Clinical trial of gabexate in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis

Clinical Practice Guidelines for post-ERCP pancreatitis 2023

The Clinical Practice Guidelines for post-ERCP pancreatitis (PEP) 2023 provide updated recommendations for the prevention, diagnosis, and management of PEP. Endoscopic retrograde cholangiopancreatography (ERCP), a valuable procedure for diagnosing and treating pancreatobiliary diseases, can result in PEP as the most common adverse event. Since the first guidelines were published in 2015, advances in techniques and new research findings have necessitated this revision. The guidelines developed using the GRADE methodology target adult patients undergoing ERCP. They offer a comprehensive framework for clinicians to minimize the risk of PEP. For high-risk patients, endoscopic ultrasound before ERCP is recommended to avoid unnecessary procedures. The guidelines also discuss procedural and patient-related risk factors for PEP, highlighting that operator experience does not significantly affect PEP rates if performed under the supervision of skilled endoscopists. The diagnostic criteria include monitoring serum pancreatic enzyme levels postprocedure, and early computed tomography is advised in suspected cases. For treatment, the guidelines recommend following acute pancreatitis protocols. Key preventive measures include the use of temporary pancreatic duct stents and rectal nonsteroidal anti-inflammatory drugs, both of which are supported by strong evidence for reducing the incidence of PEP. Overall, these guidelines aim to enhance clinical outcomes by reducing PEP incidence and improving its management through evidence-based practices.

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.

An Insight on Pharmacological and Mechanical Preventive Measures of Post-ERCP PANCREATITIS (PEP)—A Review

Pancreatitis is the most common complication following endoscopic retrograde cholangio-pancreatography (ERCP). With the progress of research in many drugs and technologies, promising efficacy has been achieved in preventing post-ERCP pancreatitis (PEP). Recently, combined prevention has received more attention in order to further reduce the incidence of PEP. However, there is no review about the combined prevention of PEP. This review summarizes the medication and ERCP techniques that are used to prevent PEP and emphasizes that appropriate combination prevention approaches should be based on risk stratification.

Taiwanese consensus recommendations for acute pancreatitis

The incidence of acute pancreatitis and related health care utilization are increasing. Acute pancreatitis may result in organ failure and various local complications with risks of morbidity and even mortality. Recent advances in research have provided novel insights into the assessment and management for acute pancreatitis. This consensus is developed by Taiwan Pancreas Society to provide an updated, evidence-based framework for managing acute pancreatitis.

Comparative Efficacy of 9 Major Drugs for Postendoscopic Retrograde Cholangiopancreatography Pancreatitis: A Network Meta-Analysis

BACKGROUND

Postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is one of the most common complications after ERCP. The optimal drugs for reducing the risk of PEP are still unclear. This study aimed to compare the efficacy of 9 major drugs used worldwide for the prevention of PEP through a network meta-analysis.

METHODS

We conducted a systematic search of the literature up to October 2018 on PubMed, Embase, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov. Randomized controlled trials (RCTs) comparing allopurinol, diclofenac, gabexate (GAB), glyceryl trinitrate (GTN), indomethacin, nafamostat, octreotide, somatostatin, and ulinastatin for protection against PEP were included.

RESULTS

Eighty-six randomized controlled trials involving 25,246 patients were included in this network meta-analysis. Results indicated that diclofenac, GAB, GTN, indomethacin, somatostatin, and ulinastatin were more effective than placebo with odds ratios ranging between 0.48 (95% credible interval, 0.26-0.86) for GAB and 0.61 (0.39-0.94) for somatostatin. However, allopurinol, nafamostat, and octreotide showed similar efficacy as placebo in reducing the risk of PEP. No significant differences were found in the efficacy between diclofenac, GAB, GTN, indomethacin, somatostatin, and ulinastatin. In terms of prognosis, GAB may be the most effective treatment (surface under the cumulative ranking curve=70.6%) and the least effective was octreotide (surface under the cumulative ranking curve=28%).

CONCLUSIONS

Although our analysis suggests that GAB may be the most effective drug in preventing PEP, the limitations of our study warrants more high-quality head-to-head trials of these clinical drugs in the future.

Clinical practice guideline for post-ERCP pancreatitis

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.

The "Scope" of Post-ERCP Pancreatitis

Pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography, with the potential for clinically significant morbidity and mortality. Several patient and procedural risk factors have been identified that increase the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Considerable research efforts have identified several pharmacologic and procedural interventions that can drastically affect the incidence of PEP. This review article addresses the underlying mechanisms at play for the development of PEP, identifying patient and procedural risk factors and meaningful use of risk-stratification information, and details current interventions aimed at reducing the risk of this complication.

