in which they did not receive the drug (p=0·0003). Other than pancreatitis, adverse events occurred in 41 (3%; two severe) patients in the universal indometacin group and 48 (4%; one severe) patients in the risk-stratified group. The most common adverse events were biliary infection (22 [2%] patients vs 33 [3%] patients) and gastrointestinal bleeding (13 [1%] vs ten [1%]).

INTERPRETATION

Compared with a risk-stratified, post-procedural strategy, pre-procedural administration of rectal indometacin in unselected patients reduced the overall occurrence of post-ERCP pancreatitis without increasing risk of bleeding. Our results favour the routine use of rectal indometacin in patients without contraindications before ERCP.

FUNDING

National Key Technology R&D Program, National Natural Science Foundation of China.

Pancreatic Stenting Reduces Post-ERCP Pancreatitis and Biliary Sepsis in High-Risk Patients: A Randomized, Controlled Study

Background. Endoscopic retrograde cholangiopancreatography (ERCP) is an established treatment modality for bile duct disorders, but patients have a risk of post-ERCP pancreatitis (PEP) and biliary sepsis. Aim. To evaluate the effectiveness and safety of pancreatic stent for prophylaxis of PEP and biliary sepsis in high-risk patients with complicating common bile duct (CBD) disorders. Methods. Two hundred and six patients with complicating confirmed or suspected CBD disorders were randomly assigned to receive ERCP with pancreatic stenting (experimental group) or without stenting (control group). Primary outcome measure was frequency of PEP, and secondary outcome measures included operative time, blood loss, postoperative recovery times, and other ERCP-associated morbidities. Results. Baseline age, sex, CBD etiology, concomitant medical/surgical conditions, cannulation difficulty, and ERCP success were comparable between the two groups (all P > 0.05). Compared to the control group, the experimental group had a significantly lower frequency of PEP (7.7% versus 17.7%, P < 0.05) and positive bile microbial culture (40.4% versus 62.7%, P < 0.05). However, the two groups were similar in operative time, blood loss, postoperative recovery times, and other ERCP-associated morbidities (all P > 0.05). Conclusions. Pancreatic stenting can reduce the occurrence of PEP and biliary sepsis in high-risk patients with complicating CBD disorders but does not increase other ERCP-associated morbidities. This trial is registered with the Chinese Clinical Trial Registry (registration identifier ChiCTR-OCH-14005134).

Direct spraying of shakuyakukanzoto onto the duodenal papilla: a novel method for preventing pancreatitis following endoscopic retrograde cholangiopancreatography

BACKGROUND/AIMS

Topical epinephrine application to the duodenal papilla reduces spasm of the sphincter of Oddi and prevents acute pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). Shakuyakukanzoto (TJ-68) has an inhibitory effect on muscle contraction. Therefore, TJ-68 potentially allows the relaxation of the sphincter of Oddi, which can aid in the prevention of post-ERCP pancreatitis.

METHODS

Thirty-six patients planned for ERCP were divided into TJ-68 (n = 17) and control groups (n = 19). In the TJ-68 group, the TJ-68 solution was endoscopically sprayed directly onto the duodenal papilla of patients. To assess the effects of TJ-68, serum amylase levels were measured at 1 h and 1 day after ERCP and symptoms were evaluated.

RESULTS

The serum amylase levels at 1 h after ERCP were 273.6 ± 212.0 IU/l in the TJ-68 group and 428.7 ± 281.6 IU/l in the control group, showing a statistically significant difference (p = 0.036). The serum amylase levels at 24 h after ERCP were 230.0 ± 182.7 IU/l in the TJ-68 group and 497.4 ± 514.0 IU/l in the control group (p = 0.011). Post-ERCP pancreatitis was observed in 0 and 4 patients (21.1%) in the TJ-68 and control groups, respectively, which was not statistically significant (p = 0.11).

CONCLUSION

Direct TJ-68 solution application to the duodenal papilla significantly inhibited the elevation of serum amylase levels. However, the preventive effect regarding post-ERCP pancreatitis was not confirmed in this study.

Prophylactic effect of somatostatin in preventing Post-ERCP pancreatitis: an updated meta-analysis

BACKGROUND/AIMS

Somatostatin is regarded as a prophylactic agent on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), but studies are still controversial.

MATERIALS AND METHODS

Electronic databases, including PubMed, EMBASE, the Cochrane library, and the Science Citation Index, were searched to retrieve relevant trials. In addition, meeting abstracts and the reference lists of retrieved articles were reviewed for further relevant studies.

RESULTS

Eleven randomized controlled trials (RCTs), enrolling a total of 2869 patients, were included in the meta-analysis. After data were pooled from somatostatin trials, PEP occurred in 8.36% of controls versus 5.62% of the treated group, with a slight significance [relative risk (RR) =0.58, 95% confidence interval (CI) 0.35-0.98, P = 0.04]. The funnel plot showed no asymmetry with a negative slope (P = 0.108). The meta-analysis produced negative results for short-term infusion of somatostatin (RR = 1.40, 95% CI 0.93-2.12, P = 0.11), whereas a bolus or long-term injection of the drug proved effective (RR = 0.25, 95% CI 0.13-0.47,P < 0.0001; RR = 0.44, 95% CI 0.27-0.71,P = 0.0008). Postprocedure hyperamylasemia and pain was also observed in the meta-analysis, the pooled RR was significant for reduced risk of postprocedure hyperamylasemia (RR = 0.72, 95%CI 0.63 to 0.81,P < 0.00001), but not for the pain (RR = 0.67, 95% CI 0.42 to 1.08,P= 0.10).

