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Elmunzer BJ, Zhang J, Coté GA, Edmundowicz SA, Wani S, Shah R, Bang JY, Varadarajulu S, Singh MD VK, Khashab M, Kwon RS, Scheiman JM, Willingham FF, Keilin SA, Papachristou GI, Chak A, Slivka A, Mullady D, Kushnir V, Buxbaum J, Keswani R, Gardner TB, Forbes N, Rastogi A, Ross A, Law J, Yachimski P, Chen YI, Barkun A, Smith ZL, Serrano J, Petersen B, Wang AY, Saltzman JR, Spitzer RL, Ordiah C, Spino C, Foster LD, Durkalski-Mauldin V. Technical Factors Associated With the Benefit of Prophylactic Pancreatic Stent Placement During High-Risk Endoscopic Retrograde Cholangiopancreatography: A Secondary Analysis of the SVI Trial Data Set. Am J Gastroenterol 2025; 120:811-815. [PMID: 39207308 PMCID: PMC11865352 DOI: 10.14309/ajg.0000000000003052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/11/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Prophylactic pancreatic stent placement (PSP) is effective for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk cases, but the optimal technical approach to this intervention remains uncertain. METHODS In this secondary analysis of 787 clinical trial patients who underwent successful stent placement, we studied the impact of (i) whether pancreatic wire access was achieved for the sole purpose of PSP or naturally during the conduct of the case, (ii) the amount of effort expended on PSP, (iii) stent length, (iv) stent diameter, and (v) guidewire caliber. We used logistic regression models to examine the adjusted association between each technical factor and post-ERCP pancreatitis (PEP). RESULTS Ninety-one of the 787 patients experienced PEP. There was no clear association between PEP and whether pancreatic wire access was achieved for the sole purpose of PSP (vs occurring naturally; odds ratio [OR] 0.82, 95% confidence interval [CI] 0.37-1.84), whether substantial effort expended on stent placement (vs nonsubstantial effort; OR 1.58, 95% CI 0.73-3.45), stent length (>5 vs ≤5 cm; OR 1.01, 95% CI 0.63-1.61), stent diameter (≥5 vs <5 Fr; OR 1.13, 95% CI 0.65-1.96), or guidewire caliber (0.035 vs 0.025 in; 0.83, 95% CI 0.49-1.41). DISCUSSION The 5 modifiable technical factors studied in this secondary analysis of large-scale randomized trial data did not appear to have a strong impact on the benefit of prophylactic PSP in preventing PEP after high-risk ERCP. Within the limitations of post hoc subgroup analysis, these findings may have important implications in procedural decision making and suggest that the benefit of PSP is robust to variations in technical approach.
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Affiliation(s)
- B. Joseph Elmunzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory A. Coté
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Steven A. Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Raj Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ji Young Bang
- Orlando Health Digestive Health Institute, Orlando Health, Orlando, Florida, USA
| | - Shyam Varadarajulu
- Orlando Health Digestive Health Institute, Orlando Health, Orlando, Florida, USA
| | - Vikesh K. Singh MD
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Richard S. Kwon
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - James M. Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Field F. Willingham
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Steven A. Keilin
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Georgios I. Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Daniel Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - James Buxbaum
- Division of Gastroenterology, Department of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rajesh Keswani
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Timothy B. Gardner
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - Nauzer Forbes
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amit Rastogi
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andrew Ross
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Joanna Law
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yen-I Chen
- Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
| | - Zachary L. Smith
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jose Serrano
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Bret Petersen
- Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Y. Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - John R. Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Rebecca L. Spitzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Collins Ordiah
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Cathie Spino
- Department of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Lydia D. Foster
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Valerie Durkalski-Mauldin
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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Michael FA, Feldmann C, Erasmus HP, Kubesch A, Goerguelue E, Knabe M, Abedin N, Heilani M, Hessz D, Graf C, Walter D, Finkelmeier F, Mihm U, Lingwal N, Zeuzem S, Bojunga J, Friedrich-Rust M, Dultz G. A novel ultrasound-based algorithm for the detection of pancreatic stents placed for prophylaxis of post-ERCP pancreatitis: a prospective trial. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2025; 46:177-185. [PMID: 39222928 PMCID: PMC11964603 DOI: 10.1055/a-2407-9651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024]
Abstract
Before removal of retained pancreatic stents placed during endoscopic retrograde cholangiopancreatography to avoid post-ERCP pancreatitis, imaging is recommended. The aim of the present study was to evaluate a new ultrasound-based algorithm.Patients who received a pancreatic stent for PEP prophylaxis were included. Straight 5Fr (0.035inch) 6cm stents with an external flap that were visualized by ultrasound were removed endoscopically with no further imaging. If the ultrasound result reported the stent to be dislodged or was inconclusive, X-ray imaging was performed. The endpoints were positive and negative predictive value, specificity, sensitivity, and contingency coefficient between ultrasound and X-ray and/or endoscopy.88 patients were enrolled in the present study. X-ray was performed in 23 (26%) patients. Accordingly, the ultrasound algorithm saved an X-ray examination in 65 cases, leading to a reduction of 74%. Stents were retained in 67 patients (76%) and visualized correctly by ultrasound in 54 patients with a sensitivity of 81%. The positive predictive value was 83%. The specificity was 48%, because ultrasound described 10/21 dislodged stents correctly. The negative predictive value was 43%, since 10/23 stents were correctly classified by ultrasound as dislodged. In 11 patients (13%), esophagogastroduodenoscopy was performed even though the pancreatic stent was already dislodged.A novel ultrasound-based algorithm reduced the need for X-ray imaging by three quarters. To avoid unnecessary endoscopic examinations, the algorithm should be implemented with a learning phase and procedures should be performed by experienced examiners. An important limitation might be stent length since shorter stents might be more difficult to visualize by ultrasound.
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Affiliation(s)
- Florian Alexander Michael
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Clara Feldmann
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Hans-Peter Erasmus
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Alica Kubesch
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Esra Goerguelue
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Mate Knabe
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
- Centrum Gastroenterology Bethanien, Bethanien-Hospital, Frankfurt am Main, Germany
| | - Nada Abedin
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Myriam Heilani
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Daniel Hessz
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Christiana Graf
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
- Medical Clinic 2, LMU Hospital, Munchen, Germany
| | - Dirk Walter
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Fabian Finkelmeier
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Ulrike Mihm
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Neelam Lingwal
- Institute for Biostatistics and Mathematical Modeling, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Joerg Bojunga
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Mireen Friedrich-Rust
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Georg Dultz
- Medical Clinic 1, Goethe University Frankfurt Frankfurt University Hospital, Frankfurt am Main, Germany
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Li L, Li X, Liu K, Wu W, Li M, Liu Y. Mitigating Postoperative Fistula Risks in Laparoscopic Pancreatic Enucleation: A Retrospective Study. Ann Surg Oncol 2025; 32:1887-1895. [PMID: 39710806 PMCID: PMC11811477 DOI: 10.1245/s10434-024-16702-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 11/28/2024] [Indexed: 12/24/2024]
Abstract
BACKGROUND Pancreatic enucleation is a reliable surgical method for treating benign and borderline pancreatic tumors; however, the incidence of postoperative pancreatic fistula (POPF) is high, especially when the tumor is close to the main pancreatic duct. This study aimed to reduce the incidence of pancreatic fistula by preoperative placement of pancreatic stents and to summarize our center's experience with this procedure. METHODS From June 2020 to July 2023, patients diagnosed with benign or borderline pancreatic tumors at Renji Hospital were included. The pancreatic duct stent is placed through endoscopic retrograde cholangiopancreatography on the day of surgery or 1 day before surgery. The effectiveness of preoperative pancreatic stent placement in reducing pancreatic fistula was investigated by comparing the incidence of perioperative and postoperative complications. RESULTS Overall, 63 patients were included in the study, 41 of whom had preoperative pancreatic stents. Multivariate logistic regression showed that tumors located in proximity to the main pancreatic duct (≤ 2 mm) (odds ratio [OR] 5.58, p = 0.020) is an independent risk factor for pancreatic fistula, while preoperative stent placement (OR 0.23, p = 0.021) significantly reduces the occurrence of pancreatic fistula. There was no difference in the incidence of grade Ш-IV complications (p = 0.33) and postoperative pancreatitis (p > 0.99) between groups with or without pancreatic stent. CONCLUSION Preoperative placement of pancreatic stents is associated with a lower incidence of pancreatic fistula, especially in patients with tumors adjacent to the main pancreatic duct. Moreover, preoperative pancreatic stents do not increase the incidence of postoperative pancreatitis or grade Ш-IV complications.