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.

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

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

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

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.

Nafamostat mesilate for prevention of post-ERCP pancreatitis: a meta-analysis of prospective, randomized, controlled trials

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.

Randomized controlled trial for efficacy of nafamostat mesilate in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis

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.

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.

Gabexate mesylate in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis update

BACKGROUND

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP), and the benefit of pharmacologic treatment of the condition is unclear. Although prophylactic use of gabexate mesylate (GM) for the reduction of pancreatic injury after ERCP has been evaluated, uncertainty remains regarding the effectiveness of GM treatment in post-ERCP pancreatitis (PEP).

OBJECTIVE

The aim of this study was to determine through systematic review and meta-analysis the effectiveness and tolerability of GM in the prophylaxis of PEP.

METHODS

MEDLINE (January 1966-July 2007), EMBASE (January 1966- July 2007), the Cochrane Controlled Trials Register on The Cochrane Library (Issue 2, 2007), and the China Biological Medicine Database (January 1978-July 2007) were searched. We used the method recommended by The Cochrane Collaboration to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) of GM in the prevention of PEP.

RESULTS

Of the 38 studies identified, 31 were excluded for the following reasons: they were reviews or editorials (9 articles); were meta-analyses (4); had differences in cointerventions (4); were nonrandomized controlled trials or had incorrect randomization (4); were repeat publications (2); lacked a placebo group (1); or other (7). Seven RCTs, totaling 2883 patients, conducted in a variety of languages were included in the meta-analysis. When the RCTs were analyzed, odds ratios for GM were 0.65 (95% CI, 0.36-1.18; P 0.16) for PER 1.90 (95% CI, 0.54-6.65; P 0.32) for severe PEP, 0.55 (95% CI, 0.17-1.77; P 0.32) for the case-fatality ratio of PEP, 0.88 (95% CI, 0.74-1.05; P 0.16) for post-ERCP hyperamylasemia, and 0.78 (95% CI, 0.49 1.25; P 0.30) for post-ERCP abdominal pain. No evidence of publication bias was found.

CONCLUSIONS

No beneficial effects of GM on acute pancreatitis, the PEP mortality rate, or post-ERCP abdominal pain or hyperamylasemia were found; therefore, GM cannot be recommended for the prophylaxis of PEP.

Pharmacologic prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis: protease inhibitors and NSAIDs in a meta-analysis

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is the most frequent complication of ERCP. Several meta-analyses have examined the effects of protease inhibitors (gabexate mesilate, ulinastatin, and nafamostat mesilate) and non-steroidal anti-inflammatory drugs (NSAIDs) on post-ERCP pancreatitis, but the results have been confusing. Since the previous meta-analysis, several new studies have been published on this topic. To provide an updated quantitative assessment of the effectiveness of protease inhibitors and NSAIDs in preventing post-ERCP pancreatitis, we conducted a meta-analysis of randomized trials for patients at risk of post-ERCP pancreatitis. Twenty-six articles were included in this meta-analysis. Nafamostat mesilate (summary RR = 0.41; 95 %CI 0.28-0.59; n = 4 studies) and NSAIDs (summary RR = 0.58; 95 %CI = 0.44-0.76; n = 7 studies) were associated with decreased risk of post-ERCP pancreatitis in the high-quality studies. However, gabexate mesilate (summary RR = 0.64; 95 %CI = 0.36-1.13; n = 6 studies) and ulinastatin (summary RR = 0.65; 95 %CI = 0.33-1.30; n = 2 studies) were not associated with decreased risk of post-ERCP pancreatitis in the high-quality studies. This is the first meta-analysis to compare the effects of three protease inhibitors. Solid evidence supports the use of nafamostat mesilate and NSAIDs for preventing post-ERCP pancreatitis.

Post-ERCP pancreatitis: review of current preventive strategies

PURPOSE OF REVIEW

This article reviews the most recent literature with significant findings pertaining to the prevention of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

RECENT FINDINGS

Despite several promising reports of pharmacologic agents that have demonstrated the efficacy for prophylaxis against post-ERCP pancreatitis such as nonsteroidal anti-inflammatory drugs and secretin, there are currently no universally accepted agents for use in high-risk patients. The greatest reductions in the incidence of post-ERCP pancreatitis in high-risk patients have been demonstrated through advancements in endoscopic techniques such as pancreatic duct stenting and dye-free guidewire cannulation.