CONCLUSION

The current meta-analysis on the prophylactic use of somatostatin in patients undergoing ERCP documents a lack of benefit when given as short-term infusion, but showed an advantage of a single bolus or long-term injection. The beneficial effect of somatostatin, in reducing the incidence of postprocedural hyperamylasemia seems of marginal clinical significance. However, more new confirmatory data are needed to settle residual doubts.

Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials

BACKGROUND

Data regarding the incidence and severity of post-ERCP pancreatitis (PEP) are primarily from nonrandomized studies.

OBJECTIVE

To determine the incidence, severity, and mortality of PEP from a systematic review of the placebo or no-stent arms of randomized, controlled trials (RCTs).

DESIGN

MEDLINE, EMBASE, and Cochrane databases were searched to identify RCTs evaluating the efficacy of drugs and/or pancreatic stents to prevent PEP.

SETTING

Systematic review of patients enrolled in RCTs evaluating agents for PEP prophylaxis.

PATIENTS

Patients in the placebo or no-stent arms of the RCTs

INTERVENTION

ERCP.

MAIN OUTCOME MEASUREMENTS

Incidence, severity, and mortality of PEP.

RESULTS

There were 108 RCTs with 13,296 patients in the placebo or no-stent arms. Overall, the PEP incidence was 9.7% and the mortality rate was 0.7%. Severity of PEP was reported for 8857 patients: 5.7%, 2.6%, and 0.5% of cases were mild, moderate, and severe, respectively. The incidence of PEP in 2345 high-risk patients was 14.7% and the severity of PEP was mild, moderate, and severe in 8.6%, 3.9%, and 0.8%, respectively, with a 0.2% mortality rate. The incidence of PEP was 13% in North American RCTs compared with 8.4% in European and 9.9% in Asian RCTs. ERCPs conducted before and after 2000 had a PEP incidence of 7.7% and 10%, respectively.

LIMITATIONS

Difference in PEP risk among patients in the included RCTs.

CONCLUSION

The incidence of PEP and severe PEP is similar in high-risk patients and the overall cohort. Discrepancies in the incidence of PEP across geographic regions require further study.

Somatostatin administration prior to ERCP is effective in reducing the risk of post-ERCP pancreatitis in high-risk patients

Somatostatin has been extensively studied for the prophylaxis of pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). However, the results remain controversial. The present retrospective cohort study aimed to investigate the efficacy of pre- and post-ERCP somatostatin administration in the prevention of post-ERCP pancreatitis (PEP). All ERCP procedures performed at one hospital between January 2009 and December 2012 were reviewed. They were divided into three groups based on somatostatin administration: pre-ERCP som group (somatostatin administration: 0.25 mg/h for 24 h, starting 1 h prior to ERCP), post-ERCP som group (somatostatin administration: 0.25 mg/h for 24 h, starting immediately following ERCP), and control group (no somatostatin administration). Out of a total of 304 cases, 81 received pre-ERCP somatostatin; 126 received post-ERCP somatostatin and 97 were not administered somatostatin. Pre-ERCP somatostatin was effective in reducing the incidence of PEP compared with that in the control group (4.9 vs. 16.5%; P=0.017). This benefit was significant in high-risk patients (8.9 vs. 26.0%; P=0.035), but not in low-risk patients (0 vs. 6.4%; P=0.254). Post-ERCP somatostatin was not effective in preventing PEP in high- or low-risk patients. In conclusion, pre-ERCP somatostatin may be effective in reducing the risk of PEP in high-risk patients, but not in low-risk patients. Post-ERCP somatostatin did not reveal a benefit in high- or low-risk patients. However, large randomized controlled trials are required to further confirm these findings.

Losartan to prevent hyperenzymemia after endoscopic retrograde cholangiopan-creatography: A randomized clinical trial

AIM: To study if the angiotensin II receptor blockers (ARB) losartan counteracts pancreatic hyperenzymemia as measured 24 h after endoscopic retrograde cholangiopancreatography (ERCP).

METHODS: A triple-blind and placebo-controlled randomized clinical trial was performed at two Swedish hospitals in 2006-2008. Patients over 18 years of age undergoing ERCP, excluding those with current pancreatitis, current use of ARB, and severe disease, such as sepsis, liver and renal failure. One oral dose of 50 mg losartan or placebo was given one hour before ERCP. The relative risk of hyperenzymemia 24 h after ERCP was estimated using multivariable logistic regression, and expressed as odds ratio with 95% confidence intervals (CIs), including adjustment for potential remaining confounding.

RESULTS: Among 76 participating patients, 38 were randomized to the losartan and the placebo group, respectively. The incidence rates of hyperenzymemia and acute pancreatitis among all 76 participating patients were 21% and 12%, respectively. Hyperenzymemia was detected in 9 and 7 patients in the losartan and placebo group, respectively. There were no major differences between the comparison groups regarding cannulation difficulty, findings, or proportion of patients requiring drainage of the bile ducts. There were, however, more pancreatic duct injections, a greater extent of pancreatography, and more biliary sphincterotomies in the losartan group than in the placebo group. Losartan was not associated with risk of hyperenzymemia compared to the placebo group after multi-varible logistic regression analysis (odds ratio 1.6, 95%CI 0.3-7.8).

