Published online Nov 28, 2014. doi: 10.3748/wjg.v20.i44.16582
Revised: March 11, 2014
Accepted: April 28, 2014
Published online: November 28, 2014
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is not an uncommon adverse event but may be an avoidable complication. Although pancreatitis of severe grade is reported in 0.1%-0.5% of ERCP patients, a serious clinical course may be lethal. For prevention of severe PEP, patient risk stratification, appropriate selection of patients using noninvasive diagnostic imaging methods such as magnetic resonance cholangiopancreatography or endoscopic ultrasonography (EUS), and avoidance of unnecessary invasive procedures, are important measures to be taken before any procedure. Pharmacological prevention is also commonly attempted but is usually ineffective. No ideal agent has not yet been found and the available data conflict. Currently, rectal non-steroidal anti-inflammatory drugs are used to prevent PEP in high-risk patients, but additional studies using larger numbers of subjects are necessary to confirm any prophylactic effect. In this review, we focus on endoscopic procedures seeking to prevent or decrease the severity of PEP. Among various cannulation methods, wire-guided cannulation, precut fistulotomy, and transpancreatic septostomy are reviewed. Prophylactic pancreatic stent placement, which is the best-known prophylactic method, is reviewed with reference to the ideal stent type, adequate duration of stent placement, and stent-related complications. Finally, we comment on other treatment alternatives, and make the point that further advances in EUS-guided techniques may afford useful PEP prophylaxis.
Core tip: Endoscopic prevention and/or reduction in the severity of pancreatitis (PEP) are considered to be an essential component of appropriate therapy for Post-endoscopic retrograde cholangiopancreatography patients, especially those at high risk. Numerous techniques and drugs have been developed. However, their proven benefits in terms of reducing the severity of pancreatitis are limited. Currently, one popular endoscopic method is prophylactic placement of a pancreatic stent. In this review, we focus primarily on the ideal type of stent, the timing of stent insertion, and the duration of stent placement adequate to prevent PEP. Also, we describe initial cannulation methods including wire-guided cannulation and precut fistulotomy (infundibulotomy), and the alternative techniques of percutaneous biliary drainage and recently emerging endoscopic ultrasonography-guided methodology.