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Affiliation(s)
- Lin Li
- Department of Biliary-Pancreatic Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuechuan Li
- Department of Biliary-Pancreatic Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ke Liu
- Department of Biliary-Pancreatic Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenguang Wu
- Department of Biliary-Pancreatic Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of General Surgery, Jiading Branch, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Systems Regulation and Clinical Translation for Cancer, Shanghai, China
- State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Shanghai, China
| | - Maolan Li
- Department of Biliary-Pancreatic Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of General Surgery, Jiading Branch, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Systems Regulation and Clinical Translation for Cancer, Shanghai, China
- State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Shanghai, China
| | - Yingbin Liu
- Department of Biliary-Pancreatic Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Department of General Surgery, Jiading Branch, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai Key Laboratory of Systems Regulation and Clinical Translation for Cancer, Shanghai, China.
- State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Shanghai, China.
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Tintara S, Buxbaum J. Updates in Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastroenterol Clin North Am 2025; 54:97-112. [PMID: 39880535 DOI: 10.1016/j.gtc.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2025]
Abstract
Although endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be a safe and effective approach in treating these diseases while carrying lower morbidity than traditional surgical treatments, ERCP has associated risks, with post-ERCP pancreatitis (PEP) being the most common serious adverse event and carries significant morbidity and health care cost. PEP results from multifactorial factors involving trauma to the pancreatic duct and papilla, leading to subsequent obstruction and impairment of pancreatic drainage. Important risk factors for PEP include history of prior PEP, suspected sphincter of Oddi dysfunction, difficult cannulation, pancreatic duct contrast injections, and pancreatic sphincterotomy.
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Affiliation(s)
- Supisara Tintara
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Los Angeles, California, USA
| | - James Buxbaum
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Los Angeles, California, USA.
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Takada Y, Ishikawa T, Yamao K, Mizutani Y, Iida T, Uetsuki K, Kawashima H. A case of pancreatic fistula with disruption of the inferior branch of the pancreatic duct caused by a pancreatic stent after endoscopic papillectomy. Clin J Gastroenterol 2025; 18:169-175. [PMID: 39576492 DOI: 10.1007/s12328-024-02067-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Accepted: 11/13/2024] [Indexed: 02/01/2025]
Abstract
A 73-year-old man underwent upper gastrointestinal endoscopy for abdominal pain, which revealed an ampullary adenoma with no obvious extension into the bile or pancreatic ducts. Endoscopic papillectomy (EP) was performed and a 5-Fr 5-cm stent was placed in the pancreatic duct. The patient developed acute pancreatitis on postoperative day (POD) 1 and contrast-enhanced computed tomography performed on POD 2 revealed that the proximal end of the stent had migrated into the retroperitoneum, forming a pancreatic fistula. Stent removal and endoscopic nasopancreatic drainage were performed and the pancreatitis rapidly improved. The tumor was completely resected and after approximately three years of follow-up, no tumor recurrence or acute pancreatitis was observed.Retrospectively, the inferior branch of the pancreatic duct was prominent on pancreatography at the time of EP and the proximal end of the stent had dislocated into the inferior branch. The stent subsequently moved proximally, which could have caused pancreatitis and pancreatic fistula. The morphology of the pancreatic duct should be carefully monitored during stenting. Selecting a stent that matches each patient's specific pancreatic duct morphology may help physicians minimize the risk of adverse outcomes.
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Affiliation(s)
- Yoshihisa Takada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65, Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65, Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan.
| | - Kentaro Yamao
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65, Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65, Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Tadashi Iida
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Kota Uetsuki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65, Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65, Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
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Meeusen V, Kim M, Ma R, Roque M, Sivalingam P, Hamarneh Z, Hourigan L. A Randomized Controlled Trial of Patient Positioning During Endoscopic Retrograde Cholangiopancreatography (ERCP) Procedures: A Comparison Between Semi-Prone- and Prone-Positioned Patients. Gastroenterol Nurs 2025; 48:51-61. [PMID: 39874119 PMCID: PMC11776873 DOI: 10.1097/sga.0000000000000849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 07/02/2024] [Indexed: 01/30/2025] Open
Abstract
The prone "swimmers" position is preferable for endoscopic retrograde cholangiopancreatography (ERCP) as it provides the best visualization for selective bile duct cannulation. However, "swimmers" position does not comply with best-practice patient positioning guidelines. Our objective was to determine whether the semi-prone patient position was suitable for ERCP without negatively influencing the outcomes of the procedure. We conducted a randomized controlled trial, 50 patients in prone and 50 patients in semi-prone patient position, measuring the number of attempts and time to successfully cannulate the bile duct. Safety outcomes measured were airway access, pharyngeal endoscope passage, and complications. Between the two groups, there were no statistical differences in demographic variables, selective bile duct cannulation attempts, or cannulation time. Airway access scored significantly better in the semi-prone position. There was a significant positive correlation between the total number of cannulation attempts and papilla type. No intra- or post-procedural significant complications occurred. The semi-prone position was comparable to the "swimmers" position regarding the number of attempts and time required for selective bile duct cannulation but scored significantly better in airway access by anesthetists. A semi-prone patient position is advisable for ERCP procedures as it complies with best-practice patient positioning guidelines.
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Affiliation(s)
- Vera Meeusen
- About the authors: Gastroenterology & Hepatology Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Meeusen, Ma, Roque, Hamarneh, and Hourigan)
- Anaesthesia Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Kim and Sivalingam)
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia (Meeusen, Sivalingam, Hamarneh, and Hourigan)
| | - Mijin Kim
- About the authors: Gastroenterology & Hepatology Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Meeusen, Ma, Roque, Hamarneh, and Hourigan)
- Anaesthesia Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Kim and Sivalingam)
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia (Meeusen, Sivalingam, Hamarneh, and Hourigan)
| | - Regan Ma
- About the authors: Gastroenterology & Hepatology Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Meeusen, Ma, Roque, Hamarneh, and Hourigan)
- Anaesthesia Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Kim and Sivalingam)
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia (Meeusen, Sivalingam, Hamarneh, and Hourigan)
| | - Marilyn Roque
- About the authors: Gastroenterology & Hepatology Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Meeusen, Ma, Roque, Hamarneh, and Hourigan)
- Anaesthesia Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Kim and Sivalingam)
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia (Meeusen, Sivalingam, Hamarneh, and Hourigan)
| | - Pal Sivalingam
- About the authors: Gastroenterology & Hepatology Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Meeusen, Ma, Roque, Hamarneh, and Hourigan)
- Anaesthesia Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Kim and Sivalingam)
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia (Meeusen, Sivalingam, Hamarneh, and Hourigan)
| | - Zaki Hamarneh
- About the authors: Gastroenterology & Hepatology Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Meeusen, Ma, Roque, Hamarneh, and Hourigan)
- Anaesthesia Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Kim and Sivalingam)
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia (Meeusen, Sivalingam, Hamarneh, and Hourigan)
| | - Luke Hourigan
- About the authors: Gastroenterology & Hepatology Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Meeusen, Ma, Roque, Hamarneh, and Hourigan)
- Anaesthesia Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia (Kim and Sivalingam)
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia (Meeusen, Sivalingam, Hamarneh, and Hourigan)
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Akshintala VS, Singh VK. Postendoscopic Retrograde Cholangiopancreatography Pancreatitis Pathophysiology and Prevention. Gastrointest Endosc Clin N Am 2023; 33:771-787. [PMID: 37709410 DOI: 10.1016/j.giec.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreato-biliary disorders. Pancreatitis remains the most frequent complication of the ERCP procedure, and it is, therefore, necessary to recognize the pathophysiology and risk factors contributing to the development of pancreatitis and understand the methods to prevent this complication.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Rivas A, Pherwani S, Mohamed R, Smith ZL, Elmunzer BJ, Forbes N. ERCP-related adverse events: incidence, mechanisms, risk factors, prevention, and management. Expert Rev Gastroenterol Hepatol 2023; 17:1101-1116. [PMID: 37899490 DOI: 10.1080/17474124.2023.2277776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/27/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure for pancreaticobiliary disease. While ERCP is highly effective, it is also associated with the highest adverse event (AE) rates of all commonly performed endoscopic procedures. Thus, it is critical that endoscopists and caregivers of patients undergoing ERCP have clear understandings of ERCP-related AEs. AREAS COVERED This narrative review provides a comprehensive overview of the available evidence on ERCP-related AEs. For the purposes of this review, we subdivide the presentation of each ERCP-related AE according to the following clinically relevant domains: definitions and incidence, proposed mechanisms, risk factors, prevention, and recognition and management. The evidence informing this review was derived in part from a search of the electronic databases PubMed, Embase, and Cochrane, performed on 1 May 20231 May 2023. EXPERT OPINION Knowledge of ERCP-related AEs is critical not only given potential improvements in peri-procedural quality and related care that can ensue but also given the importance of reviewing these considerations with patients during informed consent. The ERCP community and researchers should aim to apply standardized definitions of AEs. Evidence-based knowledge of ERCP risk factors should inform patient care decisions during training and beyond.
