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Saito H, Fujimoto A, Oomoto K, Kadowaki Y, Tada S. Current approaches and questions yet to be resolved for the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastrointest Endosc 2022; 14:657-666. [PMID: 36438884 PMCID: PMC9693687 DOI: 10.4253/wjge.v14.i11.657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/06/2022] [Accepted: 10/26/2022] [Indexed: 11/14/2022] Open
Abstract
Prophylaxis is important for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), which is the most common and serious complication of ERCP. Although the current guidelines include independent patient- and procedure-related risk factors for PEP and available PEP prophylactic measures, the synergistic effect of these risk factors on PEP should also be considered, given that patients often harbor multiple risk factors. Furthermore, a combination of prophylactic measures is often selected in clinical practice. However, established methods estimating the synergistic effect of independent risk factors on PEP incidence are lacking, and evidence on the impact of combining prophylactic measures on PEP should be discussed. Selection of appropriate candidate patients for ERCP is also important to reduce the incidence of PEP associated with unnecessary ERCP. ERCP indications in patients with asymptomatic common bile duct stones (CBDSs) and in those with suspected CBDSs with no imaging-based evidence of stones are controversial. Further studies are warranted to predict the synergistic effect of independent risk factors on PEP, determine the best prophylactic PEP measures, and identify appropriate candidates for ERCP in patients with asymptomatic CBDSs and those with suspected CBDSs.
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Affiliation(s)
- Hirokazu Saito
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
| | - Atsushi Fujimoto
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
| | - Kana Oomoto
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
| | - Yoshitaka Kadowaki
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
| | - Shuji Tada
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
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Stenting of the pancreatic duct in the early phase of acute pancreatitis: a retrospective study. BMC Gastroenterol 2022; 22:414. [PMID: 36088309 PMCID: PMC9463836 DOI: 10.1186/s12876-022-02494-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/25/2022] [Indexed: 11/15/2022] Open
Abstract
Background The effectiveness of pancreatic duct (PD) stenting in the early stages of acute pancreatitis (AP) remains controversial. This study aimed to investigate the efficacy and safety of PD stenting in the early stages of AP. Methods This is a retrospective cohort study. The clinical data of 131 patients with AP from 2018 to 2019 were analysed and divided into two groups: the study group (n = 46, PD stenting) and the control group (n = 85, standard treatment). Results There was a statistically significant reduction in pain relief, oral refeeding, hospitalization, and intensive care unit (ICU) stay in the study group compared with that of the control group (P < 0.05). There were no significant differences in the incidence of complications between the two groups. Further multivariate analysis of risk factors for new-onset organ failure showed that the control group (odds ratio [OR] (95% confidence interval [CI]): 6.533 (1.104–70.181)) and a higher level of haematocrit (HCT) at admission (HCT > 46.1%, OR (95%CI): 8.728 (1.264–116.767)) were independent risk factors. Conclusions In the early phase of AP, PD stenting has the potential to reduce pain relief time, oral refeeding time, ICU stay time, and overall hospital stay time. This finding highlights a new route for the treatment of AP. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02494-5.
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Ribeiro IB, do Monte Junior ES, Miranda Neto AA, Proença IM, de Moura DTH, Minata MK, Ide E, dos Santos MEL, Luz GDO, Matuguma SE, Cheng S, Baracat R, de Moura EGH. Pancreatitis after endoscopic retrograde cholangiopancreatography: A narrative review. World J Gastroenterol 2021; 27:2495-2506. [PMID: 34092971 PMCID: PMC8160616 DOI: 10.3748/wjg.v27.i20.2495] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/30/2021] [Accepted: 03/18/2021] [Indexed: 02/06/2023] Open
Abstract
Acute post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a feared and potentially fatal complication that can be as high as up to 30% in high-risk patients. Pre-examination measures, during the examination and after the examination are the key to technical and clinical success with a decrease in adverse events. Several studies have debated on the subject, however, numerous topics remain controversial, such as the effectiveness of prophylactic medications and the amylase dosage time. This review was designed to provide an update on the current scientific evidence regarding PEP available in the literature.
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Affiliation(s)
- Igor Braga Ribeiro
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | | | - Antonio Afonso Miranda Neto
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Igor Mendonça Proença
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | | | - Mauricio Kazuyoshi Minata
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Edson Ide
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | | | - Gustavo de Oliveira Luz
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Sergio Eiji Matuguma
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Spencer Cheng
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Renato Baracat
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
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Boškoski I, Costamagna G. How to Prevent Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastroenterology 2020; 158:2037-2040. [PMID: 32197979 DOI: 10.1053/j.gastro.2020.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS; and Centre for Endoscopic Research, Therapeutics and Training (CERTT), Catholic University of Rome, Rome, Italy.
