Brief Article
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World J Gastroenterol. Sep 28, 2013; 19(36): 6026-6034
Published online Sep 28, 2013. doi: 10.3748/wjg.v19.i36.6026
Endoscopic retrograde cholangiopancreatography with rendezvous cannulation reduces pancreatic injury
Fredrik Swahn, Sara Regnér, Lars Enochsson, Lars Lundell, Johan Permert, Magnus Nilsson, Henrik Thorlacius, Urban Arnelo
Fredrik Swahn, Lars Enochsson, Lars Lundell, Johan Permert, Magnus Nilsson, Urban Arnelo, Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, S-141 86 Stockholm, Sweden
Fredrik Swahn, Lars Enochsson, Lars Lundell, Johan Permert, Magnus Nilsson, Urban Arnelo, Department of Surgical Gastroenterology, Karolinska University Hospital, S-141 86 Stockholm, Sweden
Sara Regnér, Henrik Thorlacius, Department of Clinical Science, Lund University, Skåne University Hospital, SE-205 02 Malmö, Sweden
Sara Regnér, Henrik Thorlacius, Department of Surgery, Skåne University Hospital, SE-205 02 Malmö, Sweden
Author contributions: Swahn F, Arnelo U, Enochsson L and Lundell L wrote the paper; Swahn F, Arnelo U and Permert J designed the research; Swahn F and Regnér S did the research; Swahn F, Enochsson L, Nilsson M and Thorlacius H analyzed the data.
Supported by KI-fonder at Karolinska Institutet, Bengt Ihre Foundation, Stockholm, Sweden; the Foundations of Research at the University Hospital, Hedbergs Stiftelse and Mossbergs Stiftelse, Malmö Sweden, Research Grants from the Stockholm County and Skane County Council (ALF)
Correspondence to: Fredrik Swahn, MD, PhD, Department of Surgical Gastroenterology, Karolinska University Hospital, S-141 86 Stockholm, Sweden. fredrik.swahn@ki.se
Telephone: +46-8-58586019 Fax: +46-8-58582340
Received: September 11, 2012
Revised: March 13, 2013
Accepted: March 21, 2013
Published online: September 28, 2013
Abstract

AIM: To examine whether rendezvous endoscopic retrograde cholangiopancreatography (ERCP) is associated with less pancreatic damage, measured as leakage of proenzymes, than conventional ERCP.

METHODS: Patients (n = 122) with symptomatic gallstone disease, intact papilla and no ongoing inflammation, were prospectively enrolled in this case-control designed study. Eighty-one patients were subjected to laparoscopic cholecystectomy and if intraoperative cholangiography suggested common bile duct stones (CBDS), rendezvous ERCP was performed intraoperatively (n = 40). Patients with a negative cholangiogram constituted the control group (n = 41). Another 41 patients with CBDS, not subjected to surgery, underwent conventional ERCP. Pancreatic proenzymes, procarboxypeptidase B and trypsinogen-2 levels in plasma, were analysed at 0, 4, 8 and 24 h. The proenzymes were determined in-house with a double-antibody enzyme linked immunosorbent assay. Pancreatic amylase was measured by an enzymatic colourimetric modular analyser with the manufacturer’s reagents. All samples were blinded at analysis.

RESULTS: Post ERCP pancreatitis (PEP) occurred in 3/41 (7%) of the patients cannulated with conventional ERCP and none in the rendezvous group. Increased serum levels indicating pancreatic leakage were significantly higher in the conventional ERCP group compared with the rendezvous ERCP group regarding pancreatic amylase levels in the 4- and 8-h samples (P = 0.0015; P = 0.03), procarboxypeptidase B in the 4- and 8-h samples (P < 0.0001; P < 0.0001) and trypsinogen-2 in the 24-hour samples (P = 0.03). No differences in these markers were observed in patients treated with rendezvous cannulation technique compared with patients that underwent cholecystectomy alone (control group). Post procedural concentrations of pancreatic amylase and procarboxypeptidase B were significantly correlated with pancreatic duct cannulation and opacification.

CONCLUSION: Rendezvous ERCP reduces pancreatic enzyme leakage compared with conventional ERCP cannulation technique. Thus, laparo-endoscopic technique can be recommended with the ambition to minimise the risk for post ERCP pancreatitis.

Keywords: Common bile duct stones; Procarboxypeptidase B; Trypsinogen-2; Pancreatic amylase; Intraoperative endoscopic retrograde cholangiopancreatography

Core tip: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction is a standard procedure in the management of common bile duct stones. Rendezvous ERCP reduces pancreatic enzyme leakage compared with conventional ERCP cannulation technique. Thus laparo-endoscopic technique can be recommended to prevent post ERCP pancreatitis.