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Affiliation(s)
- Angelica Rivas
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Simran Pherwani
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rachid Mohamed
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Medas R, Ferreira-Silva J, Girotra M, Barakat M, Tabibian JH, Rodrigues-Pinto E. Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage. J Clin Gastroenterol 2023; 57:553-568. [PMID: 36040964 DOI: 10.1097/mcg.0000000000001760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Joel Ferreira-Silva
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mohit Girotra
- Digestive Health Institute, Swedish Medical Center, Seattle, WA
| | | | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA CA
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
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10
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Keswani RN, Duloy A, Nieto JM, Panganamamula K, Murad MH, Bazerbachi F, Shaukat A, Elmunzer BJ, Day LW. Interventions to improve the performance of ERCP and EUS quality indicators. Gastrointest Endosc 2023; 97:825-838. [PMID: 36967249 DOI: 10.1016/j.gie.2022.12.010] [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: 11/30/2022] [Accepted: 12/11/2022] [Indexed: 04/21/2023]
Affiliation(s)
- Rajesh N Keswani
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Anna Duloy
- Division of Gastroenterology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Jose M Nieto
- Digestive Disease Consultants, Jacksonville, Florida, USA
| | - Kashyap Panganamamula
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - M Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St Cloud Hospital, St Cloud, Minnesota, USA
| | - Aasma Shaukat
- Division of Gastroenterology and Hepatology, NYU Grossman School of Medicine, New York, New York, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, Zuckerberg San Francisco General Hospital and University of San Francisco, San Francisco, California, USA
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11
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Borrelli de Andreis F, Mascagni P, Schepis T, Attili F, Tringali A, Costamagna G, Boškoski I. Prevention of post-ERCP pancreatitis: current strategies and novel perspectives. Therap Adv Gastroenterol 2023; 16:17562848231155984. [PMID: 36895283 PMCID: PMC9989421 DOI: 10.1177/17562848231155984] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/23/2023] [Indexed: 03/08/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that might lead to severe adverse events. Post-ERCP pancreatitis (PEP) is the most common post-procedural complication, which is related to significant mortality and increasing healthcare costs. Up to now, the prevalent approach to prevent PEP consisted of employing pharmacological and technical expedients that have been shown to improve post-ERCP outcomes, such as the administration of rectal nonsteroidal anti-inflammatory drugs, aggressive intravenous hydration, and the placement of a pancreatic stent. However, it has been reported that PEP originates from a more complex interaction of procedural and patient-related factors. Appropriate ERCP training has a pivotal role in PEP prevention strategy, and it is not a chance that a low PEP rate is universally considered one of the most relevant indicators of proficiency in ERCP. Scant data on the acquisition of skills during the ERCP training are currently available, although some efforts have been recently done to shorten the learning curve by way of simulation-based training and demonstrate competency by meeting technical requirements as well as adopting skill evaluation scales. Besides, the identification of adequate indications for ERCP and accurate pre-procedural risk stratification of patients might help to reduce PEP occurrence regardless of the endoscopist's technical abilities, and generally preserve safety in ERCP. This review aims at delineating current preventive strategies and highlighting novel perspectives for a safer ERCP focusing on the prevention of PEP.
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Affiliation(s)
- Federica Borrelli de Andreis
- First Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, Pavia, Italy
- Gastroenterology Unit, Istituti Clinici Maugeri, University of Pavia, Pavia, Italy
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Pietro Mascagni
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Institute of Image-Guided Surgery, IHU-Strasbourg, France
| | - Tommaso Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Fabia Attili
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Roma, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, Rome, 00168, Italy
- IHU Strasbourg 1, Place de l’Hopital 67091 Strasbourg Cedex, France
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Roma, Italy
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12
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Buxbaum JL, Freeman M, Amateau SK, Chalhoub JM, Chowdhury A, Coelho-Prabhu N, Das R, Desai M, Elhanafi SE, Forbes N, Fujii-Lau LL, Kohli DR, Kwon RS, Machicado JD, Marya NB, Pawa S, Ruan WH, Sadik J, Sheth SG, Thiruvengadam NR, Thosani NC, Zhou S, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: methodology and review of evidence. Gastrointest Endosc 2023; 97:163-183.e40. [PMID: 36517309 DOI: 10.1016/j.gie.2022.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/26/2022] [Indexed: 01/22/2023]
Affiliation(s)
- James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Martin Freeman
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Stuart K Amateau
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jean M Chalhoub
- Department of Gastroenterology and Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Aneesa Chowdhury
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | | | - Rishi Das
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Sherif E Elhanafi
- Department of Gastroenterology, Texas Tech University, El Paso, Texas, USA
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Heart Hospital, Spokane, Washington, USA
| | - Richard S Kwon
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jorge D Machicado
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Neil B Marya
- Division of Gastroenterology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Wenly H Ruan
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jonathan Sadik
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhil R Thiruvengadam
- Department of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Selena Zhou
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, University of Florida, Gainesville, Florida, USA
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13
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Buxbaum JL, Freeman M, Amateau SK, Chalhoub JM, Coelho-Prabhu N, Desai M, Elhanafi SE, Forbes N, Fujii-Lau LL, Kohli DR, Kwon RS, Machicado JD, Marya NB, Pawa S, Ruan WH, Sheth SG, Thiruvengadam NR, Thosani NC, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: summary and recommendations. Gastrointest Endosc 2023; 97:153-162. [PMID: 36517310 DOI: 10.1016/j.gie.2022.10.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/04/2022] [Indexed: 01/22/2023]
Affiliation(s)
- James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Martin Freeman
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Stuart K Amateau
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jean M Chalhoub
- Department of Gastroenterology and Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | | | - Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Sherif E Elhanafi
- Department of Gastroenterology, Texas Tech University, El Paso, Texas, USA
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Heart Hospital, Spokane, Washington, USA
| | - Richard S Kwon
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jorge D Machicado
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Neil B Marya
- Division of Gastroenterology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Wenly H Ruan
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhil R Thiruvengadam
- Department of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, University of Florida, Gainesville, Florida, USA
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14
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An Insight on Pharmacological and Mechanical Preventive Measures of Post-ERCP PANCREATITIS (PEP)—A Review. GASTROENTEROLOGY INSIGHTS 2022. [DOI: 10.3390/gastroent13040038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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15
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Ryu J, Paik KH, Kwon CI, Koh DH, Song TJ, Jeong S, Park WS. The Safety and Efficacy of an Unflanged 4F Pancreatic Stent in Transpancreatic Precut Sphincterotomy for Patients with Difficult Biliary Cannulation: A Prospective Cohort Study. J Clin Med 2022; 11:jcm11195692. [PMID: 36233560 PMCID: PMC9573508 DOI: 10.3390/jcm11195692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Prophylactic pancreatic stenting effectively reduces the rate and severity of post-ERCP pancreatitis (PEP) in the precut technique; however, studies on the optimal type and duration of the stent are still lacking. This prospective study evaluated the incidence and severity of PEP and the rate of spontaneous stent dislodgement in patients undergoing transpancreatic precut sphincterotomy (TPS) accompanied by prophylactic pancreatic stenting with an unflanged plastic stent (4F × 5 cm) for difficult biliary cannulation. A total of 247 patients with naïve papilla were enrolled in this study, and data were collected prospectively. In the final analysis, 170 and 61 patients were included in the standard cannulation technique and TPS groups, respectively. The incidence of PEP in the standard cannulation technique and TPS groups was 3.5% and 1.6% (p = 0.679), respectively. The technical success rate of selective biliary cannulation in the TPS group was 91.8%. The spontaneous dislodgement rate of the prophylactic plastic stent was 98.4%. In conclusion, an unflanged pancreatic stent (4F × 5 cm) placement in TPS for patients with failed standard cannulation technique is a safe and effective measure due to low adverse events and few additional endoscopic procedures for removing the pancreatic duct (PD) stent.
