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Kato H, Tomoda T, Matsumi A, Matsumoto K. Current status and issues for prediction and prevention of postendoscopic retrograde cholangiopancreatography pancreatitis. Dig Endosc 2025; 37:362-372. [PMID: 39633248 DOI: 10.1111/den.14966] [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: 07/14/2024] [Accepted: 11/10/2024] [Indexed: 12/07/2024]
Abstract
Acute pancreatitis, which sometimes results in mortality, is a significant complication of endoscopic retrograde cholangiopancreatography (ERCP). Many studies have been conducted to predict and prevent post-ERCP pancreatitis (PEP), and meta-analyses have been reported that summarized these studies. However, many issues remain unresolved. Many risk factors for PEP have been reported, and it is rare for patients undergoing ERCP to have only one risk factor. The use of artificial intelligence may be important for analyzing complex and diverse risk factors. It is desirable to develop an alternative test for pancreatic enzymes that can predict the onset of PEP within 1 h after ERCP. The effectiveness of low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) are controversial. Nitrate and tacrolimus are considered medications that have additional effects on NSAIDs and may be used for the prevention of PEP. Pancreatic stent placement with deliberate placement of the guidewire into the pancreatic duct may be more effective in preventing PEP. A comparison between transpancreatic sphincterotomy with deliberate guidewire placement into the pancreatic duct and needle-knife precut sphincterotomy is necessary. Early precutting is thought to be effective for the prevention of PEP, and the effectiveness of primary precut has been reported. However, the optimal timing of precut for the prevention of PEP has not been sufficiently discussed. Further research on prediction and prevention must be conducted to eliminate the mortality caused by PEP.
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Affiliation(s)
- Hironari Kato
- Department of Gastroenterology, Okayama City Hospital, Okayama, Japan
| | - Takeshi Tomoda
- Department of Gastroenterology, Okayama City Hospital, Okayama, Japan
| | - Akihiro Matsumi
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
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Yamada R, Tanaka T, Shimada Y, Owa H, Nose K, Nakamura Y, Miwata T, Tsuboi J, Hara K, Hashigo S, Hashimoto A, Hijioka S, Okamoto K, Hirooka Y, Imai H, Inoue T, Iwata K, Kamada H, Kawaguchi S, Kawashima H, Kobayashi Y, Maruta A, Mukai T, Murabayashi T, Nakashima S, Naota H, Okumura F, Oya Y, Sato J, Sugimoto K, Hamaya Y, Tano S, Yoshinari M, Imai Y, Ogura T, Tamaru S, Nakagawa H. 6-mm vs 10-mm diameter fully covered self-expandable metal stents in patients with unresectable malignant distal bile duct stricture (COSMIC UNISON): study protocol for a multicenter, randomized controlled trial. Trials 2025; 26:56. [PMID: 39966935 PMCID: PMC11834171 DOI: 10.1186/s13063-025-08771-4] [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: 08/27/2024] [Accepted: 02/11/2025] [Indexed: 02/20/2025] Open
Abstract
BACKGROUND Unresectable malignant bile duct stricture (often caused by unresectable pancreatic cancer and cholangiocarcinoma) can be drained via insertion of self-expandable metal stents (SEMS) during endoscopic retrograde cholangiopancreatography (ERCP). Because recurrent biliary obstruction (RBO) and complications following stent insertion can delay chemotherapy and other treatments, a longer time to RBO (TRBO) is desirable. Although a longer TRBO has been reported among patients who undergo insertion with larger diameter SEMS, patients who undergo insertion with smaller diameter fully covered SEMS (FCSEMS) may have a lower incidence of complications than those with larger diameter FCSEMS. The aim of this study is to determine the TRBO and incidence of complications with 6-mm FCSEMS vs 10-mm FCSEMS in patients with unresectable malignant distal bile duct stricture. METHODS In this multicenter, open-label, randomized controlled, non-inferiority trial (COSMIC UNISON), a target of 250 patients over 23 locations in Japan will receive either the 6-mm FCSEM or the standard 10-mm FCSEM during ERCP, with 125 patients in each group. The observation period will be 24 months, and patients will be enrolled from 15 March 2024 and assessed until the date of RBO or the study end (31 March 2029). The primary endpoint is TRBO, with RBO defined as the coexistence of abnormal liver enzyme values and dilation of the common bile duct and intrahepatic bile duct upstream of the stent. The secondary endpoints are the incidence and rates (at 3, 6, and 12 months) of non-RBO events, overall survival, cause of RBO, and symptomatic stent deviation. Adverse events from endoscopic procedures will be classified by the Lexicon Classification from the American Society of Endoscopy, and all other adverse events will be classified per the Japanese translation of the Common Terminology Criteria for Adverse Events version 5.0. DISCUSSION The COSMIC UNISON study is anticipated to provide evidence regarding the efficacy and safety of 6-mm vs 10-mm FCSEMS to inform the use of 6-mm FCSEMS for the treatment of unresectable malignant distal bile duct stricture. TRIAL REGISTRATION Japan Registry of Clinical Trials identifier: jRCT1042230170. Prospectively registered on 15 March 2024.