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS; and Centre for Endoscopic Research, Therapeutics and Training (CERTT), Catholic University of Rome, Rome, Italy
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Dubravcsik Z, Hritz I, Szepes A, Madácsy L. Risk factors of post-ERCP pancreatitis in high-risk patients despite prevention with prophylactic pancreatic stents. Scand J Gastroenterol 2020; 55:95-99. [PMID: 31852319 DOI: 10.1080/00365521.2019.1701069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives: To analyze risk factors of post-ERCP pancreatitis (PEP) in high risk patients in whom prophylactic pancreatic stents (PPSs) were intended to use to prevent endoscopic retrograde cholangiography (ERCP)-related complications.Patients and methods: Three hundred and seventeen high-risk patients for developing PEP were considered for preventive pancreatic stent placement in our endoscopy unit over 5 years. 5 Fr, 3-5 cm long PPSs were used. All data were collected in a predefined database. Development of PEP despite PPS placement was analyzed.Results: PEP occurred in 29 of 288 successfully stented patients (10.07%; 24 mild, four moderate, one severe). PPS was protective against all risks factors except for sphincter of Oddi dysfunction (SOD). PPS related complication rate was 2.78% (n = 8). Unsuccessful stenting occurred in 29 patients (9.15%), PEP developed in 41.38% (n = 12; seven mild, four moderate, one severe). Those patients who had more patient related risk factors were more likely to develop PEP despite preventive measures with PPS. On the contrary, PPS placement was less successful in patients who had more procedure related risk factors.Conclusions: PPS is protective against all risks factors of PEP except for SOD in high-risk patients. More vulnerable patients who have more patient-related risk factors are more likely to develop PEP despite PPS is used, while more complex procedures predispose to unsuccessful PPS placement in patients with more procedure-related risk factors. PPS insertion in high-risk patients is effective and safe preventive method and the procedure related complication rate is reasonably low.
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Affiliation(s)
- Zsolt Dubravcsik
- Department of Gastroenterology, Bács-Kiskun Megyei Kórház, Kecskemét, Hungary
| | - István Hritz
- Department of Gastroenterology, Bács-Kiskun Megyei Kórház, Kecskemét, Hungary
| | - Attila Szepes
- Department of Gastroenterology, Bács-Kiskun Megyei Kórház, Kecskemét, Hungary
| | - László Madácsy
- Department of Gastroenterology, Bács-Kiskun Megyei Kórház, Kecskemét, Hungary
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Lee JK, Jang DK, Kang HW, Lee SH. Feasibility of Temporary Pancreatic Stenting after Early Endoscopic Retrograde Cholangiopancreatography in Patients with Acute Biliary Pancreatitis. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 70:247-252. [PMID: 29161794 DOI: 10.4166/kjg.2017.70.5.247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background/Aims To assess the safety and effectiveness of temporary pancreatic stenting after early endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis regardless of the severity or concomitant cholangitis. Methods Temporary pancreatic stenting was performed in 79 patients with visualized pancreatic duct during ERCP. The outcomes of 64 patients with adequate pancreatic stenting (PS) and 15 patients with inadequate pancreatic stenting (no PS) were compared in this prospective, observational trial. Results The baseline characteristics were similar. Development of systemic inflammatory response syndrome (7.8% for PS vs. 13.3% for no PS; p=0.50) and mortality (none for both groups; p=0.99) did not differ. However, fewer local complications occurred in PS than in no PS (4.7% for PS vs. 20.0% for no PS; p=0.04) and the difference was most outstanding in necrosis (1.6% for PS vs. 13.3% for no PS; p=0.03). Conclusions Temporary pancreatic stenting after early ERCP should be considered safe, as complications did not increase even in cases of inadequate stenting. However, if successful, there appears to be a reduction in local complications.