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Affiliation(s)
- Jieun Ryu
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea
| | - Kyu-Hyun Paik
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea
| | - Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13497, Korea
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
| | - Dong Hee Koh
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea
| | - Tae Jun Song
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Division of Gastroenterology, Department of Internal Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Seok Jeong
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon 22332, Korea
| | - Won Suk Park
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Correspondence: ; Tel.: +82-42-220-9339
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16
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Akshintala VS, Singh A, Singh VK. Prevention and Management of Complications of Biliary Endoscopy. Gastrointest Endosc Clin N Am 2022; 32:397-409. [PMID: 35691688 DOI: 10.1016/j.giec.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreaticobiliary disorders. ERCP is, however, associated with the risk of complications including pancreatitis, bleeding, perforation, infection, and instrument failure, which can often be fatal. It is, therefore, necessary to recognize the risk of ERCP-associated complications and understand the methods to prevent and treat such complications.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA
| | - Anmol Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA.
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17
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Obeidat AE, Mahfouz R, Monti G, Kozai L, Darweesh M, Mansour MM, Alqam A, Hernandez D. Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: What We Already Know. Cureus 2022; 14:e21773. [PMID: 35251843 PMCID: PMC8890589 DOI: 10.7759/cureus.21773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 11/05/2022] Open
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18
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Li SL, Li W, Yin J, Wang ZK. Endoscopic papillectomy for ampullary adenomatous lesions: A literature review. World J Gastrointest Oncol 2021; 13:1466-1474. [PMID: 34721778 PMCID: PMC8529916 DOI: 10.4251/wjgo.v13.i10.1466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/02/2021] [Accepted: 08/09/2021] [Indexed: 02/06/2023] Open
Abstract
Ampullary adenomatous lesions of the gastrointestinal tract are rare and can be asymptomatic. Therefore, ampullary adenomas with malignant potential require prompt removal, regardless of whether they are adenomatous or carcinomatous lesions. Endoscopic papillectomy is a safe and effective alternative therapy to surgery to treat duodenal papillary lesions in selected patients. Accurate preoperative diagnosis and staging of ampullary adenomatous lesions are critical for predicting prognosis and determining the most appropriate therapeutic approach. Furthermore, the management and prevention of adverse events and endoscopic treatment for remnant or recurrent lesions and surveillance are essential for successful endoscopic management of ampullary adenomatous lesions. This literature review was based on PubMed and MEDLINE and focused on recent advancements in the endoscopic papillectomy technique to provide a comprehensive view of endoscopic papillectomy to treat ampullary adenomatous lesions.
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Affiliation(s)
- Shu-Ling Li
- Department of Gastroenterology and Hepatology, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
| | - Wen Li
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Jian Yin
- Department of Gastroenterology and Hepatology, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
| | - Zi-Kai Wang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
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19
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Michael FA, Gerber L, Weiler N, Hunyady PM, Abedin N, de la Vera ALL, Stoffers P, Filmann N, Zeuzem S, Bojunga J, Friedrich-Rust M, Dultz G. Transabdominal ultrasonography to reduce the burden of X-ray imaging in prophylactic pancreatic stent localization after ERCP-A prospective trial. United European Gastroenterol J 2021; 9:469-477. [PMID: 33887119 PMCID: PMC8259253 DOI: 10.1002/ueg2.12063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/13/2021] [Accepted: 02/07/2021] [Indexed: 11/25/2022] Open
Abstract
Background Before performing endoscopy to remove prophylactic pancreatic stents placed in patients with high risk of post‐endoscopic retrograde cholangiopancreatography pancreatitis (PEP), X‐ray imaging is recommended to confirm the stents position in the pancreatic duct. Objectives The aim of the present study was to investigate the feasibility of prophylactic pancreatic stent detection by transabdominal ultrasonography, to reduce the burden of X‐ray imaging, which is currently the golden standard. Methods All patients who received a pancreatic stent for PEP prophylaxis were included in the present prospective trial. First, stent position was determined by transabdominal ultrasonography. Afterwards, it was verified by X‐ray imaging. Retained stents were removed by esophagogastroduodenoscopy. Dislocated stents needed no further intervention. Results Fourty‐one patients were enrolled in this study. All prophylactic pancreatic stents were straight 6 cm long 5 Fr stents with external flap. All stents were removed between day 1 and 10 (median: 3 days) in all cases. In 34 of 41 cases (83.0%), the pancreatic stent was still in place on the day of examination. Twenty‐nine of 34 (85.3%) stents were detected correctly by transabdominal ultrasonography. Overlying gas prevented visualization of the pancreas in 3/41 (7.3%) cases. Sensitivity of sonographic detection of the stent was 93.5% (29/31). Six of seven stents were determined correctly as dislocated by ultrasonography. Here, specificity was 85.7%. A positive predictive value of 96.7% (29/30) was examined. The negative predictive value was 75.0% (6/8). Conclusion Transabdominal ultrasonography detects the majority of prophylactic pancreatic stents. Thereby, it helps to identify patients with an indication for endoscopy sufficiently. X‐ray imaging could subsequently be omitted in about 70% of examinations, reducing the radiation exposure for the patient and the endoscopy staff.
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Affiliation(s)
| | - Ludmilla Gerber
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Nina Weiler
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Peter Marton Hunyady
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Nada Abedin
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Philipp Stoffers
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Frankfurt, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Jörg Bojunga
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Georg Dultz
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
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20
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Han S, Attwell AR, Tatman P, Edmundowicz SA, Hammad HT, Wagh MS, Wani S, Shah RJ. Adverse Events Associated With Therapeutic Endoscopic Retrograde Pancreatography. Pancreas 2021; 50:378-385. [PMID: 33835969 PMCID: PMC8041157 DOI: 10.1097/mpa.0000000000001769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Data regarding the safety of endoscopic retrograde pancreatography (ERP) are limited compared with biliary endoscopic retrograde cholangiopancreatography. The aim of this study was to determine adverse events (AEs) associated with therapeutic ERP. METHODS This single-center retrospective study examined consecutive therapeutic ERPs with the primary intention of cannulating the pancreatic duct. Multivariate logistic regression was performed to identify risk factors for AEs. RESULTS A total of 3023 ERPs were performed in 1288 patients (mean age, 50.3 years; 57.8% female) from January 2000 to January 2017. Overall AE rate was 18.9% with abdominal pain requiring admission (9.8%) and post-ERP pancreatitis (5.7%) being most common. On multivariate analysis, female sex (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.9-2.9), acute recurrent pancreatitis (aOR, 5.0; 95% CI, 1.7-15.3), chronic pancreatitis (aOR, 1.8; 95% CI, 1.3-2.6), and pancreatic sphincter of Oddi dysfunction (aOR, 2.1; 95% CI, 1.4-3.3) were associated with an increased risk of overall AEs. Pancreatic sphincterotomy (aOR, 1.9; 95% CI, 1.5-2.4) and therapeutic stenting (aOR, 1.6; 95% CI, 1.2-2.2) also increased the risk of AEs. CONCLUSIONS Nearly 1 in 5 patients who undergo therapeutic ERP will experience an AE; however, the rates of major AEs, including post-ERP pancreatitis, bleeding, and perforation, are low.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Augustin R. Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Philip Tatman
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Steven A. Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Hazem T. Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Mihir S. Wagh
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Raj J. Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
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21
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Bhatt H. Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: An Updated Review of Current Preventive Strategies. Clin Exp Gastroenterol 2021; 14:27-32. [PMID: 33564256 PMCID: PMC7866941 DOI: 10.2147/ceg.s276361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022] Open
Abstract
Pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography, with incidence rates as high as 16% in some centers. Recent studies have also shown an upward trend in hospitalization due to endoscopic retrograde cholangiopancreatography-related pancreatitis. Early interventions taken before, during, and after the procedure can significantly reduce the risk of pancreatitis and decrease morbidity and mortality of the patients. To select appropriate patients for endoscopic retrograde cholangiopancreatography, in-depth knowledge of the patient-related and procedure-related risk factors is required. This updated clinical review outlines various pharmacological agents and surgical methods used for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Current evidence supports the use of rectal non-steroidal anti-inflammatory drugs and pancreatic stent placement as an effective preventive strategy. Further research is needed to compare these preventive modalities to improve patient outcomes after endoscopic retrograde cholangiopancreatography.