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Affiliation(s)
- Reiko Yamada
- Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Takamitsu Tanaka
- Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuaki Shimada
- Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hirono Owa
- Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Kenji Nose
- Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yoshifumi Nakamura
- Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Tetsuro Miwata
- Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Junya Tsuboi
- Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shunpei Hashigo
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto, Japan
| | - Akira Hashimoto
- Department of Internal Medicine, Saiseikai Matsusaka General Hospital, Matsusaka, Mie, Japan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kohei Okamoto
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Gastroenterological Oncology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hajime Imai
- Department of Gastroenterology, Okanami General Hospital, Iga, Japan
| | - Tadahisa Inoue
- Department of Gastroenterology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Hideki Kamada
- Department of Gastroenterology and Neurology, Kagawa University, Takamatsu, Kagawa, Japan
| | - Shinya Kawaguchi
- Department of Gastroenterology, Shizuoka General Hospital, Shizuoka, Japan
| | - Hiroki Kawashima
- Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yosuke Kobayashi
- Department of Gastroenterology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Akinori Maruta
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterological Endoscopy, Kanazawa Medical University, Uchinada, Ishikawa, Japan
| | - Toji Murabayashi
- Department of Gastroenterology, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Shigehito Nakashima
- Department of Gastroenterology, Yokkaichi Hazu Medical Center, Yokkaichi, Mie, Japan
| | - Hiroaki Naota
- Department of Gastroenterology, Matsusaka Chuo General Hospital, Matsusaka, Mie, Japan
| | - Fumihiro Okumura
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Gifu, Japan
| | - Yumi Oya
- Department of Gastroenterology, Kuwana City Medical Center, Kuwana, Mie, Japan
| | - Junya Sato
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ken Sugimoto
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yasushi Hamaya
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shunsuke Tano
- Department of Gastroenterology, Suzuka Kaisei Hospital, Suzuka, Mie, Japan
| | - Motohiro Yoshinari
- Department of Gastroenterology and Hepatology, Kumamoto University, Kumamoto, Japan
| | - Yasuhito Imai
- Clinical Research Support Center, Mie University Hospital, Tsu, Mie, Japan
| | - Toru Ogura
- Clinical Research Support Center, Mie University Hospital, Tsu, Mie, Japan
| | - Satoshi Tamaru
- Clinical Research Support Center, Mie University Hospital, Tsu, Mie, Japan
| | - Hayato Nakagawa
- Department of Gastroenterology and Hepatology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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Park CH, Park SW, Lee KJ, Park DH, Cha H, Choi A, Koh DH, Lee J, Cho E. Prospective validation and revision of predictive models for post-ERCP pancreatitis: focus on procedure-related factors and a novel risk stratification approach. Surg Endosc 2025; 39:1207-1216. [PMID: 39738907 DOI: 10.1007/s00464-024-11464-9] [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: 06/10/2024] [Accepted: 12/01/2024] [Indexed: 01/02/2025]
Abstract
INTRODUCTION Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common serious adverse event after endoscopic retrograde cholangiopancreatography (ERCP). Although retrospective models to predict PEP have shown promise, their real-world applicability remains uncertain. Thus, we used prospectively derived cohort data to validate current prediction models. METHODS We conducted a prospective cohort study involving patients who underwent ERCP between August 2020 and December 2023. We validated the original PEP-risk prediction models using prospective cohort data and, if necessary, refined them using logistic regression analysis. RESULTS Among the 1112 study participants, the original PEP-risk prediction models had limited performance. Although PEP incidence tended to increase across risk groups, the differences were mostly insignificant. Logistic regression highlighted procedural factors-total procedure time [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.01-1.26 per 5 min], unintended pancreatic duct cannulation (OR 2.56, 95% CI 1.11-5.93), and pancreatic opacification (OR 2.57, 95% CI 1.19-5.58)-as independent PEP risk factors. This led to a revised model that assigned 1, 8, and 8 points to these factors. Patients stratified into low- (0-2 points), intermediate- (3-10 points), and high-risk groups (≥ 11 points) exhibited PEP incidences of 2.6% (95% CI 1.5-4.1%), 7.1% (95% CI 4.8-10.3%), and 12.6% (95% CI 8.6-17.8%), respectively. CONCLUSIONS We highlighted limitations of existing PEP-prediction models that necessitate refinement based on procedural variables. Our revised model accounted for the prolonged total procedure time, unintended pancreatic duct cannulation, and pancreatic opacification, offering enhanced accuracy in predicting PEP risk.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Chung-Ang University H.C.S. Hyundae Hospital, Namyangju, Republic of Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong, Gyeonggi-do, 18450, Republic of Korea.
| | - Kyong Joo Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong, Gyeonggi-do, 18450, Republic of Korea
| | - Da Hae Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong, Gyeonggi-do, 18450, Republic of Korea
| | - Hyewon Cha
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong, Gyeonggi-do, 18450, Republic of Korea
| | - Anna Choi
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong, Gyeonggi-do, 18450, Republic of Korea
| | - Dong Hee Koh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong, Gyeonggi-do, 18450, Republic of Korea
| | - Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong, Gyeonggi-do, 18450, Republic of Korea
| | - Eunae Cho
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
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Forslund A, Haraldsson E, Holmberg E, Naredi P, Rizell M. Risks and use of ERCP during the diagnostic workup in a national cohort of biliary cancer. Surg Endosc 2025; 39:991-1001. [PMID: 39672987 PMCID: PMC11794412 DOI: 10.1007/s00464-024-11449-8] [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: 09/06/2024] [Accepted: 11/23/2024] [Indexed: 12/15/2024]
Abstract
BACKGROUND In biliary cancer, the indication of endoscopic intervention might be diagnostic as well as therapeutic, in the latter situation with the aim to relieve biliary obstruction e.g. by stenting. Our aim was to investigate the use of endoscopic biliary interventions during the diagnostic workup of biliary cancers in a national cohort, and to evaluate their complications, especially cholangitis and pancreatitis. METHODS This is a registry-based study of national cohort of patients with biliary cancers in Sweden 2010-2020. The use of endoscopic retrograde cholangiopancreatography (ERCP) during the diagnostic work up period before treatment onset, and risk of complications were evaluated in patients with gallbladder cancer, intrahepatic-, perihilar- and distal cholangiocarcinoma. The risk of complications was compared depending on age, sex, comorbidity, in relation to stage and curative intent, endoscopy unit size, and with relation to survival. RESULTS Forty percent of the patients with biliary cancer underwent ERCP during the diagnostic workup, with variations depending on diagnosis. There was a 20% overall risk of periprocedural complications, a 9% risk of post-ERCP-pancreatitis (PEP), and a 6% risk of cholangitis. Increasing tumor stage did not increase risk, nor did comorbidity. The complication rates were slightly higher for younger patients and those undergoing curative treatment. For perihilar cholangiocarcinoma (pCCA) treated with curative intention, the risk of periprocedural complications was as high as 30.7%. No association between post-ERCP complications and survival was found. CONCLUSION Irrespective of type of biliary cancer, ERCP is frequently used during diagnostic workup. The complication risk indicates that primary biliary cancers are complication prone, regardless of stage. Notably the risk of complications was the highest for younger patients with low comorbidity scores, as well as for patients undergoing curatively aiming treatment.
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Affiliation(s)
- Anna Forslund
- Transplant Institute, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden.
| | - Erik Haraldsson
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Peter Naredi
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Rizell
- Transplant Institute, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
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Sugimoto M, Takagi T, Suzuki T, Shimizu H, Shibukawa G, Nakajima Y, Takeda Y, Noguchi Y, Kobayashi R, Imamura H, Asama H, Konno N, Waragai Y, Akatsuka H, Suzuki R, Hikichi T, Ohira H. A new preprocedural predictive risk model for post-endoscopic retrograde cholangiopancreatography pancreatitis: The SuPER model. eLife 2025; 13:RP101604. [PMID: 39819489 PMCID: PMC11741517 DOI: 10.7554/elife.101604] [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: 01/19/2025] Open
Abstract
Background Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a severe and deadly adverse event following ERCP. The ideal method for predicting PEP risk before ERCP has yet to be identified. We aimed to establish a simple PEP risk score model (SuPER model: Support for PEP Reduction) that can be applied before ERCP. Methods This multicenter study enrolled 2074 patients who underwent ERCP. Among them, 1037 patients each were randomly assigned to the development and validation cohorts. In the development cohort, the risk score model for predicting PEP was established via logistic regression analysis. In the validation cohort, the performance of the model was assessed. Results In the development cohort, five PEP risk factors that could be identified before ERCP were extracted and assigned weights according to their respective regression coefficients: -2 points for pancreatic calcification, 1 point for female sex, and 2 points for intraductal papillary mucinous neoplasm, a native papilla of Vater, or the pancreatic duct procedures (treated as 'planned pancreatic duct procedures' for calculating the score before ERCP). The PEP occurrence rate was 0% among low-risk patients (≤0 points), 5.5% among moderate-risk patients (1-3 points), and 20.2% among high-risk patients (4-7 points). In the validation cohort, the C statistic of the risk score model was 0.71 (95% CI 0.64-0.78), which was considered acceptable. The PEP risk classification (low, moderate, and high) was a significant predictive factor for PEP that was independent of intraprocedural PEP risk factors (precut sphincterotomy and inadvertent pancreatic duct cannulation) (OR 4.2, 95% CI 2.8-6.3; p<0.01). Conclusions The PEP risk score allows an estimation of the risk of PEP prior to ERCP, regardless of whether the patient has undergone pancreatic duct procedures. This simple risk model, consisting of only five items, may aid in predicting and explaining the risk of PEP before ERCP and in preventing PEP by allowing selection of the appropriate expert endoscopist and useful PEP prophylaxes. Funding No external funding was received for this work.