CONCLUSION: In this randomized trial 50 mg losartan given orally had no prophylactic effect on development of hyperenzymemia after ERCP.

Endoscopic complications--avoidance and management

The frequency of endoscopic complications is likely to rise owing to the increased number of indications for therapeutic procedures and also to the increased complexity of endoscopic techniques. Informed patient consent should be obtained as part of the procedure. Prevention of endoscopic adverse events is based on knowledge of the relevant risk factors and their mechanisms of occurrence. Thus, suitable training of future gastroenterologists and endoscopists is required for these complex procedures. When facing a complication, appropriate management is generally provided by an early diagnosis followed by prompt therapeutic care tailored to the situation. The most common complications of diagnostic and therapeutic upper gastrointestinal endoscopy, retrograde cholangiopancreatography, small bowel endoscopy and colonoscopy are reviewed here. Different modalities of medical, endoscopic or surgical management are also considered.

Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis by epinephrine sprayed on the papilla

BACKGROUND AND AIM

Epinephrine sprayed on the papilla may reduce papillary edema and prevent acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to evaluate the effects of localized irrigation with epinephrine saline for prevention of post-ERCP pancreatitis (PEP).

METHODS

A total of 941 patients who were scheduled for ERCP were recruited into this study. We randomized the patients to have 20 mL of either 0.02% epinephrine or saline sprayed on the papilla after diagnostic ERCP to prevent post-ERCP pancreatitis. We recorded duct visualization, presence of pancreatic acinarization, number of injections into the pancreatic duct, total volume of contrast used, and procedure duration. The serum amylase levels were measured at 6, 24 and 48 h after ERCP. We counted the patients of PEPs and compared whether there was significant difference between the pancreatitis group and the no pancreatitis group.

RESULTS

A univariate analysis of the explanatory variables between the epinephrine and control groups, the pancreatitis and no pancreatitis groups revealed the treatment to be effective, but most of the groups were not statistically significant. PEPs occurred in 40 of the 941 patients (4.25%), the incidence of pancreatitis tended to be higher in the control group (31/480, 6.45%) than in the epinephrine group (9/461, 1.95%) (P = 0.0086).

CONCLUSIONS

Epinephrine sprayed on the papilla may be effective to prevent PEP. Female patients (aged ≥ 18 years and < 35 years) (7/40, 17.5%), common bile duct diameter < 10 mm (27/40, 67.5%), previous cholangitis (3/40, 7.5%), body mass index ≥ 24 (22/40, 55%), and/or serum triglycerides ≥ 5.65 mmol/L (6/40, 15%), might be risk factors for post-ERCP pancreatitis, but are not statistically significant in the study.

Prophylactic injection of hypertonic saline-epinephrine oral to the papilla for prevention of postsphincterotomy bleeding

GOALS/BACKGROUND

Endoscopic injection of hypertonic saline-epinephrine (HSE) solution oral to the papilla effectively arrests uncontrolled bleeding after endoscopic sphincterotomy (ES). The aim of this study was to evaluate the efficacy of a prophylactic injection of HSE solution oral to the papilla before ES for prevention of post-ES bleeding.

STUDY

Patients scheduled for ES were recruited into this study. Before ES, patients randomly underwent a single submucosal injection of HSE solution (1 mL) 1 to 2-cm oral to the papilla (injection group) or no injection (noninjection group). After ES, patients were prospectively evaluated for occurrence of post-ES complications such as bleeding, perforation, and pancreatitis between the groups.

RESULTS

A total of 120 patients were randomized to the injection group (n=60) or the noninjection group (n=60). The 2 groups were similar with respect to all background variables. Bleeding occurred in 10 patients (8.3%), and the incidence of bleeding was significantly higher in the noninjection group (9/60) than in the injection group (1/60) (P=0.017). Retroperitoneal perforation occurred in 1 patient (injection group) (0.83%). Pancreatitis occurred in 10 patients (8.3%), and the incidence of pancreatitis tended to be higher in the noninjection group (8/60) than in the injection group (2/60) (P=0.095).

CONCLUSIONS

Prophylactic injection of HSE solution oral to the papilla before ES is a simple and inexpensive method, and is effective for prevention of post-ES bleeding.

Meta-analysis: somatostatin or its long-acting analogue, octreotide, for prophylaxis against post-ERCP pancreatitis

BACKGROUND

Acute pancreatitis is a most serious complication following endoscopic retrograde cholangiopancreatography (ERCP). Previous meta-analyses and randomized controlled trials have shown conflicting results regarding the preventive efficacy of somatostatin or octreotide for this complication. The aim of this study was to resolve these conflicts.

METHODS

A standardized comprehensive literature search was performed through September 2009. Depending on heterogeneity of outcomes, either random-effects model (REM) or fixed-effects model (FEM) was applied to calculate pooled estimates of drug efficacy.