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Affiliation(s)
- Harshil Bhatt
- Goshen Hospital, Goshen, IN, USA
- Indiana University School of Medicine, South Bend, IN, USA
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22
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Giuliani T, Marchegiani G, Girgis MD, Crinò SF, Muthusamy VR, Bernardoni L, Pea A, Ramera M, Paiella S, Landoni L, Gabbrielli A, Salvia R, Donahue TR, Bassi C. Endoscopic placement of pancreatic stent for "Deep" pancreatic enucleations operative technique and preliminary experience at two high-volume centers. Surg Endosc 2020; 34:2796-2802. [PMID: 32180000 DOI: 10.1007/s00464-020-07501-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic enucleation (PE) is a viable option for the removal of non-malignant pancreatic masses leading to complete preservation of organ function. Nevertheless, PE is associated with substantial rates of post-operative pancreatic fistula (POPF), particularly when the mass is close to the main pancreatic duct (MPD). Preoperative stenting of the MPD may prevent its injury when performing PE. This paper describes a novel technique of "deep" PE preceded by endoscopic stenting of the MPD. METHODS From January 2017 to May 2019, patients with small pancreatic neuroendocrine tumors proximal to the MPD were candidates for PE with previous stenting of the MPD at the University of Verona, Italy, and at the UCLA Medical Center, Los Angeles, California. The endoscopic stenting was scheduled either the day before or 3 weeks before surgery, depending on the participating institute. RESULTS Ten patients were included in this pilot study. The endoscopic procedure was successful and well tolerated in all cases. Open, laparoscopic and robotic PE were performed. Seven patients had surgical complications. Among these, six developed a post-operative pancreatic fistula (POPF), but neither grade C fistulas nor disruptions of the MPD were detected. At pathology, a low grade pancreatic neuroendocrine tumor was confirmed in all cases. CONCLUSION In the setting of high-volume centers, this procedure is safe, and it is associated with acceptable short-term surgical morbidity. The preoperative stenting of the MPD might extend the surgical indications for PE.
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Affiliation(s)
- Tommaso Giuliani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Mark D Girgis
- Division of Surgical Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Stefano Francesco Crinò
- Unit of Gastroenterology and Digestive Endoscopy, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | | | - Laura Bernardoni
- Unit of Gastroenterology and Digestive Endoscopy, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Antonio Pea
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Marco Ramera
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy.
| | - Armando Gabbrielli
- Unit of Gastroenterology and Digestive Endoscopy, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Timothy R Donahue
- Division of Surgical Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
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23
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Abstract
INTRODUCTION Endoscopic papillectomy (EP) has been established as a useful endoscopic therapy by the efforts of many pancreatobiliary endoscopists and is presently accepted as a reliable alternative therapy to surgery in patients with ampullary adenoma. Moreover, there have been numerous advancements in EP techniques in recent years. Various approaches and attempts toward expanding the indications of endoscopic resection have been reported. Furthermore, the management and prevention of adverse events (AEs) and endoscopic treatment for remnant or recurrent lesions have also been reported. In the present review, we focus on recent advancements in the EP technique, as well as speculate on the future issues of EP. AREA COVERED This review of EP encompasses the indications, preoperative assessments, endoscopic techniques, outcomes, and AEs of EP, post-EP surveillance techniques, and treatments for remnant or recurrence lesions. EXPERT OPINION The ultimate goal of EP is the complete resection of ampullary tumors, regardless of whether they are adenomatous or carcinomatous lesions, without causing any AEs. Therefore, the most important issue is preoperative evaluation, that is, the accurate diagnosis of lesions contraindicated for EP. In addition, further research on the prevention of AEs is also necessary towards establishing EP as a safe endoscopic procedure.
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Affiliation(s)
- Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University , Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine , Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University , Tokyo, Japan
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24
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Minami K, Iwasaki E, Kawasaki S, Fukuhara S, Seino T, Katayama T, Takimoto Y, Tamagawa H, Machida Y, Horibe M, Kitago M, Ogata H, Kanai T. A long (7 cm) prophylactic pancreatic stent decreases incidence of post-endoscopic papillectomy pancreatitis: a retrospective study. Endosc Int Open 2019; 7:E1663-E1670. [PMID: 31788550 PMCID: PMC6877413 DOI: 10.1055/a-1010-5581] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/06/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Endoscopic papillectomy (EP) is a minimally invasive treatment for ampullary neoplasms and is recognized as an alternative treatment to surgical resection; however, there are few reports on a suitable pancreatic stent (PS) after EP for preventing pancreatitis. The aim of this study was to evaluate the efficacy of a long PS after EP. Patients and methods In this retrospective single-center study, 39 patients with pathologically proven ampullary neoplasms who underwent EP between March 2012 and August 2018 were enrolled. The study participants were divided into two subgroups according to the PS length: those with a PS shorter than 5 cm (short PS group, n = 17) and those with a PS of 7 cm (long PS group, n = 22). The incidence of adverse events and risk factors for pancreatitis were evaluated. Results The diameter of all PSs was 5 Fr. Post-EP pancreatitis occurred in nine patients (23.1 %), with two cases of severe pancreatitis (5.1 %). Pancreatitis occurred more frequently in the short PS group (7/17, 41.2 %) than in the long PS group (2/22, 9.1 %) ( P = 0.026). There were no significant differences between the two groups in terms of other adverse events. Univariate and multivariate analyses showed that a long PS was the only factor associated with a decreased incidence of post-EP pancreatitis ( P = 0.042; odds ratio, 0.16; 95 % confidence interval, 0.027-0.94). Conclusion A long (7 cm) PS significantly decreased incidence of pancreatitis after EP. Prospective randomized studies with a larger number of patients and wider range of PS lengths are required.
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Affiliation(s)
- Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Seino
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Katayama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoichi Takimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Tamagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Kitago
- Division of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan,Corresponding author Takanori Kanai MD, PhD Chief Professor, Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of Medicine35 ShinanomachiShinjuku-ku, Tokyo 160-8582Japan+81-(0)3-3353-6247
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25
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Phillip V, Pukitis A, Epstein A, Hapfelmeier A, Haf D, Schwab M, Demir IE, Rosendahl J, Hoffmeister A, Schmid RM, Weber A, Algül H. Pancreatic stenting to prevent post-ERCP pancreatitis: a randomized multicenter trial. Endosc Int Open 2019; 7:E860-E868. [PMID: 31281872 PMCID: PMC6609234 DOI: 10.1055/a-0886-6384] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/29/2019] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Acute pancreatitis (AP) is one of the most common gastrointestinal disorders leading to hospitalization and the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Besides pharmaco-prophylaxis, pancreatic stenting has been demonstrated to protect from post-ERCP pancreatitis (PEP). However, it remains unclear which patients benefit from pancreatic stenting. We therefore hypothesized that in an unselected population, inadvertent cannulation of the pancreatic duct during first-time ERCP increases risk of PEP and that this risk can be significantly reduced by pancreatic stenting. Patients and methods This study was a multicenter, prospective, randomized controlled trial conducted at four European centers. A total of 167 patients undergoing first-time ERCP were enrolled in this trial. In the case of inadvertent cannulation of the pancreatic duct, patients were randomly assigned to receive either a 5 French plastic pancreatic stent of various length or no routine prophylactic intervention for PEP. Results A total of 167 patients were included in the final analysis. Prophylactic stent insertion significantly reduced the rate of PEP during first-time ERCP (odds ratio 0.43; 95% confidence interval 0.19 - 0.98; P = 0.04). The number needed to treat to prevent one case of PEP by prophylactic stent insertion after inadvertent cannulation of the pancreatic duct was 8.1 for the intention-to-treat population. Conclusion In an unselected patient population, inadvertent cannulation of the pancreatic duct during first-time ERCP is associated with a high risk for PEP. This risk can be significantly reduced by prophylactic pancreatic stenting, which is a safe and feasible procedure.