SUMMARY

Pancreatitis requiring hospitalization is the most common complication of ERCP. Numerous pharmaceutical and procedure related interventions have been studied in attempts to prevent this complication; however, morbidity associated with ERCP remains significant. The most effective methods for preventing post-ERCP pancreatitis are careful patient selection and identification of risk factors prior to procedure.

Prevention of Post-ERCP Pancreatitis

Pancreatitis is the most common complication of ERCP. It can be associated with substantial morbidity. Hence, the minimization of both the incidence and severity of post-ERCP pancreatitis is paramount. Considerable efforts have been made to identify factors that may be associated with an increased risk of this complication. In addition, both procedure- and pharmacological-related interventions have been proposed that may prevent this complication. This paper outlines these interventions and presents the evidence to support their use in the prevention of post-ERCP pancreatitis.

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.

Protease inhibitors for preventing complications associated with ERCP: an updated meta-analysis

BACKGROUND AND OBJECTIVES

The prophylactic use of protease inhibitors in patients undergoing ERCP is still controversial. Our purpose was to evaluate the efficacy of protease inhibitors in preventing ERCP-associated complications.

DESIGN AND SETTING

Meta-analysis; randomized trials that evaluated the efficacy of protease inhibitors were identified.

PATIENTS

A total of 4966 patients were evaluated.

MAIN OUTCOME MEASUREMENTS

ERCP-associated pancreatitis, hyperamylasemia, abdominal pain, and death.

RESULTS

Eighteen studies (19 cohorts) met the inclusion criteria. Overall results for protease inhibitors showed a significant but small risk reduction in ERCP-associated pancreatitis (pooled risk difference [RD]: -0.029; 95% CI, -0.051 to -0.008 and the number needed to treat, 34.5; 95% CI, 19.6-125). Subgroup analysis in 8 high-quality studies showed a borderline significant efficacy (pooled RD, -0.027; 95% CI, -0.051 to -0.004). Subgroup analysis in 8 gabexate studies did not show significant efficacy (pooled RD, -0.030; 95% CI, -0.062 to 0.003). Subgroup analysis in 5 ulinastatin studies was significant (pooled RD, -0.035; 95% CI, -0.063 to -0.006). Two high-quality studies on ulinastatin yielded nonsignificant results. Analyses for the other outcomes were all nonsignificant. Sensitivity analysis showed that the effect size and level of statistical significance were decreased with increasing study quality.

CONCLUSIONS

At present, there is no solid evidence to support the use of protease inhibitors to prevent ERCP-associated complications. Although overall and ulinastatin subgroup analyses showed a small risk reduction for pancreatitis, it seems very possible that low-quality primary studies produced a veneer of efficacy.

Nafamostat mesilate for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a prospective, randomized, double-blind, controlled trial

OBJECTIVES

Pancreatitis is the most common major complication of endoscopic retrograde cholangiopancreatography (ERCP). Efforts have been made to identify pharmacologic agents capable of reducing its incidence and severity. The aim of this trial was to determine whether prophylactic nafamostat mesilate, a synthetic protease inhibitor, would reduce the frequency and severity of post-ERCP pancreatitis.

METHODS

A total of 286 patients were randomized to receive either intravenous nafamostat mesilate or placebo 60 minutes before ERCP and for 6 hours after ERCP. A database was prospectively collected by a defined protocol. Standardized criteria were used to diagnose and grade the severity of pancreatitis.

RESULTS

The groups were similar with regard to patient demographics and to patient and procedure risk factors for pancreatitis. The overall incidence of pancreatitis was 5.9%. It occurred in 4 (2.8%) of 143 patients in the nafamostat group and in 13 (9.1%) of 143 patients in the control group (P = 0.03). Pancreatitis was graded mild in 2.1% and moderate in 0.7% of the nafamostat group and mild in 7.0% and moderate in 2.1% of the control group. There was no significant difference between the groups in the severity of pancreatitis.

CONCLUSIONS

Prophylactic intravenous nafamostat mesilate reduces the frequency of post-ERCP pancreatitis.

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.

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.

Acute pancreatitis

PURPOSE OF REVIEW

To review advances over the last year in the prevention, diagnosis and management of acute pancreatitis.