RESULTS

Seventeen studies, including 3818 participants, met the inclusion criteria. Analysis of somatostatin and octreotide trials showed that these drugs prevented post-ERCP pancreatitis (pooled risk ratio [95% confidence interval; CI], 0.63 [0.42-0.96] in REM. Pooled risk ratios [95% CI] of each subgroup were: 0.52 [0.30-0.90] for somatostatin in REM; 0.30 [0.17-0.53] for high-dose somatostatin infused over 12 h in FEM; 0.27 [0.13-0.52] for bolus somatostatin in FEM; 0.35 [0.15-0.82] for pancreatic duct (PD) injection with somatostatin in FEM; 0.33 [0.16-0.70] for biliary sphincterotomy (BS) with somatostatin in FEM; 0.53 [0.24-1.17] for intention-to-treat (ITT) analysis with somatostatin in REM; 0.42 [0.20-0.90] for high-dose octreotide in FEM; 0.61 [0.27-1.35] for PD injection with octreotide in FEM; 0.64 [0.32-1.29] for BS with octreotide in FEM; and 0.83 [0.34-2.03] for ITT analysis with octreotide in REM.

CONCLUSIONS

Somatostatin and high-dose octreotide may prevent post-ERCP pancreatitis. The preventive efficacy of somatostatin is more prominent in cases of PD injection, or BS, or high-dose administration over 12 h, or bolus injection.

Endoscopic retrograde cholangiopancreatography associated pancreatitis: A 15-year review

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

Somatostatin and the gastrointestinal tract

PURPOSE OF REVIEW

Somatostatin influences motility, secretion, and absorption and often has in vivo a modulating, indirect effect on target cells in the gastrointestinal tract. Knowledge on tissue-specific expression of the five somatostatin receptors (SSTRs), their capacities for internalization and downregulation, their subtype-specific intracellular messengers, and the possibility of forming functionally distinct homodimers or heterodimers, has further complicated the actual in-vivo mechanism of action of somatostatin. This review reports recent in-vivo and in-vitro studies on somatostatin effects on the gastrointestinal tract and pancreas, most of them using a new engineered animal model able to define specific roles of somatostatin and/or its receptor subtypes.

RECENT FINDINGS

SSTR2 knockout mice showed normal circulating gastrin and unchanged acid output, suggesting a high degree of plasticity behind gastric acid secretion. Intestinal inflammation significantly increased somatostatin mRNA in SSTR2 null compared to wild type suggesting that somatostatin mediates inflammation also in SSTR2 null mice. In pancreatic islets of SSTR1-5 null mice no variations of islet size, cellular organization or glucagon or insulin content was shown when compared with null SSTRs and control mice.

SUMMARY

Although none of the recent findings produced on somatostatin seem ready to be considered for clinical application, recent developments of animal models such as SSTR knockout mice have highlighted promising results to better understand the direct and indirect effects of somatostatin on gastrointestinal tract functions.

Epinephrine sprayed on the papilla for prevention of post-ERCP pancreatitis

BACKGROUND

Epinephrine sprayed on the papilla may reduce papillary edema and thus prevent acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to determine the efficacy of this technique for prevention of post- ERCP pancreatitis.

METHODS

Patients scheduled for ERCP were recruited into this study. We randomized the patients to have 10 ml of either 0.02% epinephrine (epinephrine group) or saline (control group) sprayed on the papilla after diagnostic ERCP and prospectively analyzed the occurrence of post-ERCP pancreatitis between the groups. We recorded duct visualization, presence of pancreatic acinarization, number of injections into the pancreatic duct, total volume of contrast used, and procedure duration.

RESULTS

There was no significant difference between the groups with regard to visualization of the bile duct and/or the main and accessory pancreatic ducts, presence of pancreatic acinarization, number of injections into the pancreatic duct, total volume of contrast used, and procedure duration. Overall, post-ERCP pancreatitis occurred in 4 of the 370 patients (1.1%). The incidence of pancreatitis tended to be higher in the control group (4/185) than in the epinephrine group (0/185) (P = 0.1230).

CONCLUSIONS

Epinephrine sprayed on the papilla tended to prevent post-ERCP pancreatitis, although it was not statistically significant because of the low incidence of pancreatitis. Further studies on the efficacy of this technique in patients at high risk for pancreatitis, and on other volumes and/or concentrations of epinephrine, are warranted.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

INTERVENTIONS

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

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Preventive effects of ulinastatin on post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: a prospective, randomized, placebo-controlled trial

OBJECTIVES

Previous studies have shown that ulinastatin may be effective at preventing pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, routine administration of ulinastatin is unlikely to be cost-effective. So the aim of this prospective study was to evaluate the effectiveness of low-dose ulinastatin at preventing pancreatitis in patients at high risk of post-ERCP pancreatitis.

METHODS

A total of 227 patients (mean age, 63 years; 54% men) were randomized to receive placebo (n = 108) or active drug (n = 119) immediately after ERCP and received active drug (100,000 U of ulinastatin) or placebo. Occurrence of post-ERCP pancreatitis and hyperamylasemia were compared between the 2 groups.

RESULTS

The overall incidence of pancreatitis was 6.2%, and no significant differences were observed between placebo- and ulinastatin-treated patients in terms of the frequencies of pancreatitis (5.6% vs 6.7%), abdominal pain, or hyperamylasemia. Pancreatic duct acinarization, papillectomy of ampulla of Vater adenoma, difficult cannulation, and female sex were identified as risk factors for pancreatitis in univariate analysis.