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Affiliation(s)
- Veit Phillip
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Aldis Pukitis
- Pauls Stradins Clinical University Hospital, Center of Gastroenterology, Hepatology and Nutrition, Riga, Latvia
| | - Alexey Epstein
- First Clinical Hospital named after E.E. Volosevich, Arkhangelsk, Russia
| | - Alexander Hapfelmeier
- Institut für Medizinische Informatik, Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - David Haf
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Miriam Schwab
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Ihsan Ekin Demir
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Jonas Rosendahl
- Klinik für Gastroenterologie und Rheumatologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik für Gastroenterologie und Rheumatologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Roland M. Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Andreas Weber
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Hana Algül
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany,Corresponding author Prof. Dr. Hana Algül, MPH Klinikum rechts der Isar, Technische Universität MünchenKlinik und Poliklinik für Innere Medizin IIIsmaningerstr. 22, 81675 MünchenGermany+49089-4140-4115
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26
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Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Watanabe K, Nakamura J, Kikuchi H, Takasumi M, Hashimoto M, Hikichi T, Ohira H. Pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis. World J Meta-Anal 2019; 7:249-258. [DOI: 10.13105/wjma.v7.i5.249] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/07/2019] [Accepted: 05/11/2019] [Indexed: 02/06/2023] Open
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27
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Sahar N, Ross A, Lakhtakia S, Coté GA, Neuhaus H, Bruno MJ, Haluszka O, Kozarek R, Ramchandani M, Beyna T, Poley JW, Maranki J, Freeman M, Kedia P, Tarnasky P. Reducing the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis using 4-Fr pancreatic plastic stents placed with common-type guidewires: Results from a prospective multinational registry. Dig Endosc 2019; 31:299-306. [PMID: 30506606 DOI: 10.1111/den.13311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/26/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Pancreatic plastic stents (PPS) can reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Prospective multicenter documentation of PEP rate after PPS placement is scarce. A new 4-Fr stent designed to be deployed over a 0.035-inch guidewire was used to assess the effectiveness of PEP prophylaxis. METHODS High-PEP-risk patients received a 4-Fr PPS for primary or secondary prophylaxis at seven centers in four countries. Patients were followed until spontaneous PPS migration, endoscopic stent removal, or for 4 months, whichever came first. Main outcome was PEP rate. RESULTS One hundred six (106) patients received PPS for PEP prophylaxis [61 (58%) primary, 45 (42%) secondary prophylaxis]. Median age was 54 years. Eighty-one (76%) PPS were placed using a 0.035-inch guidewire. By investigator choice 99 (93%) stents were single pigtail. Median stent length was 8 cm (range 3-12 cm). Technical success achieved in 100% of cases. Two patients in the primary prophylaxis group (3%, 95% CI 0.4-11%) experienced mild/moderate PEP. Seventy-eight PPS available for analysis underwent spontaneous migration after a median of 29 days. There were no reports of stent-induced ductal trauma. Post-hoc analysis of migration rate by PPS length showed no statistically significant trend. CONCLUSIONS Among high-risk patients in the primary prophylaxis group, observed rates of PEP are low (3%, 95% CI 0.4-11%) with the use of prophylactic 4-Fr pancreatic duct stents compatible with a 0.035-inch guidewire. This low rate is not unequivocally due to the prophylactic stent.
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Affiliation(s)
| | | | | | | | - Horst Neuhaus
- Evangelical Hospital Dusseldorf, Dusseldorf, Germany
| | - Marco J Bruno
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Oleh Haluszka
- Temple University Health System, Philadelphia
- Southern Arizona VA Health Care System, Tucson
| | | | | | - Torsten Beyna
- Evangelical Hospital Dusseldorf, Dusseldorf, Germany
| | - Jan W Poley
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jennifer Maranki
- Temple University Health System, Philadelphia
- Penn State Milton S. Hershey Medical Center, Hershey
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28
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Shih HY, Hsu WH, Kuo CH. Postendoscopic retrograde cholangiopancreatography pancreatitis. Kaohsiung J Med Sci 2019; 35:195-201. [PMID: 30887733 DOI: 10.1002/kjm2.12040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 01/09/2019] [Indexed: 12/11/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has been a mainstay examination to clarify the biliary and pancreatic system. Not just diagnostic purpose, it could achieve therapeutic goal. Under the trend of more and more procedures about ERCP being interventional, the rate of adverse events after the procedure is increasing. Among them, post-ERCP pancreatitis (PEP) is the most common and sometimes tremendous complication. This mini-review will overview the PEP from definition, pathogenesis, and risk factors to prevention.
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Affiliation(s)
- Hsiang-Yao Shih
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chao-Hung Kuo
- Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
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29
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Dultz G, Gerber L, Zeuzem S, Bojunga J, Friedrich-Rust M. Prolonged retention of prophylactic pancreatic stents is not associated with increased complications. Pancreatology 2019; 19:39-43. [PMID: 30502123 DOI: 10.1016/j.pan.2018.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 11/20/2018] [Accepted: 11/22/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The risk of post-ERCP pancreatitis (PEP) can be reduced effectively by the placement of a self dislodging pancreatic stent. The present study analyzed whether a prolonged interval until stent passage evaluation and removal of retained stents is associated with an increased risk for clinically relevant complications. METHODS In the retrospective study 182 patients receiving a pancreatic stent for PEP prophylaxis were included and clinical data and complications until documented spontaneous stent dislodgement or removal were analyzed. RESULTS The main indication for ERCP was choledocholithiasis (40.1%) followed by malignant stenosis (30.8%). Stent passage evaluation was performed in 34.1% at day 1-4, 23.6% at day 5-10, 17.6% at day 11-28 and 24.7% at day >28. PEP occurred in 13.1% of patients with no case of severe PEP. No association between PEP and day of stent passage evaluation (p = 0.719), retention of the pancreatic stent at time of evaluation (0.867) or prolonged stent retention >10 days (0.234) was observed. Only the duration of the procedure was associated with risk for PEP (p = 0.037). Besides PEP only one clinically relevant complication was observed in the cohort (0.5%) which was a late possibly stent related pancreatitis at day 9 after the procedure that resolved completely. CONCLUSIONS A prolonged interval for stent passage evaluation and stent retention is not associated with an increase of clinically relevant complications. A later evaluation and extraction of retained stents might be acceptable in selected cases where an additional endoscopic procedure can be saved due to a planned follow-up endoscopy.
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Affiliation(s)
- Georg Dultz
- Medizinische Klinik 1, Schwerpunkt Gastroenterologie und Hepatologie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt/Main, Germany.
| | - Ludmila Gerber
- Medizinische Klinik 1, Schwerpunkt Gastroenterologie und Hepatologie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt/Main, Germany
| | - Stefan Zeuzem
- Medizinische Klinik 1, Schwerpunkt Gastroenterologie und Hepatologie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt/Main, Germany
| | - Jörg Bojunga
- Medizinische Klinik 1, Schwerpunkt Gastroenterologie und Hepatologie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt/Main, Germany
| | - Mireen Friedrich-Rust
- Medizinische Klinik 1, Schwerpunkt Gastroenterologie und Hepatologie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt/Main, Germany
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30
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Leerhøy B, Elmunzer BJ. How to Avoid Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastrointest Endosc Clin N Am 2018; 28:439-454. [PMID: 30241637 DOI: 10.1016/j.giec.2018.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatitis remains the most common and potentially devastating complication of endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Recent advances in prophylaxis have improved but not eliminated this problem, underscoring the importance of ongoing research toward this goal. This review aims to provide an evidence-based approach to post-ERCP pancreatitis prevention through patient selection, risk stratification, procedural technique, and multimodality prophylaxis, and discusses ongoing and future research initiatives in this important area.