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Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University, School of MedicineFukushimaJapan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, School of MedicineFukushimaJapan
| | - Tomohiro Suzuki
- Department of Gastroenterology, Fukushima Rosai HospitalIwakiJapan
| | - Hiroshi Shimizu
- Department of Gastroenterology, Fukushima Rosai HospitalIwakiJapan
| | - Goro Shibukawa
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical UniversityAizuJapan
| | - Yuki Nakajima
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical UniversityAizuJapan
| | - Yutaro Takeda
- Department of Gastroenterology, Ohta Nishinouchi HospitalKoriyamaJapan
| | - Yuki Noguchi
- Department of Gastroenterology, Ohta Nishinouchi HospitalKoriyamaJapan
| | - Reiko Kobayashi
- Department of Gastroenterology, Ohta Nishinouchi HospitalKoriyamaJapan
| | - Hidemichi Imamura
- Department of Gastroenterology, Ohta Nishinouchi HospitalKoriyamaJapan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Redcross HospitalFukushimaJapan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Redcross HospitalFukushimaJapan
| | - Yuichi Waragai
- Department of Gastroenterology, Soma General HospitalSomaJapan
| | - Hidenobu Akatsuka
- Department of Gastroenterology, Saiseikai Fukushima General HospitalFukushimaJapan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University, School of MedicineFukushimaJapan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University HospitalFukushimaJapan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, School of MedicineFukushimaJapan
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Guler M, Akay O, Demir A, Rakici IT, Sevik H, Colak S, Cakir C, Sevinc MM, Idiz UO. Use of Pancreatic Density on Computed Tomography to Predict Postendoscopic Retrograde Cholangiopancreatography Pancreatitis. J Surg Res 2025; 305:100-106. [PMID: 39667248 DOI: 10.1016/j.jss.2024.11.010] [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] [Received: 09/10/2024] [Revised: 10/28/2024] [Accepted: 11/18/2024] [Indexed: 12/14/2024]
Abstract
INTRODUCTION Postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a frequent complication, and its pathogenesis remains unclear, with various patient and procedural factors proposed as potential contributors. This study aimed to assess the predictive value of pancreatic to splenic density ratio on computed tomography (CT) for PEP in patients with inadvertent pancreatic duct cannulation. METHODS This retrospective study involved 2556 patients undergoing ERCP from January 2014 to December 2020. Inclusion criteria comprised patients with choledocholithiasis, preprocedural CT imaging, and inadvertent pancreatic duct cannulation during ERCP. Demographics, preprocedural laboratory values, pancreatic to splenic density ratios from CT scans, and pancreatic stent usage were analyzed in relation to the development of PEP. RESULTS A total of 90 patients were included in the study. Of all patients, 51.1% were female (n = 46), and 48.9% were male (n = 44). The mean (±standard deviation) age was 58.93 (±17.01). Significant differences in sodium levels and the pancreatic to splenic density ratio were noted between the PEP and non-PEP groups. Pancreatic to splenic density ratio <0.74 (odds ratio: 8.253; P = 0.020) was identified as an independent risk factor for PEP. CONCLUSIONS Pancreas to spleen density ratio on CT imaging serves as a potential predictive marker for PEP, offering insights into risk stratification and guiding prophylactic measures in high-risk patients.
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Affiliation(s)
- Mert Guler
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey.
| | - Omer Akay
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Anil Demir
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | | | - Husnu Sevik
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Sukru Colak
- Department of General Surgery, Nisantasi University, Istanbul, Turkey
| | - Coskun Cakir
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Mert Mahsuni Sevinc
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Ufuk Oguz Idiz
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
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Beran A, Aboursheid T, Ali AH, Nayfeh T, Albunni H, Vargas A, Mohamed MF, Elfert K, Shaear M, Obaitan I, Saleem N, Ahmed A, Gromski MA, DeWitt JM, Al-Haddad M, Watkins JL, Fogel E, Easler JJ. Predictors of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Comprehensive Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)01097-8. [PMID: 39694210 DOI: 10.1016/j.cgh.2024.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 11/19/2024] [Accepted: 11/21/2024] [Indexed: 12/20/2024]
Abstract
BACKGROUND & AIMS Pancreatitis is the most common serious adverse event associated with endoscopic retrograde cholangiopancreatography (ERCP). This meta-analysis aimed to precisely assess the risk factors for post-ERCP pancreatitis (PEP). METHODS We searched electronic databases for studies that assessed risk factors for PEP after adjusting for ≥3 risk factors, including at least one pre-specified patient-related and one procedure-related risk factor, and reported the data as adjusted odds ratios (ORs) with 95% confidence intervals. Meta-analyses were conducted using a random-effects model, and pooled adjusted ORs for risk factors reported in ≥3 studies were constructed. RESULTS A total of 159 studies with 315,580 ERCPs were included, assessing 31 unique risk factors (20 patient-related and 11 procedure-related). Key patient-related predictors of PEP were age ≤60 years (OR, 1.81; high credibility), prior acute pancreatitis (OR, 2.59; moderate), age ≤40 years (OR, 2.33; moderate), asymptomatic choledocholithiasis (OR, 4.76; low), prior PEP (OR, 4.40; low), sphincter of Oddi dysfunction (OR, 3.11; low), and female gender (OR, 1.70; low). Key procedure-related predictors of PEP were any guidewire passage into the pancreatic duct (PD) (OR, 2.18; high), first ERCP with a native papilla (OR, 1.91; high), endoscopic papillary balloon dilation of an intact papilla (OR, 2.91; moderate), pancreatic acinarization (OR, 4.23; low), any PD cannulation (OR, 2.73; low), pancreatic sphincterotomy (OR, 2.64; low), difficult cannulation (OR, 2.60; low), any pancreatogram (OR, 2.40; low), and precut sphincterotomy (OR, 1.98; low). CONCLUSIONS Our meta-analysis focused on adjusted risk factors to provide precise estimates of the most important risk factors for PEP. Incorporating our results into a prediction model may reliably help identify high-risk patients, optimize informed consent, and guide prevention and management strategies for PEP.