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Affiliation(s)
- Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Hyun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul, Korea
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Mizandari M, Azrumelashvili T, Kumar J, Habib N. Percutaneous Image-Guided Pancreatic Duct Drainage: Technique, Results and Expected Benefits. Cardiovasc Intervent Radiol 2017; 40:1911-1920. [PMID: 28681224 DOI: 10.1007/s00270-017-1727-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 06/19/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE The aim of this study is to provide a technical detail and feasibility of percutaneous image-guided pancreatic duct (PD) drainage and to discuss its subtleties in a series of patients with obstructed PD. MATERIALS AND METHODS Thirty patients presenting with PD obstruction from pancreatic head tumour or pancreatitis were subjected to percutaneous image-guided PD drainage under a guidance of ultrasound or computed tomography. Following the successful puncture of PD, a locking loop drainage catheter was placed using conventional guidewire techniques under real-time fluoroscopy guidance. RESULTS The percutaneous drainage of obstructed PD was completed in 29 (96.7%) patients as an independent therapeutic intent or as a bridge to further percutaneous procedures. Clinical improvement following drainage was documented by the gradual reduction in clinical symptoms, including pain, nausea and fever and improved blood test results, showing the significant decrease of amylase concentration. The amount of pancreatic fluid drained post procedure was between 300 and 900 mL/day. No major procedure-related complications were observed. Subsequently, 14 of 29 patients underwent further procedures, including endoluminal placement of metal stent with or without radiofrequency ablation, balloon assisted percutaneous descending litholapaxy (BAPDL), endoluminal biopsy and balloon dilatation using the same drainage tract. CONCLUSION The percutaneous PD drainage appears to be a safe and effective procedure. It should be considered in patients with obstructed PD secondary to malignancy, pancreatitis etc., where endoscopic retrograde cannulation has been failed or impracticable. The procedure can also be contemplated either as an independent treatment option or as an initial step for the subsequent therapeutic endoluminal procedures.
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Affiliation(s)
- M Mizandari
- Department of Radiology, Tbilisi State Medical University (TSMU), Tbilisi, Georgia.
- High Technology Medical Center - University Clinic, 9, Tsinandali St., 0144, Tbilisi, Georgia.
| | - T Azrumelashvili
- Department of Radiology, Tbilisi State Medical University (TSMU), Tbilisi, Georgia
| | - J Kumar
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - N Habib
- Department of Surgery and Cancer, Imperial College London, London, UK
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Tarnasky PR, Kedia P. Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul R. Tarnasky
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
| | - Prashant Kedia
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
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Elmunzer BJ. Preventing Postendoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:725-36. [PMID: 26431600 DOI: 10.1016/j.giec.2015.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Postendoscopic retrograde cholangiopancreatography pancreatitis is a common and potentially devastating complication of endoscopic retrograde cholangiopancreatography. Advances in risk-stratification, patient selection, procedure technique, and prophylactic interventions have substantially improved the ability to prevent this complication. This article presents the evidence-based approaches to preventing postendoscopic retrograde cholangiopancreatography pancreatitis and discusses timely research questions in this important area.
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Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty Street, Suite 249, Charleston, SC 29425, USA.
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Dubravcsik Z, Madácsy L, Gyökeres T, Vincze Á, Szepes Z, Hegyi P, Hritz I, Szepes A. Preventive pancreatic stents in the management of acute biliary pancreatitis (PREPAST trial): pre-study protocol for a multicenter, prospective, randomized, interventional, controlled trial. Pancreatology 2015; 15:115-123. [PMID: 25754525 DOI: 10.1016/j.pan.2015.02.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 02/10/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND The outcome of the most common biliary form of acute pancreatitis has not changed even with the better described indications for early endoscopic intervention. It may be due to the fact that this intrevention theoretically can cause further pancreatic injury or cannot always relieve the pancreatic duct obstruction. We hypothesize that maintaining the outflow of the pancreatic duct with preventive pancreatic stents at the early ERCP improves the outcome of acute biliary pancreatitis. METHODS/DESIGN PREPAST is a prospective, randomized, controlled, multicenter trial. Patients with acute biliary pancreatitis with coexisting cholangitis are randomized to undergo urgent endoscopic intervention with or without pancreatic stenting within 48 h from the onset of pain, and in addition patients without signs of cholangitis but cholestasis are randomly allocated to recieve conservative treatment or early endoscopic intervention with or without pancreatic stenting within 48 h from the onset of pain. Patients without acute cholangitis and signs of cholestasis recieve conservative treatment. 230 patients are planned to be enrolled during a 48 months period from different centers. The primary endpoint is the outcome of acute biliary pancreatitis as described by the latest guidelines. Secondary endpoints include mortality data, and other variables not analyzed as a primary endpoint but related to the pancreatitis or the pancreatic stenting. DISCUSSION The PREPAST trial is designed to show whether early endoscopic intervention with the usage of preventive pancreatic stenting improves the outcome of acute biliary pancreatitis. The study has been registered at the International Standard Randomised Controlled Trial Number (ISRCTN) Register (trial ID: ISRCTN13517695).