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Affiliation(s)
- Bonna Leerhøy
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen Nielsine Nielsens Vej 11, entrance 8, Copenhagen DK-2400, Denmark
| | - 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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31
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García-Cano J, Viñuelas Chicano M, del Moral Martínez M, Muñiz Muñoz M, Murillo Matamoros C, Suárez Matías M, Valiente González L, Martínez Pérez T, Martínez Fernández R, Gómez Ruiz CJ, Pérez García JI, Morillas Ariño J. Pancreatic stent insertion after an unintentional guidewire cannulation of the pancreatic duct during ERCP. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:416-420. [DOI: 10.17235/reed.2018.5230/2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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32
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Jamry A. Risk factors of pancreatitis after endoscopic sphincterotomy. Review of literature and practical remarks based on approximately 10,000 ERCPs. POLISH JOURNAL OF SURGERY 2017; 89:29-33. [PMID: 29154236 DOI: 10.5604/01.3001.0010.5409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Post-endoscopic pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Depending on the presence of risk factors, PEP can occur in 4,1% to about 43% of patients. According to the European Society of Gastrointestinal Endoscopy (ESGE) guidelines, only three to patient-associated risk factors have been identified: suspected sphincter of Oddi dysfunction (SOD) (OR 4.09), female gender (OR 2.23), and previous pancreatitis (OR 2.46). Another three procedure-associated factors include cannulation attempt duration > 10 minutes (OR 1.76), more than one pancreatic guidewire passage (OR 2.77, CI: 1.79 - 4.30), and pancreatic injection (OR 2.2, CI: 1.60 - 3.01). Importantly, analyses of cumulative risk due to coexistence of several factors emphasize the importance of female sex, difficult cannulation, CBD diameter <5 mm, young age, and many other factors. Unfortunately, studies performed to date have included only small numbers of patients with several co-existing risk factors. Therefore, further analysis of other risk factors and the cumulative risk related to their co-occurrence is necessary. Based on current evidence, special care must be given to patients with several risk factors. Also, care should be given to proper qualification of patients, use of guidewires, early pre-cut incision, protective Wirsung's duct stenting, and rectal NSAID administration.
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Affiliation(s)
- Andrzej Jamry
- II Surgical Department, Hospital of Starachowice, Starachowice, Poland
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Abstract
Pancreatitis is the most common and potentially devastating complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in significant morbidity, occasional mortality, and increased health-care expenditure. Accordingly, the prevention of post-ERCP pancreatitis (PEP) remains a major clinical and research priority. Strategies to reduce the incidence of PEP include thoughtful patient selection, appropriate risk-stratification, sound procedural technique, prophylactic pancreatic stent placement, and pharmacoprevention. Despite advances in all these areas, however, the incidence of PEP remains as high as 15% in high-risk cases. Thus, additional research towards the goal of eliminating PEP is necessary. Herein is an evidence-based review of strategies to prevent pancreatitis after ERCP, focusing on recent important developments in the field.
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Affiliation(s)
- B Joseph Elmunzer
- The Peter B. Cotton Endowed Chair in Endoscopic Innovation, Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, USA
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Ma MX, Bourke MJ. Management of duodenal polyps. Best Pract Res Clin Gastroenterol 2017; 31:389-399. [PMID: 28842048 DOI: 10.1016/j.bpg.2017.04.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 04/28/2017] [Indexed: 01/31/2023]
Abstract
Duodenal adenomas are the most common type of polyp arising from the duodenum. These adenomas can occur within and outside of genetic syndromes, and are broadly classified as non-ampullary or ampullary depending on their location. All adenomas have malignant potential and are therefore appropriately treated by endoscopic resection. However, the unique anatomical properties of the duodenum, namely its relatively thin and vascular walls, narrow luminal diameter and relationship to the ampulla and its associated pancreatic and biliary drainage, pose an increased degree of complexity for any endoscopic interventions in this area. This review will discuss the epidemiology of duodenal adenomas, their endoscopic detection and diagnosis, and techniques for safe and effective endoscopic resection of ampullary and non-ampullary lesions.
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Affiliation(s)
- Michael X Ma
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia.
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Williams E, Beckingham I, El Sayed G, Gurusamy K, Sturgess R, Webster G, Young T. Updated guideline on the management of common bile duct stones (CBDS). Gut 2017; 66:765-782. [PMID: 28122906 DOI: 10.1136/gutjnl-2016-312317] [Citation(s) in RCA: 246] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 12/08/2016] [Accepted: 12/15/2016] [Indexed: 02/06/2023]
Abstract
Common bile duct stones (CBDS) are estimated to be present in 10-20% of individuals with symptomatic gallstones. They can result in a number of health problems, including pain, jaundice, infection and acute pancreatitis. A variety of imaging modalities can be employed to identify the condition, while management of confirmed cases of CBDS may involve endoscopic retrograde cholangiopancreatography, surgery and radiological methods of stone extraction. Clinicians are therefore confronted with a number of potentially valid options to diagnose and treat individuals with suspected CBDS. The British Society of Gastroenterology first published a guideline on the management of CBDS in 2008. Since then a number of developments in management have occurred along with further systematic reviews of the available evidence. The following recommendations reflect these changes and provide updated guidance to healthcare professionals who are involved in the care of adult patients with suspected or proven CBDS. It is not a protocol and the recommendations contained within should not replace individual clinical judgement.
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Affiliation(s)
- Earl Williams
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Ian Beckingham
- HPB Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ghassan El Sayed
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Kurinchi Gurusamy
- Department of Surgery, University College London Medical School, London, UK
| | - Richard Sturgess
- Aintree Digestive Diseases Unit, Aintree University Hospital Liverpool, Liverpool, UK
| | - George Webster
- Department of Hepatopancreatobiliary Medicine, University College Hospital, London, UK
| | - Tudor Young
- Department of Radiology, The Princess of Wales Hospital, Bridgend, UK
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36
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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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Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, Bruining DH, Eloubeidi MA, Fanelli RD, Faulx AL, Gurudu SR, Kothari S, Lightdale JR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85:32-47. [PMID: 27546389 DOI: 10.1016/j.gie.2016.06.051] [Citation(s) in RCA: 517] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 02/07/2023]
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Wang AY, Strand DS, Shami VM. Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Medications and Techniques. Clin Gastroenterol Hepatol 2016; 14:1521-1532.e3. [PMID: 27237430 DOI: 10.1016/j.cgh.2016.05.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia.
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Vanessa M Shami
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
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Talukdar R. Complications of ERCP. Best Pract Res Clin Gastroenterol 2016; 30:793-805. [PMID: 27931637 DOI: 10.1016/j.bpg.2016.10.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 10/11/2016] [Accepted: 10/21/2016] [Indexed: 01/31/2023]
Abstract
Even though considered safe, endoscopic retrograde cholangiopancreatography (ERCP) is among the endoscopic procedures associated with the highest rate of complications. Post ERCP pancreatitis (PEP) is the most common complication of ERCP. Several independent risk factors have been associated with PEP. Prophylactic PD stenting has been shown to be highly effective in preventing PEP. More recent studies have suggested that NSAIDs, especially rectal indomethacin, could by itself be effective in preventing PEP. However, head to head RCTs comparing PD stents with NSAIDs would be required to confirm this. Other complications include ERCP induced bleeding, perforation, and cholangitis. Bleeding is related to morphological, procedural, and patient related factors. Early identification and correction of the risk factors are of paramount importance in preventing bleeding. Risk of infection is particularly high during ERCP. It is important to ensure complete drainage of obstructed biliary system in order to reduce the risk of post-ERCP cholangitis.