CONCLUSIONS

Low-dose prophylactic treatment with ulinastatin immediately after ERCP did not show a beneficial influence on the incidence of post-ERCP pancreatitis and hyperamylasemia in high-risk patients.

Pharmacological approach to acute pancreatitis

The aim of the present review is to summarize the current knowledge regarding pharmacological prevention and treatment of acute pancreatitis (AP) based on experimental animal models and clinical trials. Somatostatin (SS) and octreotide inhibit the exocrine production of pancreatic enzymes and may be useful as prophylaxis against Post Endoscopic retrograde cholangiopancreatography Pancreatitis (PEP). The protease inhibitor Gabexate mesilate (GM) is used routinely as treatment to AP in some countries, but randomized clinical trials and a meta-analysis do not support this practice. Nitroglycerin (NGL) is a nitrogen oxide (NO) donor, which relaxes the sphincter of Oddi. Studies show conflicting results when applied prior to ERCP and a large multicenter randomized study is warranted. Steroids administered as prophylaxis against PEP has been validated without effect in several randomized trials. The non-steroidal anti-inflammatory drugs (NSAID) indomethacin and diclofenac have in randomized studies showed potential as prophylaxis against PEP. Interleukin 10 (IL-10) is a cytokine with anti-inflammatory properties but two trials testing IL-10 as prophylaxis to PEP have returned conflicting results. Antibodies against tumor necrosis factor-alpha (TNF-α) have a potential as rescue therapy but no clinical trials are currently being conducted. The antibiotics beta-lactams and quinolones reduce mortality when necrosis is present in pancreas and may also reduce incidence of infected necrosis. Evidence based pharmacological treatment of AP is limited and studies on the effect of potent anti-inflammatory drugs are warranted.

Relationship between post-ERCP pancreatitis and the change of serum amylase level after the procedure

AIM: To clarify the relationship between the change of serum amylase level and post-ERCP pancreatitis.

METHODS: Between January 1999 and December 2002, 1291 ERCP-related procedures were performed. Serum amylase concentrations were measured before the procedure and 3, 6, and 24 h afterward. The frequency and severity of post-ERCP pancreatitis and the relationship between these phenomena and the change in amylase level were estimated.

RESULTS: Post-ERCP pancreatitis occurred in 47 patients (3.6%). Pancreatitis occurred in 1% of patients with normal amylase levels 3 h after ERCP, and in 1%, 5%, 20%, 31% and 39% of patients with amylase levels elevated 1-2 times, 2-3 times, 3-5 times, 5-10 times and over 10 times the upper normal limit at 3 h after ERCP, respectively (level < 2 times vs≥ 2 times, P < 0.001). Of the 143 patients with levels higher than the normal limit at 3 h after ERCP followed by elevation at 6 h, pancreatitis occurred in 26%. In contrast, pancreatitis occurred in 9% of 45 patients with a level higher than two times the normal limit at 3 h after ERCP followed by a decrease at 6 h (26% vs 9%, P < 0.05).

CONCLUSION: Post-ERCP pancreatitis is frequently associated with an increase in serum amylase level greater than twice the normal limit at 3 h after ERCP with an elevation at 6 h. A decrease in amylase level at 6 h after ERCP suggests the unlikelihood of development of post-ERCP pancreatitis.

Somatostatin and gabexate for post-endoscopic retrograde cholangiopancreatography pancreatitis prevention: meta-analysis of randomized placebo-controlled trials

BACKGROUND AND AIM

Prior studies have suggested the efficacy of somatostatin and gabexate in post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis prevention. We examined this notion in our study.

METHODS

An extensive literature search led to the inclusion of seven homogeneous high-quality studies (Jadad score >or=4), involving 3,130 patients. The studies were grouped according to the drug's length of administration: given as an infusion for 12 h (groups SOM1 and GAB1 for somatostatin and gabexate, respectively); given as an infusion for less then 12 h (groups SOM2 and GAB2 for somatostatin and gabexate, respectively); and given as a bolus (group SOM3 for somatostatin, none identified for gabexate). Separate meta-analyses investigating post-procedural pancreatitis and hyperamylasemia rates were conducted in a random effects model.

RESULTS

Pancreatitis analyses yielded significant risk differences for the SOM1, SOM3 and GAB1 groups. The resulting values were 7.7% (95% confidence intervals [CI][3.4 to 12.0], P < 0.0001), 8.2% (95% CI [4.4 to 12.0], P < 0.0001) and 5.2% (95% CI [1.1 to 9.4], P = 0.01), respectively. No statistically significant risk differences were observed for the SOM2 and GAB2 groups: -2.3% (95% CI [-5.2 to 0.5], P = 0.11) and -1.1% (95% CI [-3.8 to 1.6], P = 0.41), respectively. Hyperamylasemia analyses yielded significant risk differences for the SOM1 and SOM3 groups (P = 0.017 and 0.001, respectively), although not for the SOM2, GAB1 and GAB2 groups (P = 0.44, 0.49 and 0.47, respectively).

CONCLUSIONS

Somatostatin administered as a bolus seems to be an efficacious measure of post-ERCP pancreatitis prevention, reducing pancreatitis and hyperamylasemia rates, and being applicable to clinical practice. Further study is required before its introduction into routine care.