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Affiliation(s)
- Zsolt Dubravcsik
- Department of Gastroenterology and Endoscopy, Bács-Kiskun County Hospital, Nyíri út 38, 6000 Kecskemét, Hungary.
| | - László Madácsy
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi u. 46, 1088 Budapest, Hungary
| | - Tibor Gyökeres
- Department of Gastroenterology, State Health Centre, Podmaniczky u. 111, 1062 Budapest, Hungary
| | - Áron Vincze
- 1st Department of Internal Medicine, University of Pécs, Rákóczi út 2, 7622 Pécs, Hungary
| | - Zoltán Szepes
- 1st Department of Internal Medicine, University of Szeged, Korányi fasor 8-10, 6720 Szeged, Hungary
| | - Péter Hegyi
- 1st Department of Internal Medicine, University of Szeged, Korányi fasor 8-10, 6720 Szeged, Hungary; MTA-SZTE Lendület Translational Gastroenterology Research Group, Korányi fasor 8-10, 6720 Szeged, Hungary
| | - István Hritz
- Department of Gastroenterology and Endoscopy, Bács-Kiskun County Hospital, Nyíri út 38, 6000 Kecskemét, Hungary; 1st Department of Internal Medicine, University of Szeged, Korányi fasor 8-10, 6720 Szeged, Hungary
| | - Attila Szepes
- Department of Gastroenterology and Endoscopy, Bács-Kiskun County Hospital, Nyíri út 38, 6000 Kecskemét, Hungary
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is widely used in the diagnosis and treatment of cholangiopancreatic diseases, and pancreatitis remains the most common and severe complication. It is therefore important to minimize the incidence and severity of pancreatitis. This paper discusses the recent progress in the prevention and treatment of post-ERCP pancreatitis.
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Kubiliun NM, Elmunzer BJ. Preventing pancreatitis after endoscopic retrograde cholangiopancreatography. Gastrointest Endosc Clin N Am 2013; 23:769-86. [PMID: 24079789 DOI: 10.1016/j.giec.2013.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is a common and potentially devastating complication of ERCP. Advances in risk stratification, patient selection, procedure technique, and prophylactic interventions have substantially improved the endoscopists' ability to prevent this complication. This article presents the evidence-based approaches to preventing post-ERCP pancreatitis and suggests timely research questions in this important area.
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Affiliation(s)
- Nisa M Kubiliun
- Division of Gastroenterology, University of Michigan Medical Center, 3912 Taubman Center, Ann Arbor, MI 48109, USA
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Czakó L. [Urgent endoscopic retrograde cholangio-pancreatography: to whom, when and how to perform?]. Orv Hetil 2012; 153:1456-1464. [PMID: 22961415 DOI: 10.1556/oh.2012.29449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Although the effectivity of an urgent endoscopic retrograde cholangio-pancreatography was documented, some aspects relating to this method are still debated. Timing of this procedure has not been established yet. Indications for urgent endoscopic retrograde cholangio-pancreatography with stone extraction from the common bile duct in patients with biliary pancreatitis remains controversial. Biliary decompression and drainage is the cornerstone of acute cholangitis treatment. The timing of endoscopic retrograde cholangio-pancreatography should be based on the grade of the severity of the disease. Using endoscopic retrograde cholangio-pancreatography, the accurate diagnosis and treatment of bile leaks in a timely manner is imperative to limit associated morbidity and mortality. Difficulty in cannulating the common bile duct is one of the main risk factors for pancreatitis occurring after the procedure. Alternative techniques to facilitate difficult cannulation are discussed. Organized training and introduction of objective measures of the investigator's competence are emphasized to improve the performance of the procedure in Hungary.
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Affiliation(s)
- László Czakó
- Szegedi Tudományegyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Szeged Pf. 407 6701.