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Affiliation(s)
- Azizullah Beran
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Tarek Aboursheid
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, Illinois
| | - Adel Hajj Ali
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Tarek Nayfeh
- Evidence-based Practice Research Program, Mayo Clinic, Rochester, Minnesota
| | - Hashem Albunni
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Alejandra Vargas
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia
| | - Mouhand F Mohamed
- Department of Internal Medicine, Warren Alpert Medical School Brown University, Providence, Rhode Island
| | - Khaled Elfert
- Department of Internal Medicine, St. Barnabas Hospital Health System, Bronx, New York
| | - Mohammad Shaear
- Department of General Surgery, College of Medicine, Central Michigan University, Saginaw, Michigan
| | - Ite Obaitan
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Nasir Saleem
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Awais Ahmed
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - John M DeWitt
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana; Department of Medicine, University of Jordan, Amman, Jordan
| | - James L Watkins
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Evan Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
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Lee KJ, Cho E, Park DH, Cha HW, Koh DH, Lee J, Park CH, Park SW. Identification of risk factors associated with post-ERCP pancreatitis in patients with easy cannulation: a prospective multicenter observational study (with videos). Gastrointest Endosc 2024:S0016-5107(24)03728-3. [PMID: 39557201 DOI: 10.1016/j.gie.2024.11.018] [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] [Received: 04/16/2024] [Revised: 09/28/2024] [Accepted: 11/11/2024] [Indexed: 11/20/2024]
Abstract
BACKGROUND AND AIMS Difficult biliary cannulation is an independent risk factor for post-ERCP pancreatitis (PEP); however, there is a noticeable lack of studies focusing on the incidence and risk factors of PEP among patients undergoing easy cannulation. Therefore, we systematically investigated the risk factors for PEP in patients who underwent easy cannulation. METHODS We prospectively enrolled patients with naive major papillae who underwent diagnostic or therapeutic ERCP between June 2018 and June 2023. The primary endpoint was to determine the incidence of PEP in patients with easy cannulation; secondary endpoints were identifying PEP risk factors and evaluating procedure-related adverse events (AEs). RESULTS Overall, 1930 patients were included, with 1061 (54.9%) undergoing easy cannulation. Within this cohort, PEP incidence was 3.0%, whereas 2.9% experienced procedure-related AEs, excluding PEP. A history of acute pancreatitis (odds ratio [OR], 6.75; 95% confidence interval [CI], 1.83-20.14; P = .001) and acute cholangitis on admission (OR, 2.25; 95% CI, 1.07-5.08; P = .039) were identified as independent risk factors for PEP in patients with easy cannulation. Endoscopic sphincterotomy and biliary stent placement were independent factors for procedure-related AEs. CONCLUSIONS Our findings underscore the importance of assessing patient- and procedure-related factors to mitigate the risk of PEP in patients undergoing easy cannulation. Despite the low incidence of PEP, the potential for the occurrence of severe cases emphasizes the need for cautious intervention, particularly in patients with a history of acute pancreatitis and acute cholangitis on admission. (Clinical trial registration number: KCT0005950.).
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Affiliation(s)
- Kyong Joo Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Eunae Cho
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Da Hae Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Hye Won Cha
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Dong Hee Koh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
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9
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Akazawa Y, Ohtani M, Nosaka T, Takahashi K, Naito T, Matsuda H, Nakamoto Y. Usefulness of pancreatic volume quantitative analysis as a predictor of development and severity of post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreatology 2024; 24:698-705. [PMID: 38879434 DOI: 10.1016/j.pan.2024.06.002] [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: 12/06/2023] [Revised: 04/01/2024] [Accepted: 06/03/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is one of the most common and serious adverse events associated with ERCP. Thus, we aimed to investigate the usefulness of pre-ERCP pancreatic volume, which is deeply involved in exocrine pancreatic function, as a predictor of PEP development and severity. METHODS In total, 1107 patients who underwent their first ERCP were recruited from January 2012 to December 2022 for this retrospective study. Pancreatic volume was measured by cross-sectional analysis using pre-ERCP computed tomography images. The potential risk factors for PEP were analyzed using multivariate logistic regression. RESULTS Of the 745 patients included in the study, 34 (4.6 %) developed PEP: severe, moderate, or mild PEP in 1, 7, and 26 cases, respectively. Multivariate analysis revealed that only a large pancreatic volume (>70 cm3) was an independent risk factor for the development of PEP (odds ratio, 7.98; 95 % confidence interval, 11.80-67.50; P < 0.001). Additionally, the incidence of PEP was significantly higher in patients with a pancreatic volume >70 cm3 than in those with a pancreatic volume ≤70 cm3 (18.5 % [31/168] vs. 0.5 % [3/577]; P < 0.001). Also, the association between the pre-ERCP pancreatic volume and PEP severity was positively correlated (r = 0.625, P < 0.005), with a larger pancreatic volume corresponding to increased PEP severity. CONCLUSIONS A large pancreatic volume before ERCP may be a novel risk factor for PEP incidence and severity. This finding suggests that quantitative analysis of the pre-ERCP pancreatic volume could be a useful predictor of PEP.
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Affiliation(s)
- Yu Akazawa
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Masahiro Ohtani
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Takuto Nosaka
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Kazuto Takahashi
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Tatsushi Naito
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Hidetaka Matsuda
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Yasunari Nakamoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan.
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10
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Mukherji R, Gopinath M. A Study on the Spectrum of Imaging Findings of Post-ERCP-Specific Complications: A Retrospective Descriptive Study. Indian J Radiol Imaging 2024; 34:422-434. [PMID: 38912237 PMCID: PMC11188732 DOI: 10.1055/s-0044-1779585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
Aim The aim of this study was to examine the imaging manifestations of post-endoscopic retrograde cholangiopancreatography (ERCP) specific complications by computed tomography to aid in its early and successful diagnosis and timely intervention. Method Forty-one cases of imaging having post-ERCP were complications were retrospectively collected and the spectrum of complications and their key imaging features and methods to improve their detection were analyzed. Result The most common complication detected in computed tomography (CT) post-ERCP was the presence of intra-abdominal collections seen in 21 patients (51.2%). Pancreatitis was seen in 20 of 41 patients (48.7%), while bowel perforation was present in 9 patients (21%). Pleural effusion was present in 8 patients (19.5%), liver abscess in 6 patients (14.6%), cholangitis in 4 patients (9.7%), gallbladder perforation in 4 patients (9.7%), displaced common bile duct stent in 3 patients (7.3%), possibility of main pancreatic duct cannulation in 2 patients (4.8%), vascular injury resulting in right hepatic artery pseudoaneurysm in 1 patient (2.4%), thrombosis of portal vein or its branches in 2 patients (4.8%), superior mesenteric vein thrombosis in 1 patient (2.4%), right hepatic vein thrombosis in 1 patient (2.4%), pulmonary thromboembolism in 2 patients (4.8%), duodenal inflammation in 1 patient (2.4%), bowel ileus in 4 patients (9.6%), and bowel obstruction in 1 patient (2.4%). Conclusion Complications after ERCP can cause significant morbidity and mortality if not diagnosed early and treated appropriately. Familiarity with normal findings post-ERCP and knowledge of the imaging appearance of these complications are vital in the early management of these conditions.