Efficacy of postprocedure administration of gabexate mesylate in the prevention of post-ERCP pancreatitis: a randomized, controlled, multicenter study

BACKGROUND AND OBJECTIVE

Gabexate mesylate reduces the incidence of post-ERCP pancreatitis. Patient-related risk factors associated with pancreatitis can be identified before ERCP, but the procedure-related factors are recognized only at the end of the procedure. This study's aim was to evaluate whether gabexate mesylate administered after ERCP reduces the incidence of pancreatitis.

DESIGN

Randomized, prospective, double-blind, multicenter trial.

SETTING

Tertiary care centers.

PATIENTS AND INTERVENTION

A total of 608 patients undergoing ERCP were treated with gabexate mesylate 500 mg within 1 hour before ERCP (group A, 203 patients) or within 1 hour after ERCP (group B, 203), or with saline solution (group C, 202).

MAIN OUTCOME MEASUREMENTS

The incidence and severity of pancreatitis and hyperamylasemia, as well as factors associated with the development of pancreatitis.

RESULTS

The groups were similar for demographic characteristics, indications to ERCP, risk factors for pancreatitis, and therapeutic procedures. The incidence of pancreatitis was 3.9% in group A, 3.4% in group B, and 9.4% in group C (P<.01). Two patients (in groups A and C) developed necrotizing pancreatitis, and 1 died. Hyperamylasemia occurred in 23.6% in groups A and B, and in 24.7% in group C. Levels of amylase, the incidence of abdominal pain, and other complications occurred similarly. Female sex (odds ratios [OR] 2.7, 95% CI 1.2-5.9) and difficult cannulation (OR 5.6, 95% CI 2.6-12.3) were independently associated with pancreatitis.

CONCLUSIONS

The administration of gabexate mesylate after ERCP protects against the development of pancreatitis similarly to the preprocedure administration. Factors associated with pancreatitis were mainly recognized after ERCP. We suggest administering gabexate mesylate after ERCP only in those patients recognized to be at risk of developing pancreatitis.

Prophylactic administration of somatostatin or gabexate does not prevent pancreatitis after ERCP: an updated meta-analysis

BACKGROUND

The prophylactic use of somatostatin or gabexate in patients undergoing ERCP is still controversial.

OBJECTIVE

Our purpose was to update the meta-analysis on somatostatin (SS, 16 studies) or gabexate mesylate (GM, 9 studies) prophylaxis of post-ERCP pancreatitis and to run sensitivity analyses by subgrouping trials according to schedules of drug administration.

MAIN OUTCOME MEASUREMENTS

Post-ERCP acute pancreatitis, hyperamylasemia, and pain.

RESULTS

Heterogeneity was present among selected studies, which appeared eliminated when only 9 high-quality trials on SS and 5 randomized studies on GM were considered. After data were pooled from SS trials, pancreatitis occurred in 7.3% of controls versus 5.3% of treated patients, a nonsignificant effect (odds ratio [OR] = 0.73; 95% CI 0.54-1.006). The funnel plot showed asymmetry with a negative slope (P = .05). The meta-analysis produced negative results for either short- (<6 hours) or long-term (> or =12 hours) SS infusion, whereas a bolus injection proved effective (OR = 0.271; 95% CI 0.138-0.536), with a pooled absolute risk reduction of 8.2% (95% CI 4.4-12.0%). Postprocedural hyperamylasemia, but not pain, was significantly reduced (OR = 0.67, 95% CI 0.57-0.81). In controls and patients treated with GM, pancreatitis developed in 5.7% versus 4.8%, hyperamylasemia in 40.6% versus 36.9%, and pain in 1.7% versus 8.9%. All pooled ORs were nonsignificant: P = .34, .17, and .19, respectively. The meta-analysis produced no significant effect for either short-term (<6 hours) or long-term (>12 hours) GM administration.

CONCLUSION

Short- or long-term infusion of SS or GM proved ineffective in reducing post-ERCP pancreatitis and pain. The beneficial effect of SS on postprocedural hyperamylasemia seems of marginal significance. When given as a bolus injection, SS maintains its promise in this field, but additional data are needed.

Mild ERCP-induced and non-ERCP-related acute pancreatitis: two distinct clinical entities?

BACKGROUND

The aim of this study was to evaluate the hypothesis that mild endoscopic retrograde cholangiopancreatography (ERCP)-induced acute pancreatitis (AP) runs a distinctly shorter clinical course compared with mild attacks caused by other etiological factors.

METHODS

ERCP-induced AP was defined as the persistence of postprocedure abdominal pain requiring analgesia for at least 24 h in association with hyperamylasemia of more than three times the normal value. Among 2552 patients who had undergone ERCP between 1996 and 2002 in two different hospitals, mild AP developed after "elective" ERCP in 48 (group I). Among a random sample of 10% of 700 patients admitted with AP to both hospitals during the same study period, 58 had mild non-ERCP-related AP (group II). Results shown are medians.

RESULTS

Patients in group I had significantly shorter durations of pain (55 vs. 114 h, P < 0.0001), analgesic intake (56 vs.93 h, P = 0.007), and intravenous hydration (48 vs. 80 h, P < 0.0001), a lower opiate analgesic requirement (58 mg morphine equivalent vs. 100 mg, P = 0.001), a shorter time to resumption of oral diet (3 vs. 5 days, P < 0.0001), and a shorter hospital stay (4 vs. 7 days, P < 0.0001) than patients in group II.