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Kahaleh M, Freeman M. Prevention and management of post-endoscopic retrograde cholangiopancreatography complications. Clin Endosc 2012; 45:305-12. [PMID: 22977824 PMCID: PMC3429758 DOI: 10.5946/ce.2012.45.3.305] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 07/20/2012] [Accepted: 07/20/2012] [Indexed: 12/12/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a spectrum of complications such as pancreatitis, hemorrhage, perforation, and cardiopulmonary events. These complications can range from mild to severe resulting in extended hospitalization, requiring surgical intervention, and leading to permanent disability or even death. Complications of ERCP have been better understood in the past decade, with adoption of standardized consensus-based definitions of complications and introduction of new recommendations to minimize risks of ERCP. Adequate selection of patients undergoing ERCP, skilled operators using novel techniques and prompt identification and treatment are key to successful prevention and management.
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Affiliation(s)
- Michel Kahaleh
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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Complications of endoscopic retrograde cholangiopancreatography. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2012. [DOI: 10.1016/j.tgie.2012.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Freeman ML. Complications of endoscopic retrograde cholangiopancreatography: avoidance and management. Gastrointest Endosc Clin N Am 2012; 22:567-86. [PMID: 22748249 DOI: 10.1016/j.giec.2012.05.001] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is now almost exclusively a therapeutic modality for pancreatic as well as biliary disorders. ERCP alone or with associated pancreatic and biliary therapy can cause a spectrum of mild and severe complications, including pancreatitis, hemorrhage, perforation, and cardiopulmonary events. Understanding of complications of ERCP has progressed substantially in the past decade, including widespread adoption of standardized consensus-based definitions of complications, large multicenter multivariate studies that have permitted clearer understanding of patient and technique-related risk factors for complications, and introduction of new technical approaches to minimize risks of ERCP.
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Affiliation(s)
- Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA.
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Dubravcsik Z, Hritz I, Fejes R, Balogh G, Virányi Z, Hausinger P, Székely A, Szepes A, Madácsy L. Early ERCP and biliary sphincterotomy with or without small-caliber pancreatic stent insertion in patients with acute biliary pancreatitis: better overall outcome with adequate pancreatic drainage. Scand J Gastroenterol 2012; 47:729-36. [PMID: 22414053 DOI: 10.3109/00365521.2012.660702] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To analyze the efficacy of pancreatic duct (PD) stenting following endoscopic sphincterotomy (EST) compared with EST alone in reducing complication rate and improving overall outcome in acute biliary pancreatitis (ABP). METHODS Between 1 January 2009 and 1 July 2010, 141 nonalcoholic patients with clinical, laboratory and imaging evidence of ABP were enrolled. Emergency endoscopic retrograde cholangiopancreatography (ERCP) was performed within 72 h from the onset of pain. Seventy patients underwent successful ERCP, EST, and stone extraction (control group); 71 patients (PD stent group) had EST, stone extraction and small-caliber (5 Fr, 3-5 cm) pancreatic stent insertion. All patients were hospitalized for medical therapy and jejunal feeding and were followed up. RESULTS The mean age, Glasgow score, symptom to ERCP time, mean amylase and CRP levels at initial presentation were not significantly different in the PD stent group compared to the control group: 60.6 vs. 64.3, 3.21 vs. 3.27, 34.4 vs. 40.2, 2446.9 vs. 2114.3, 121.1 vs. 152.4, respectively. Complications (admission to intensive care unit, pancreatic necrosis with septicemia, large (>6 cm) pseudocyst formation, need for surgical necrosectomy) were less frequent in the PD stent group resulting in a significantly lower overall complication rate (9.86% vs. 31.43%, p < 0.002). Mortality rates (0% vs. 4.28%) were comparable, reasonably low and without any significant differences. CONCLUSIONS Temporary small-caliber PD stent placement may offer sufficient drainage to reverse the process of ABP. Combined with EST the process results in a significantly less complication rate and better clinical outcome compared with EST alone during the early course of ABP.