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Affiliation(s)
- Ruchira Mukherji
- Department of Radiodiagnosis & Imaging, Army Hospital Research & Referral, Delhi Cantonment, New Delhi, India
| | - Manoj Gopinath
- Department of Radiodiagnosis & Imaging, Army Hospital Research & Referral, Delhi Cantonment, New Delhi, India
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11
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Cho IR, Choi JH, Park JK, Huh G, Lee SH, Paik WH, Park DH. Aggressive hydration with lactated Ringer's solution versus plasma solution for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (ALPS study): protocol for a multicentre, double-blind, randomised controlled trial. BMJ Open 2024; 14:e084052. [PMID: 38955368 PMCID: PMC11218011 DOI: 10.1136/bmjopen-2024-084052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) plays an indispensable role in treating pancreato-biliary diseases but carries a risk of post-ERCP pancreatitis (PEP). Despite advances in the prevention strategies, prevention of PEP remains imperfect, necessitating more refined hydration methods. This study investigates the effectiveness of lactated Ringer's solution versus plasma solution in preventing PEP. METHOD AND ANALYSIS This multicentre, double-blind, randomised controlled trial, will be initiated by the investigator-sponsor, and conducted in three tertiary centres in South Korea. The aim of this study is to assess the effectiveness of hydration in preventing PEP in patients with naïve papillae. It will target patients with naïve papillae, focusing on those at medium to high risk of PEP. Patients aged ≤18 years and those with serious comorbidities, acute/chronic pancreatitis and various other medical conditions will be excluded. Eligible participants will be randomly assigned into two arms in equal numbers: (1) PEP prevention using lactated Ringer's solution and (2) PEP prevention using plasma solution. The primary outcome of this study will be the occurrence of PEP, and secondary outcomes will be additional risk factors and potential adverse events related to ERCP. With a total enrolment of 844 patients, the study will be able to detect significant differences between the intervention arms. ETHICS AND DISSEMINATION Ethical approval is obtained from each institution (Asan Medical Centre, 2023-0382; Seoul National University Hospital, H-2302-05-1404; Samsung Medical Centre, SMC 2023-02-001-009). All participants provided informed consent following clear explanation of the study procedures. The results of the study will be disseminated in peer-reviewed journals and research conferences. TRIAL REGISTRATION NUMBER NCT05832047. PROTOCOL VERSION Ver 4.1 (2023).
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Affiliation(s)
- In Rae Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, Korea (the Republic of)
| | - Jin Ho Choi
- Department of Internal Medicine, Samsung Medical Center, Gangnam-gu, Seoul, Korea (the Republic of)
| | - Joo Kyung Park
- Division of Gastroenterology, Deparent of Medicine, Samsung Medical Center, Seoul, Korea (the Republic of)
| | - Gunn Huh
- Department of Gastroenterology, Asan Medical Center, Songpa-gu, Seoul, Korea (the Republic of)
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, Korea (the Republic of)
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, Korea (the Republic of)
| | - Do Hyun Park
- Department of Internal Medicine, Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea (the Republic of)
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12
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Takahashi H, Ohno E, Furukawa T, Yamao K, Ishikawa T, Mizutani Y, Iida T, Shiratori Y, Oyama S, Koyama J, Mori K, Hayashi Y, Oda M, Suzuki T, Kawashima H. Artificial intelligence in a prediction model for postendoscopic retrograde cholangiopancreatography pancreatitis. Dig Endosc 2024; 36:463-472. [PMID: 37448120 DOI: 10.1111/den.14622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES In this study we aimed to develop an artificial intelligence-based model for predicting postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). METHODS We retrospectively reviewed ERCP patients at Nagoya University Hospital (NUH) and Toyota Memorial Hospital (TMH). We constructed two prediction models, a random forest (RF), one of the machine-learning algorithms, and a logistic regression (LR) model. First, we selected features of each model from 40 possible features. Then the models were trained and validated using three fold cross-validation in the NUH cohort and tested in the TMH cohort. The area under the receiver operating characteristic curve (AUROC) was used to assess model performance. Finally, using the output parameters of the RF model, we classified the patients into low-, medium-, and high-risk groups. RESULTS A total of 615 patients at NUH and 544 patients at TMH were enrolled. Ten features were selected for the RF model, including albumin, creatinine, biliary tract cancer, pancreatic cancer, bile duct stone, total procedure time, pancreatic duct injection, pancreatic guidewire-assisted technique without a pancreatic stent, intraductal ultrasonography, and bile duct biopsy. In the three fold cross-validation, the RF model showed better predictive ability than the LR model (AUROC 0.821 vs. 0.660). In the test, the RF model also showed better performance (AUROC 0.770 vs. 0.663, P = 0.002). Based on the RF model, we classified the patients according to the incidence of PEP (2.9%, 10.0%, and 23.9%). CONCLUSION We developed an RF model. Machine-learning algorithms could be powerful tools to develop accurate prediction models.
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Affiliation(s)
- Hidekazu Takahashi
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Fujita Health University Graduate School of Medicine, Aichi, Japan
| | - Taiki Furukawa
- Department of Medical IT, Nagoya University Hospital, Aichi, Japan
| | - Kentaro Yamao
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | | | - Shintaro Oyama
- Department of Medical IT, Nagoya University Hospital, Aichi, Japan
| | - Junji Koyama
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kensaku Mori
- Department of Intelligent Systems, Nagoya University Graduate School of Informatics, Aichi, Japan
| | - Yuichiro Hayashi
- Department of Intelligent Systems, Nagoya University Graduate School of Informatics, Aichi, Japan
| | - Masahiro Oda
- Information Strategy Office, Information and Communications, Nagoya University, Aichi, Japan
| | - Takahisa Suzuki
- Department of Gastroenterology, Toyota Memorial Hospital, Aichi, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
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Matsumoto K, Noma H, Fujita K, Tomoda T, Onoyama T, Hanada K, Okazaki A, Hirao K, Goto D, Moriyama I, Kushiyama Y, Takenaka M, Maruo T, Matsumoto H, Asada M, Nebiki H, Katayama T, Kawamura T, Kurita A, Ueki T, Tsujimae M, Matsubara T, Yamada S, Tamura T, Marui S, Mitoro A, Isomoto H, Yazumi S, Kawamoto H. Prognostic Factors for Severe-to-Fatal Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Multicenter Prospective Cohort Study. J Clin Med 2024; 13:1135. [PMID: 38398448 PMCID: PMC10889235 DOI: 10.3390/jcm13041135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/07/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
The prognostic factors associated with severe-to-fatal post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remain unclear despite the extensive number of studies on PEP. In total, 3739 ERCP patients with biliary disease with an intact papilla and indicated for ERCP were prospectively enrolled at 36 centers from April 2017 to March 2018. Those with acute pancreatitis diagnosed before ERCP, altered gastrointestinal anatomy, and an American Society of Anesthesiologists (ASA) physical status > 4 were excluded. Univariate and multivariate logistic regression analyses were performed on patient-related factors, operator-related factors, procedure-related factors, and preventive measures to identify potential prognostic factors for severe-to-fatal PEP. Multivariate analyses revealed pancreatic guidewire-assisted biliary cannulation (OR 13.59, 95% CI 4.21-43.83, p < 0.001), post-ERCP non-steroidal anti-inflammatory drug (NSAID) administration (OR 11.54, 95% CI 3.83-34.81, p < 0.001), and previous pancreatitis (OR 6.94, 95% CI 1.45-33.33, p = 0.015) as significant risk factors for severe-to-fatal PEP. Preventive measures included endoscopic biliary sphincterotomy (EST; OR 0.29, 95% CI, 0.11-0.79, p = 0.015) and prophylactic pancreatic stents (PPSs; OR 0.11, 95% CI, 0.01-0.87, p = 0.036). In biliary ERCP, pancreatic guidewire-assisted biliary cannulation, NSAID administration after ERCP, and previous pancreatitis were risk factors for severe-to-fatal PEP, whereas EST and PPS were significant preventive measures for severe-to-fatal PEP.