CONCLUSIONS

The current definitions of ERCP-induced AP select a cohort of patients whose mild attacks run a significantly shorter and milder course than non-ERCP-related mild attacks. A new consensus definition of ERCP-induced AP that describes attacks of similar clinical course is needed.

Comparison between ulinastatin and gabexate mesylate for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a prospective, randomized trial

BACKGROUND

It has been reported that the administration of ulinastatin, gabexate mesylate, or somatostatin may be effective in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, few randomized trials of ulinastatin and gabexate mesylate for the prevention of post-ERCP pancreatitis have been reported. The aim of this study was to compare the efficacy of ulinastatin and gabexate mesylate for the prevention of post-ERCP pancreatitis.

METHODS

Sixty-eight patients who underwent diagnostic ERCP at our hospital were divided at random by computer-generated randomization into an ulinastatin group (n = 34) and a gabexate group (n = 34). Each patient received a continuous intravenous infusion of ulinastatin (150,000 units) or gabexate mesylate (600 mg), beginning 60-90 min before the ERCP and continuing until 22 h after the ERCP. The primary endpoint was the incidence of post-ERCP pancreatitis, and the secondary endpoints were the incidences of hyperenzymemia and pain.

RESULTS

The overall incidence of post-ERCP pancreatitis was 2.9% (two patients), comprising one patient in the ulinastatin group and one patient in the gabexate group (2.9% vs 2.9%, respectively). Neither of these two patients developed severe pancreatitis. There were no significant differences in the serum levels of pancreatic enzymes or in the levels of pain between the two groups.

CONCLUSIONS

There was no clinical difference between the effect of preventive administration of ulinastatin and that of gabexate mesylate on the incidence of post-ERCP pancreatitis. Ulinastatin may be equivalent in efficacy to gabexate for reducing the incidence of post-ERCP pancreatitis.

Pharmacotherapy for the prevention of post-ERCP pancreatitis

Post-ERCP pancreatitis (PEP) is a potential complication of ERCP. Pharmacotherapy for prevention of PEP aims at reducing basal sphincter pressure and contractility or a decrease in pancreatic secretion to reduce intraductal pressure. Timing and route of administration of drugs are critical to ensure maximum benefits from medications. Pancreatic stenting offers an alternative to decompress the pancreas and is effective in reducing PEP in high-risk patients.

Minimizing complications in endoscopic retrograde cholangiopancreatography and sphincterotomy

Endoscopic retrograde cholangiopancreatography (ERCP) is a major tool in the diagnosis and management of numerous biliary and pancreatic conditions, including choledocholithiasis as well as benign and malignant pancreatic diseases, especially those causing biliary obstruction. Since the procedure's inception, the techniques and indications have evolved along with advances in technology and an improved understanding of risks associated with ERCP. The trend has been away from purely diagnostic procedures; most ERCPs are now therapeutic in intent. ERCP remains among the more invasive of endoscopic procedures, with significant rates of complications that can be major. As advances are made in less invasive technology, it is important to understand the complications of ERCP and how best to avoid them.

Post-ERCP pancreatitis and its prevention

Pancreatitis remains the most common severe complication of endoscopic retrograde cholangiopancreatography (ERCP), and typically develops in 5-7% of patients. Although most post-ERCP pancreatitis (PEP) is mild, severe pancreatitis and its complications (including a systemic inflammatory response or the development of pseudocysts or pancreatic necrosis) can occur, and in rare cases death can result. A means of preventing PEP in all patients who undergo the procedure remains elusive. Proper patient selection for ERCP is critical to avoid unnecessary risk. Pharmacologic attempts to prevent PEP have been largely unsuccessful; encouraging results have been difficult to validate. Prophylactic stenting of the pancreatic duct and minimally traumatic cannulation techniques offer the most promise as a means of preventing PEP. This manuscript reviews risk factors for PEP as well as pharmacologic and procedural means that can be used to reduce its incidence.

Twenty-four hour prophylaxis with increased dosage of octreotide reduces the incidence of post-ERCP pancreatitis

BACKGROUND

Acute pancreatitis is a common complication of ERCP, occurring in up to 10% of cases. Chemoprevention of post-ERCP pancreatitis remains a debated issue.

OBJECTIVE

This study evaluated whether increased dosage of octreotide, a potent inhibitor of pancreatic secretion, could reduce the incidence of post-ERCP pancreatitis.

DESIGN

In a randomized, double-blind, placebo controlled trial, the effect of 500 microg octreotide, given 3 times daily subcutaneously starting 24 hours before the ERCP procedure, was compared with that of placebo in patients who underwent diagnostic and/or therapeutic ERCP.

PATIENTS

A total of 202 patients were included in the trial. The 2 groups were similar in regards to age, sex, indications for treatment, underlying diseases, and types of therapeutic procedures. Patients were clinically evaluated, and serum amylase levels were determined before ERCP and at 6 to 8 hours thereafter. Standardized criteria were used to diagnose and to grade the severity of post-ERCP pancreatitis.

RESULTS

The medication was discontinued because of an allergic reaction in 1 patient in the octreotide group. The incidence of post-ERCP pancreatitis was significantly lower in the octreotide group compared with the placebo group (2/10 [2%] vs 9/101 [8.9%], P = .03). All cases of acute pancreatitis were mild, except 2 (1 moderate and 1 severe) in the placebo group.