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Affiliation(s)
- Zsolt Dubravcsik
- Bács-Kiskun County Hospital, Kecskemét, Teaching Hospital of the University of Szeged, Kecskemet, Hungary
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Hritz I, Dubravcsik Z, Szepes A, Madácsy L. Does removal of prophylactic pancreatic stents induce acute pancreatitis? Gastrointest Endosc 2011; 74:1429-30; author reply 1430. [PMID: 22136790 DOI: 10.1016/j.gie.2011.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 07/21/2011] [Indexed: 02/08/2023]
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Choudhary A, Bechtold ML, Arif M, Szary NM, Puli SR, Othman MO, Pais WP, Antillon MR, Roy PK. Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review. Gastrointest Endosc 2011; 73:275-82. [PMID: 21295641 DOI: 10.1016/j.gie.2010.10.039] [Citation(s) in RCA: 182] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 10/25/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute pancreatitis is a common complication of ERCP. Several randomized, controlled trials (RCTs) have evaluated the use of pancreatic stents in the prevention of post-ERCP pancreatitis with varying results. OBJECTIVE We conducted a meta-analysis and systematic review to assess the role of prophylactic pancreatic stents for prevention of post-ERCP pancreatitis. DESIGN MEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched. RCTs and retrospective or prospective, nonrandomized studies comparing prophylactic stent with placebo or no stent for post-ERCP pancreatitis were included for the meta-analysis and systematic review. Standard forms were used to extract data by 2 independent reviewers. The effect of stents (for RCTs) was analyzed by calculating pooled estimates of post-ERCP pancreatitis, hyperamylasemia, and grade of pancreatitis. Separate analyses were performed for each outcome by using the odds ratio (OR) or weighted mean difference. Random- or fixed-effects models were used. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I(2) measure of inconsistency. SETTING Systematic review and meta-analysis of patients undergoing pancreatic stent placement for prophylaxis against post-ERCP pancreatitis. PATIENTS Adult patients undergoing ERCP. INTERVENTIONS Pancreatic stent placement for the prevention of post-ERCP pancreatitis. MAIN OUTCOME MEASUREMENTS Post-ERCP pancreatitis, hyperamylasemia, and complications after pancreatic stent placement. RESULTS Eight RCTs (656 subjects) and 10 nonrandomized studies met the inclusion criteria (4904 subjects). Meta-analysis of the RCTs showed that prophylactic pancreatic stents decreased the odds of post-ERCP pancreatitis (odds ratio, 0.22; 95% CI, 0.12-0.38; P<.01). The absolute risk difference was 13.3% (95% CI, 8.8%-17.8%). The number needed to treat was 8 (95% CI, 6-11). Stents also decreased the level of hyperamylasemia (WMD, -309.22; 95% CI, -350.95 to -267.49; P≤.01). Similar findings were also noted from the nonrandomized studies. LIMITATIONS Small sample size of some trials, different types of stents used, inclusion of low-risk patients in some studies, and lack of adequate study of long-term complications of pancreatic stent placement. CONCLUSIONS Pancreatic stent placement decreases the risk of post-ERCP pancreatitis and hyperamylasemia in high-risk patients.
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Fejes R, Kurucsai G, Székely A, Székely I, Altorjay A, Madácsy L. Feasibility and safety of emergency ERCP and small-caliber pancreatic stenting as a bridging procedure in patients with acute biliary pancreatitis but difficult sphincterotomy. Surg Endosc 2010; 24:1878-85. [PMID: 20108145 DOI: 10.1007/s00464-009-0864-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Accepted: 11/30/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND The aims of the present study were: (1) to assess the feasibility and safety of emergency endoscopic retrograde cholangiopancreatography (ERCP) and pancreatic duct (PD) stenting with small-caliber stents as a bridging procedure in acute biliary pancreatitis (ABP) patients in whom biliary endoscopic sphincterotomy (EST) proved difficult, failed or was contraindicated, and (2) to compare the clinical outcome of those patients having emergency ERCP with and without pancreatic stent. METHOD Eighty-seven consecutive patients with ABP were referred for emergency ERCP. In 60 of these ABP patients, ERCP, EST, and stone extraction (if necessary) were performed without PD stenting. In the remaining 27 patients, small-caliber (3-5 F, 4 cm) pancreatic stent insertion was initially applied. All patients were hospitalized for medical therapy and were followed up. RESULTS The mean ages, the initial symptom-to-ERCP times, the Glasgow severity scores, and the peak amylase and CRP levels at initial presentation were not significantly different in the ERCP + EST with PD stent group versus the ERCP + EST without PD stent group. More importantly, the complication rate was significantly lower in the ERCP + EST with PD stent group versus the ERCP + EST without PD stent group (7.4% vs. 25%); while the mortality rates (0% vs. 6.7%) were comparable, reasonably low, and demonstrated no statistically significant differences. CONCLUSIONS Temporary PD stenting with small-caliber stents is a safe and effective procedure that may afford sufficient PD decompression to reverse the process of ABP and serve as a bridging procedure in severe ABP in patients with failed, complicated, or contraindicated biliary EST.
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Affiliation(s)
- Roland Fejes
- Department of Gastroenterology and Endoscopy Unit, Fejér Megyei Szent György Hospital, Seregélyesi 3, Székesfehérvár, 8000, Hungary
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