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Affiliation(s)
- Kazuya Matsumoto
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.O.); (H.I.)
- Irisawa Medical Clinic, Matsue 690-0025, Japan
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tachikawa 190-8562, Japan;
| | - Koichi Fujita
- Department of Gastroenterology and Hepatology, Yodogawa Christian Hospital, Osaka 533-0024, Japan
- First Research Department, Medical Research Institute, Kitano Hospital, PIIF Tazuke-Kofukai, Osaka 530-8480, Japan
| | - Takeshi Tomoda
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan;
| | - Takumi Onoyama
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.O.); (H.I.)
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, Onomichi, Hiroshima 722-8508, Japan;
| | - Akihito Okazaki
- Department of Gastroenterology, Hiroshima Atomic Bomb Survivor Hospital, Hiroshima 730-0052, Japan;
| | - Ken Hirao
- Department of Internal Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima 730-8518, Japan;
| | - Daisuke Goto
- Department of Internal Medicine, Tottori Red Cross Hospital, Tottori 680-8517, Japan;
| | - Ichiro Moriyama
- Department of Hematology/Oncology, Shimane University Hospital, Innovative Cancer Center, Izumo 693-8501, Japan;
| | - Yoshinori Kushiyama
- Department of Gastroenterology, Matsue Red Cross Hospital, Matsue 690-8506, Japan;
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kinki University, Osaka 589-8511, Japan;
| | - Toru Maruo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka 814-0180, Japan; (T.M.); (T.U.)
| | - Hisakazu Matsumoto
- Department of Gastroenterology, Japan Red Cross Hospital Wakayama Medical Center, Wakayama 640-8558, Japan;
| | - Masanori Asada
- Department of Gastroenterology and Hepatology, Japan Red Cross Osaka Hospital, Osaka 543-8555, Japan;
| | - Hiroko Nebiki
- Department of Gastroenterology, Osaka City General Hospital, Osaka 534-0021, Japan;
| | - Toshihiro Katayama
- Help Center of Medical Research, Medical Research Institute, Kitano Hospital, PIIF Tazuke-Kofukai, Osaka 530-8480, Japan;
| | - Takashi Kawamura
- Department of Preventive Services, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto 606-8303, Japan;
| | - Akira Kurita
- Kitano Hospital, Tazuke-Kofukai Medical Research Institute, Kyoto 530-8480, Japan;
| | - Toshiharu Ueki
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka 814-0180, Japan; (T.M.); (T.U.)
| | - Masahiro Tsujimae
- Department of Gastroenterology, Osaka Saiseikai Nakatsu Hospital, Osaka 530-0012, Japan;
| | - Tokuhiro Matsubara
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Osaka 560-8565, Japan;
| | - Satoshi Yamada
- Department of Gastroenterology, Kobe City Medical Center West Hospital, Kobe 650-0047, Japan;
| | - Takashi Tamura
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama 641-8510, Japan;
| | - Saiko Marui
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan;
| | - Akira Mitoro
- Department of Gastroenterology, Nara Medical University, Nara 634-8522, Japan;
| | - Hajime Isomoto
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (T.O.); (H.I.)
| | - Shujiro Yazumi
- Department of Gastroenterology and Hepatology, Medical Research Institute, Kitano Hospital, PIIF Tazuke-Kofukai, Osaka 530-8480, Japan;
| | - Hirofumi Kawamoto
- General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama 701-0192, Japan;
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Altunpak B, Aydin H, Cebi F, Seyit H, Kones O, Akarsu C, Kabuli H, Gumusoglu A, Karabulut M. Post-ERCP Pancreatitis Risk Factors: Is Post-Sphincterotomy Bleeding Another Risk Factor? Surg Laparosc Endosc Percutan Tech 2024; 34:69-73. [PMID: 38063573 DOI: 10.1097/sle.0000000000001251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/04/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Despite advancements in technology and expertise, ERCP carries risks of significant complications, such as pancreatitis, bleeding, and perforation. Post-ERCP pancreatitis is the most common and important complication following ERCP. In our study, we aimed to examine the relationship between patient and procedure-related parameters and the development of pancreatitis. METHODS Four hundred patients who underwent ERCP between January 1, 2019 and December 31, 2020, at the General Surgery Clinic of the Bakirköy Dr. Sadi Konuk Health Application and Research Center of the University of Health Sciences Faculty of Medicine were retrospectively evaluated. Patient and procedure-related factors were analyzed statistically through univariate and multivariate analyses. RESULTS Age, urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, pancreatic cannulation, pancreatic stent, and bleeding were statistically significant risk factors for post-ERCP pancreatitis (+). In multivariate analysis, the effects of urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, and pancreatic cannulation on post-ERCP pancreatitis were statistically significant risk factors ( P <0.05). DISCUSSION This study demonstrates that emergency indication, ERCP history, cholangitis, precut sphincterotomy, and pancreatic cannulation are significant risk factors for the development of post- ERCP pancreatitis. One notable contribution of our study to the existing literature is the unique analysis of post-sphincterotomy bleeding as an independent factor.