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Affiliation(s)
- Rupjyoti Talukdar
- Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad, 500082, Telangana, India; Asian Healthcare Foundation, 6-3-661 Somajiguda, Hyderabad, 500082, Telangana, India.
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40
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Olsson G, Lübbe J, Arnelo U, Jonas E, Törnqvist B, Lundell L, Enochsson L. The impact of prophylactic pancreatic stenting on post-ERCP pancreatitis: A nationwide, register-based study. United European Gastroenterol J 2016; 5:111-118. [PMID: 28405329 DOI: 10.1177/2050640616645434] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/23/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The role of prophylactic pancreatic stenting (PS) in preventing post-endoscopic retrograde cholangio-pancreatography (ERCP) pancreatitis (PEP) has yet to be determined. Most previous studies show beneficial effects in reducing PEP when prophylactic pancreatic stents are used, especially in high-risk ERCP procedures. The present study aimed to address the use of PS in a nationwide register-based study in which the primary outcome was the prophylactic effect of PS in reducing PEP. METHODS All ERCP-procedures registered in the nationwide Swedish Registry for Gallstone Surgery and ERCP (GallRiks) between 2006 and 2014 were studied. The primary outcome was PEP but we also studied other peri- and postoperative complication rates. RESULTS Data from 43,595 ERCP procedures were analyzed. In the subgroup of patients who received PS with a total diameter ≤ 5 Fr, the risk of PEP increased nearly four times compared to those who received PS with a total diameter of >5 Fr (OR 3.58; 95% CI 1.40-11.07). Furthermore, patients who received PS of >5 Fr and >5 cm had a significantly lower pancreatitis frequency compared to those with shorter stents of the same diameter (1.39% vs 15.79%; p = 0.0033). CONCLUSIONS PS with a diameter of >5 Fr and a length of >5 cm seems to have a better protective effect against PEP, compared to shorter and thinner stents. However, in the present version of GallRiks it is not possible to differentiate the exact type of pancreatic stent (apart from material, length and diameter) that has been introduced, so our conclusion must be interpreted with caution.
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Affiliation(s)
- Greger Olsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Highland Hospital, Eksjö, Sweden
| | - Jeanne Lübbe
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Division of Surgery, Tygerberg Hospital and Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Eduard Jonas
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Björn Törnqvist
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Lars Lundell
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Enochsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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41
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Klein A, Tutticci N, Bourke MJ. Endoscopic resection of advanced and laterally spreading duodenal papillary tumors. Dig Endosc 2016; 28:121-30. [PMID: 26573214 DOI: 10.1111/den.12574] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 11/08/2015] [Accepted: 11/11/2015] [Indexed: 12/17/2022]
Abstract
Historically, neoplasia of the duodenal papilla has been managed surgically, which may be associated with substantial morbidity and mortality. In the absence of invasive cancer, even lesions with extensive lateral duodenal wall involvement, or limited intraductal extension may be cured endoscopically with a superior safety profile. Endoscopic papillectomy is associated with greater risks of adverse events such as bleeding than resection elsewhere in the gastrointestinal tract. Additionally site-specific complications such as pancreatitis exist. A structured approach to lesion assessment, adherence to technical aspects of resection, endoscopic management of complications and post-resection surveillance is required. Advances have been made in all facets of endoscopic papillary resection since its introduction in the 1980s; extending the boundaries of endoscopic cure, optimizing outcomes and enhancing patient safety. These will be the focus of the present review.
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Affiliation(s)
- Amir Klein
- Department of Gastroenterology and Hepatology, Westmead Hospital
| | | | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital.,University of Sydney, Sydney, Australia
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Prophylactic Efficacy of 3- or 5-cm Pancreatic Stents for Preventing Post-ERCP Pancreatitis: A Prospective, Randomized Trial. J Clin Gastroenterol 2016; 50:e30-4. [PMID: 26280707 DOI: 10.1097/mcg.0000000000000397] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND STUDY AIMS Prophylactic pancreatic stent placement is effective for preventing postendoscopic retrograde cholangiopancreatography pancreatitis (PEP). The most effective type of stent, however, remains unclear. Therefore, we prospectively compared the prophylactic efficacy for PEP prevention between short (3 cm) and long (5 cm) pancreatic stent. PATIENTS AND METHODS Between July 2012 and June 2014, 240 consecutive patients requiring therapeutic endoscopic retrograde cholangiopancreatography to remove a choledocholith or for bile drainage for obstructive jaundice were prospectively enrolled and randomized to undergo prophylactic insertion with unflanged, 5 Fr, 3 or 5-cm pancreatic stent. An efficacy of each stent for preventing PEP was evaluated as a primary endpoint. The period until stent dislodgement and the total adverse event rate were also evaluated as a secondary endpoint. RESULTS Per-protocol analysis revealed that the PEP rate was significantly lower with the short stent than with the long stent (2.0% vs. 8.8%, P=0.035), although they were not significantly different in intention-to-treat analysis. The adverse event rate excluding PEP did not differ significantly between groups (3.0% vs. 0.9%, P=0.293). The median period until dislodgement of the short stent was significantly shorter than that of the long stent (2 vs. 4 d, P<0.001). CONCLUSIONS The present study revealed a superiority of 3-cm stents compared with 5-cm stents for prophylactic pancreatic stent. On the basis of the past reports and the result of the present study, we recommend using a 5 Fr, 3-cm unflanged stent.This study was registered on the UMIN Clinical Trial Registry (UMIN000008290).
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43
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Mangiavillano B, Pagano N, Baron TH, Luigiano C. Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review. World J Gastroenterol 2015; 21:9038-9054. [PMID: 26290631 PMCID: PMC4533036 DOI: 10.3748/wjg.v21.i30.9038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/04/2015] [Accepted: 07/08/2015] [Indexed: 02/07/2023] Open
Abstract
Endoscopic stenting has become a widely method for the management of various malignant and benign pancreatico-biliary disorders. Biliary and pancreatic stents are devices made of plastic or metal used primarily to establish patency of an obstructed bile or pancreatic duct and may also be used to treat biliary or pancreatic leaks, pancreatic fluid collections and to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. In this review, relevant literature search and expert opinions have been used to evaluate the outcome of stenting in biliary and pancreatic benign and malignant diseases.
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44
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Hauser G, Milosevic M, Stimac D, Zerem E, Jovanović P, Blazevic I. Preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: what can be done? World J Gastroenterol 2015; 21:1069-1080. [PMID: 25632179 PMCID: PMC4306150 DOI: 10.3748/wjg.v21.i4.1069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 09/02/2014] [Accepted: 09/29/2014] [Indexed: 02/06/2023] Open
Abstract
Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography. The incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis varies substantially and is reported around 1%-10%, although there are some reports with an incidence of around 30%. Usually, PEP is a mild or moderate pancreatitis, but in some instances it can be severe and fatal. Generally, it is defined as the onset of new pancreatic-type abdominal pain severe enough to require hospital admission or prolonged hospital stay with levels of serum amylase two to three times greater than normal, occurring 24 h after ERCP. Several methods have been adopted for preventing pancreatitis, such as pharmacological or endoscopic approaches. Regarding medical prevention, only non-steroidal anti-inflammatory drugs, namely diclofenac sodium and indomethacin, are recommended, but there are some other drugs which have some potential benefits in reducing the incidence of post-ERCP pancreatitis. Endoscopic preventive measures include cannulation (wire guided) and pancreatic stenting, while the adoption of the early pre-cut technique is still arguable. This review will attempt to present and discuss different ways of preventing post-ERCP pancreatitis.
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Rustagi T, Jamidar PA. Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events: post-ERCP pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:107-21. [PMID: 25442962 DOI: 10.1016/j.giec.2014.09.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), and not uncommonly is the reason behind ERCP-related lawsuits. Patients at high risk for PEP include young women with abdominal pain, normal liver tests, and unremarkable imaging. Procedure-related factors include traumatic and persistent cannulation attempts, multiple injections of the pancreatic duct, pancreatic sphincterotomy, and, possibly, use of precut sphincterotomy. Aggressive hydration, use of rectal indomethacin, and prophylactic pancreatic stenting can diminish the risk (and likely severity) of PEP. Though hugely beneficial, these measures do not supersede careful patient selection and technique.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA.
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