CONCLUSIONS

The results of this trial support the use of 24-hour prophylaxis with high dose of octreotide in the prevention of post-ERCP pancreatitis.

[Utility of bolus somatostatin administration in preventing pancreatitis after endoscopic retrograde cholangiopancreatography: a controlled, non-randomized study]

INTRODUCTION

Somatostatin is one of the most extensively evaluated drugs in the prophylaxis of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP), but its utility remains controversial.

PATIENTS AND METHODS

The aim of this study was to evaluate the role of somatostatin as prophylaxis of ERCP-induced acute pancreatitis. A group of consecutive patients that underwent ERCP in our endoscopy unit was prospectively studied for 8 months. Patients in this group were administered an endovenous bolus of 250 micrograms of somatostatin immediately before introducing the catheter in the papilla of Vater (somatostatin group). This group was compared with another group composed of consecutive patients who had undergone ERCP in the 8 previous months, without somatostatin administration (placebo group). Both groups contained the same number of patients. The following variables were recorded; sex, age, contrast injection in the duct of Wirsung, endoscopist, therapeutic maneuvers, and the development of post-ERCP pancreatitis.

RESULTS

During the 16 months of patient inclusion, we performed 320 ERCP in our unit, of which 248 were included in the study: 142 in the somatostatin group and 142 in the placebo group. Of these patients, 152 (53.5%) were men and 132 (46.5%) were women. The mean age was 70.05 +/- 13.83 years (range: 27-93 years). Acute pancreatitis occurred in 10 patients in the somatostatin group and in 5 in the placebo group; this difference was not statistically significant (p > 0.05). No significant differences were found between the two groups in the remaining variables studied.

CONCLUSION

Somatostatin does not seem to be useful in preventing post-ERCP acute pancreatitis.

Endoscopic retrograde cholangiopancreatography-induced acute pancreatitis often has a benign outcome

BACKGROUND

Acute pancreatitis (AP) is the commonest complication of endoscopic retrograde cholangiopancreatography (ERCP). Data regarding the clinical course and outcome of post-ERCP pancreatitis are sparse, although the available data suggest it to be a severe disease.

OBJECTIVE

To examine the clinical course, disease severity, and outcome of patients with post-ERCP-AP.

METHODS

All consecutive patients with post-ERCP-AP were included. They were managed according to a standard protocol. Outcome measures were severity of pancreatitis, infectious complications, need for surgery and mortality. The clinical course and outcome of patients with post-ERCP-AP were also compared with those of patients with gallstone pancreatitis (GS-AP).

RESULTS

Of the 1497 de novo ERCP procedures, 57 (3.8%) patients developed AP. Their mean age was 40.2 years (13.1), 16 were males of them, 54 (95%) patients had mild pancreatitis. Only 2 patients developed organ failure. Fifty-four (95%) patients recovered with conservative management. One of the 57 patients died. As compared with patients with GS-AP (n=174), APACHE II scores at admission [3.3 (3.1) vs. 5.8 (4.8); P=0.011], occurrence of pancreatic necrosis (17.5% vs. 39.1%; P=0.020), organ failure (3.5% vs. 19.0%; P=0.015), infectious complications (8.7% vs. 24.7%; P=0.040), and mortality (1.8% vs. 13.2%; P=0.044) were significantly less among patients with post-ERCP-AP.

CONCLUSION

Unlike previous belief, we found that post-ERCP AP was a mild disease with a favorable outcome in most cases.

A prospective, randomized, placebo-controlled trial of transdermal glyceryl trinitrate in ERCP: effects on technical success and post-ERCP pancreatitis

BACKGROUND

Despite the recent improvement in techniques and patient selection, post-ERCP pancreatitis remains the most frequent and dreaded complication of ERCP. Recent studies suggest that pretreatment with glyceryl trinitrate (GTN) may prevent post-ERCP pancreatitis and improve cannulation success.

OBJECTIVE

To evaluate the effect of transdermal GTN on ERCP cannulation success and post-ERCP pancreatitis.

DESIGN

Prospective, double-blind, placebo-controlled trial.

SETTING

Tertiary referral university hospital.

PATIENTS

A total of 318 patients (mean age 62 years, 61% women) were randomized to either active (n = 155) or placebo (n = 163) arms.

INTERVENTIONS

Active patch (GTN) versus placebo patch.

MAIN OUTCOME MEASUREMENTS

Cannulation time and success. Post-ERCP pancreatitis rates.

RESULTS

There was no significant difference between the active or placebo arms for the following: successful initial cannulation (96.8% vs 98.8%), deep cannulation (96.1% vs 98.8%), time to successful cannulation, use of guidewire (27% vs 25%) or needle knife (13% vs 13%), and post-ERCP pancreatitis (7.4% of placebo patients and 7.7% active patients). Multivariate analysis identified women, younger patients, pancreatogram, number of attempts on papilla, and poor pancreatic-duct emptying after opacification as risk factors for post-ERCP pancreatitis. Transdermal GTN did not reduce post-ERCP pancreatitis in any of the identified high-risk groups.

CONCLUSIONS

Transdermal GTN did not improve the rate of success in ERCP cannulation or prevent post-ERCP pancreatitis in either average or high-risk patient groups.