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Affiliation(s)
- Burak Altunpak
- Department of General Surgery, Gaziantep Nizip State Hospital, Gaziantep
| | - Husnu Aydin
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Fevzi Cebi
- Department of General Surgery, Trabzon of State Hospital, Trabzon
| | - Hakan Seyit
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Osman Kones
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Cevher Akarsu
- Department of General Surgery, Arel University Memorial Hizmet Hospital, Istanbul, Turkey
| | - Hamit Kabuli
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Alpen Gumusoglu
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Mehmet Karabulut
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
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Sung MJ, Jo JH, Lee HS, Park JY, Bang S, Chung MJ. Comparison of Physician-Controlled Maneuver and Assistant-Controlled Maneuver during Endoscopic Retrograde Cholangiopancreatography. Yonsei Med J 2024; 65:34-41. [PMID: 38154478 PMCID: PMC10774649 DOI: 10.3349/ymj.2023.0115] [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: 04/27/2023] [Revised: 08/28/2023] [Accepted: 09/07/2023] [Indexed: 12/30/2023] Open
Abstract
PURPOSE Cannulation of the major papilla is the most challenging part of endoscopic retrograde cholangiopancreatography (ERCP) for which physician-controlled wire-guided cannulation (PCWGC) and assistant-controlled wire-guided cannulation (ACWGC) are used as the cannulation techniques. PCWGC can reportedly save up to about 30% of the labor cost by reducing the number of assistants. This study aims to compare the safety and efficacy of PCWGC and ACWGC. MATERIALS AND METHODS Of the 2151 patients aged >20 years (4193 cases) who underwent ERCP at Yonsei University Medical Center between January 2015 and December 2016, 989 were included in this study. RESULTS Among efficacy outcomes, cannulation success rate, rate of precut sphincterotomy (PCWGC vs. ACWGC: 21.3% vs. 25.9%), bile duct cannulation time (PCWGC vs. ACWGC: median 3.0 minutes vs. 3.6 minutes), and total procedure time (PCWGC vs. ACWGC: median 13.6 minutes vs. 13.1 minutes) were not significantly different. Among safety outcomes, lower rates of post-ERCP pancreatitis were observed with PCWGC than with ACWGC (PCWGC vs. ACWGC: 5.8% vs. 8.8%, p=0.128). Among other post-ERCP adverse events (bleeding, perforation, and cholangitis), the difference was not significant between the groups. Radiation exposure (total dose area product, PCWGC vs. ACWGC: median 1979.9 µGym² vs. 2062.0 µGym², p=0.194) and ERCP cost excluding labor cost (PCWGC vs. ACWGC: $1576 vs. $1547, p=0.606) were not significantly different. CONCLUSION Requiring less assistants, PCWGC showed comparable efficacy and safety to ACWGC. PCWGC can be considered as an alternative option, especially in facilities lacking manpower and resources.
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Affiliation(s)
- Min Je Sung
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jung Hyun Jo
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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16
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Fukuda R, Hakuta R, Nakai Y, Hamada T, Takaoka S, Tokito Y, Suzuki Y, Oyama H, Kanai S, Noguchi K, Suzuki T, Ishigaki K, Saito K, Saito T, Takahara N, Mizuno S, Ito Y, Kogure H, Fujishiro M. Development and external validation of a nomogram for prediction of post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreatology 2023; 23:789-796. [PMID: 37666733 DOI: 10.1016/j.pan.2023.08.008] [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: 07/09/2022] [Revised: 06/04/2023] [Accepted: 08/26/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic retrograde cholangiopancreatography (ERCP) is widely performed for management of pancreatobiliary diseases; however, post-ERCP pancreatitis (PEP) remains as an unsolved problem. Although various risk factors for PEP have been reported, the prediction of PEP remains controversial. This study aimed to develop a predictive model for PEP. METHODS Consecutive patients undergoing ERCP for biliary indications at two centers were retrospectively studied. Using data from a training cohort, we utilized a multivariable model to select five variables to construct a nomogram. The predictive model was internally and externally validated. Based on the nomogram, the patients were categorized into low-, moderate-, and high-risk groups. RESULTS Using the data of 2224 patients in the training cohort, five variables were selected to generate a nomogram: 1) sex, 2) indication for ERCP, 3) difficult cannulation, 4) guidewire insertion into the pancreatic duct, and 5) endoscopic sphincterotomy or sphincteroplasty. The most significant risk factor was endoscopic papillary balloon dilation such as endoscopic sphincterotomy or sphincteroplasty. The bias-corrected concordance index was 0.72 in the training cohort and 0.72 in the validation cohort. Calibration curves for both cohorts demonstrated good agreement between the predicted and observed frequencies of the actual outcome. In the validation cohort, PEP developed in 5.0% and 14% of patients in the moderate- and high-risk groups, respectively. CONCLUSIONS We successfully developed a good predictive model for PEP. The prevention of PEP in high risk patients should be investigated further.
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Affiliation(s)
- Rintaro Fukuda
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan.
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shinya Takaoka
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yurie Tokito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukari Suzuki
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hiroki Oyama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sachiko Kanai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kensaku Noguchi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsunori Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Chemotherapy, The University of Tokyo Hospital, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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17
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Wu CCH, Lim SJM, Khor CJL. Endoscopic retrograde cholangiopancreatography-related complications: risk stratification, prevention, and management. Clin Endosc 2023; 56:433-445. [PMID: 37460103 PMCID: PMC10393565 DOI: 10.5946/ce.2023.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/11/2023] [Indexed: 07/29/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) plays a crucial role in the management of pancreaticobiliary disorders. Although the ERCP technique has been refined over the past five decades, it remains one of the endoscopic procedures with the highest rate of complications. Risk factors for ERCP-related complications are broadly classified into patient-, procedure-, and operator-related risk factors. Although non-modifiable, patient-related risk factors allow for the closer monitoring and instatement of preventive measures. Post-ERCP pancreatitis is the most common complication of ERCP. Risk reduction strategies include intravenous hydration, rectal nonsteroidal anti-inflammatory drugs, and pancreatic stent placement in selected patients. Perforation is associated with significant morbidity and mortality, and prompt recognition and treatment of ERCP-related perforations are key to ensuring good clinical outcomes. Endoscopy plays an expanding role in the treatment of perforations. Specific management strategies depend on the location of the perforation and the patient's clinical status. The risk of post-ERCP bleeding can be attenuated by preprocedural optimization and adoption of intra-procedural techniques. Endoscopic measures are the mainstay of management for post-ERCP bleeding. Escalation to angioembolization or surgery may be required for refractory bleeding. Post-ERCP cholangitis can be reduced with antibiotic prophylaxis in high risk patients. Bile culture-directed therapy plays an important role in antimicrobial treatment.