RECENT FINDINGS

Obesity is an independent risk factor for severity in acute pancreatitis, and heavy alcohol consumption for the development of necrosis in severe acute pancreatitis. Biochemical markers have been further tested, including carbohydrate-deficient transferrin for the diagnosis of alcohol-induced acute pancreatitis, urinary trypsinogen-2 as a diagnostic marker for acute pancreatitis, and interleukin-6 and procalcitonin as markers of disease severity. A new, simple stratification system, the 'panc 3 score', has been described. There are conflicting data on the use of antibiotic prophylaxis in acute necrotizing pancreatitis, and on the chemoprevention of postendoscopic retrograde cholangiopancreatography pancreatitis. Enteral feeding is established as standard practice early in the management of acute pancreatitis of all aetiologies; probiotics and other compounds may also play a role.

SUMMARY

Over the last year, there have been further innovations in the risk stratification and management of acute pancreatitis. Unresolved issues include chemoprevention of endoscopic retrograde cholangiopancreatography-induced acute pancreatitis, the indications for antibiotic prophylaxis in severe acute pancreatitis and nutritional supplementation with probiotics and synbiotics.

New advances in acute pancreatitis

PURPOSE OF REVIEW

We endeavor to review important new advances in acute pancreatitis made in the past year. We focused on clinical aspects of acute pancreatitis, which contained new observations or insights into new or old concepts. For experimental acute pancreatitis we refer readers to a recent comprehensive review.

RECENT FINDINGS

Recently, case fatality rates of acute pancreatitis have stabilized; carbohydrate-deficient transferrin was shown to predict alcoholic acute pancreatitis; idiopathic chronic pancreatitis or occult cholelithiasis have been associated with 'recurrent acute pancreatitis' in most patients; and cystic fibrosis transmembrane conductance regulator genetic mutations were frequently found (10-50%) in patients with recurrent acute pancreatitis. In addition, alcohol was shown to increase the risk of pancreatic necrosis regardless of the cause of acute pancreatitis. Persistent organ failure and multiple organ dysfunction syndrome but not necessarily extent of necrosis were demonstrated to predict increased mortality in acute pancreatitis. Chemoprevention of post-endoscopic retrograde cholangiopancreatography acute pancreatitis remains unproven. Enteral feeding has been strongly recommended in severe acute pancreatitis. Finally, data are lacking for routine, prophylactic antibiotic administration to all patients with pancreatic necrosis.

SUMMARY

We reviewed studies this past year that further characterize the epidemiology, etiology and risk stratification of acute pancreatitis. Evolving areas include chemoprevention of post-endoscopic retrograde cholangiopancreatography acute pancreatitis and enteral feeding and antibiotics in severe acute pancreatitis. We await translation of novel therapies from the bench to bedside.

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

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

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.

Incidence, risk factors, and prevention of post-ERCP pancreatitis

Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Because of the potential risks and consequences of post-ERCP pancreatitis, considerable efforts have been made to define patient- and procedure-related factors that may be associated with an increased risk of this complication, along with determining interventions that can be done to reduce post-ERCP 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.

Gabexate in the prophylaxis of post-ERCP pancreatitis: a meta-analysis of randomized controlled trials

Background

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography and the benefit of its pharmacological treatment is unclear. Although prophylactic use of gabexate for the reduction of pancreatic injury after ERCP has been evaluated, the discrepancy about gabexate's beneficial effect on pancreatic injury still exists. This study aimed to evaluate the effectiveness and safety of gabexate in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).

Methods

We employed the method recommended by the Cochrane Collaboration to perform a meta-analysis of randomized controlled trials (RCTs) of gabexate in the prevention of post-ERCP pancreatitis (PEP) including three RCTs conducted in Italy and one in China.

Results

All of the four RCTs were of high quality. When the RCTs were analyzed, odds ratios (OR) for gabexate mesilate were 0.67 [95% CI (0.31~1.47), p = 0.32] for PEP, 3.78 [95% CI (0.62~22.98), p = 0.15] for severe PEP, 0.68 [95% CI (0.19~2.43), p = 0.56] for the case-fatality of PEP, 0.88 [95% CI (0.72~1.07), p = 0.20] for post-ERCP hyperamylasemia, 0.69 [95% CI (0.39~1.21), p = 0.19] for post-ERCP abdominal pain, thus indicating no beneficial effects of gabexate on acute pancreatitis, the death rate of PEP, hyperamylasemia and abdominal pain. No evidence of publication bias was found.

Conclusion

Gabexate mesilate can not prevent the pancreatic injury after ERCP. It is not recommended for the use of gabexate mesilate in the prophylaxis of PEP.

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.

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