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Affiliation(s)
- Clement Chun Ho Wu
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Samuel Jun Ming Lim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Christopher Jen Lock Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
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18
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Kuraishi Y, Hara K, Haba S, Kuwahara T, Okuno N, Yanaidani T, Ishikawa S, Yasuda T, Yamada M, Mizuno N. Safety and feasibility of opening window fistulotomy as a new precutting technique for primary biliary access in endoscopic retrograde cholangiopancreatography. Clin Endosc 2023; 56:490-498. [PMID: 37157966 PMCID: PMC10393574 DOI: 10.5946/ce.2022.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/26/2022] [Accepted: 06/30/2022] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND/AIMS Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common and serious complication of endoscopic retrograde cholangiopancreatography. To prevent this event, a unique precutting method, termed opening window fistulotomy, was performed in patients with a large infundibulum as the primary procedure for biliary cannulation, whereby a suprapapillary laid-down H-shaped incision was made without touching the orifice. This study aimed to assess the safety and feasibility of this novel technique. METHODS One hundred and ten patients were prospectively enrolled in this study. Patients with a papillary roof size ≥10 mm underwent opening window fistulotomy for primary biliary access. In addition, the incidence of complications and success rate of biliary cannulation were evaluated. RESULTS The median size of the papillary roof was 6 mm (range, 3-20 mm). Opening window fistulotomy was performed in 30 patients (27.3%), none of whom displayed PEP. Duodenal perforation was recorded in one patient (3.3%), which was resolved by conservative treatment. The cannulation rate was high (96.7%, 29/30 patients). The median duration of biliary access was 8 minutes (range, 3-15 minutes). CONCLUSION Opening window fistulotomy demonstrated its feasibility for primary biliary access by achieving great safety with no PEP complications and a high success rate for biliary cannulation.
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Affiliation(s)
- Yasuhiro Kuraishi
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shin Haba
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takamichi Kuwahara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takafumi Yanaidani
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Sho Ishikawa
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsukasa Yasuda
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masanori Yamada
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
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19
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Ashat M, Kandula S, Cote GA, Gromski MA, Fogel EL, Sherman S, Lehman GA, Watkins JL, Bick BL, Easler JJ. Utilization pattern of prophylactic measures for prevention of post-ERCP pancreatitis: a National Survey Study. Gastrointest Endosc 2023; 97:1059-1066.e3. [PMID: 36738796 DOI: 10.1016/j.gie.2023.01.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/05/2023] [Accepted: 01/28/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Post-ERCP pancreatitis (PEP) is the most frequent adverse event of ERCP. Various prophylactic measures are endorsed by the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy to both lower the incidence of PEP and to decrease its severity. The extent to which these interventions are practiced throughout the United States is unclear. The aim of this study was to describe the utilization pattern of various PEP measures and determine factors that affect utilization of these measures. METHODS A 27-question electronic survey was distributed using a cloud-based program (Qualtrics). The questions assessed ERCP training, practice setting, experience, practice patterns, and perceptions for PEP prophylaxis interventions. Endoscopists with practices based in the United States listed in the American Society for Gastrointestinal Endoscopy member directory received a survey invitation via e-mail. The invitation outlined the study and contained a link with instructions to complete the voluntary survey if they had an active ERCP practice. Data were de-identified for the purposes of analysis. RESULTS Of survey respondents (N = 319), 46% reported therapeutic endoscopy fellowship training and 37% practiced in teaching programs. Annualized ERCP volume of >100 cases per year were reported by 47%, with pancreatic ERCP comprising ≤5% of procedure volume reported by the majority of respondents (61%). The majority of respondents used prophylactic pancreatic stent (PPS), and 54% reported frequent use during high-risk ERCP. The most common indications for PPS were difficult cannulation, to assist biliary access, and multiple pancreatic duct injections. Most respondents reported frequent use of indomethacin (89%). Of physicians who did not use PPS, use of indomethacin was the most common reason (80%). Variables associated with frequent use of PPS were ERCP fellowship training (P ≤ .001), practice at a teaching program (P ≤ .001), <10 years in practice (P = .005), higher procedure volume (P ≤ .001), and higher proportion of pancreatic cases (P ≤ .001). CONCLUSIONS Physicians with higher annual ERCP volume, who teach at hospital-based ERCP practices, and who regularly perform pancreatic ERCP are more likely to use PPS. Therapeutic ERCP fellowship training and recent entry into practice were also associated with PPS utilization. Indomethacin use seems to be more frequent than PPS. Our findings suggest that indomethacin is supplanting PPS as the preferred method of PEP prophylaxis.
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Affiliation(s)
- Munish Ashat
- Department of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
| | - Sailesh Kandula
- Department of Statistics and Data Science, The University of Texas at Austin, Austin, Texas, USA
| | - Gregory A Cote
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Glen A Lehman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - James L Watkins
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Benjamin L Bick
- Division of Gastroenterology and Hepatology, Rockford Gastroenterology Associates, Rockford, Illinois, USA
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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20
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Balan GG, Timofte O, Gilca-Blanariu GE, Sfarti C, Diaconescu S, Gimiga N, Antighin SP, Sandu I, Sandru V, Trifan A, Moscalu M, Stefanescu G. Predicting Hospitalization, Organ Dysfunction, and Mortality in Post-Endoscopic Retrograde Cholangiopancreatography Acute Pancreatitis: Are SIRS and qSOFA Reliable Tools? APPLIED SCIENCES 2023; 13:6650. [DOI: 10.3390/app13116650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Background: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has shown constant incidence throughout time, despite advances in endoscopic technology, devices, or personal skills of the operating endoscopists, with prevention and prediction of severity in PEP being constant concerns. Several prospective studies have investigated the role of systemic inflammatory response syndrome (SIRS) criteria or the quick Sequential Organ Failure Assessment (qSOFA) score in the PEP severity assessment. However, there are no clearly defined tools for the prediction of PEP severity. Methods: A total of 403 patients were prospectively monitored 60 days after ERCP for the detection of PEP development. Consequently, we evaluated the lengths of stay, incidence of organic dysfunction, and mortality rates of these patients. The predictive power of the univariate model was evaluated by using the receiver operating characteristic curve and analyzing the area under the curve (AUC). Results: Incidence of PEP was similar to that reported in the majority of trials. The 60-day survival rate of PEP patients reached 82.8%. A qSOFA score ≥ 1 is a very good predictor for organ dysfunction (AUC 0.993, p < 0.0001). SIRS can also be considered a significant predictor for organic dysfunctions in PEP patients (AUC 0.926, p < 0.0001). However, only qSOFA was found to significantly predict mortality in PEP patients (AUC 0.885, p = 0.003), with SIRS criteria showing a much lower predictive power. Neither SIRS nor qSOFA showed any predictive value for the length of stay of PEP patients. Conclusion: Our study offers novel information about severity prediction in PEP patients. Both SIRS criteria and qSOFA showed good predictive value for organic dysfunction, mortality, and hospitalization.
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Affiliation(s)
- Gheorghe Gh. Balan
- Gastroenterology and Hepatology Clinic, “Sf. Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Oana Timofte
- Gastroenterology and Hepatology Clinic, “Sf. Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Georgiana-Emmanuela Gilca-Blanariu
- Gastroenterology and Hepatology Clinic, “Sf. Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Catalin Sfarti
- Gastroenterology and Hepatology Clinic, “Sf. Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | | | - Nicoleta Gimiga
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Clinical Department of Paediatric Gastroenterology, “Sf. Maria” Emergency Children’s Hospital, 700309 Iasi, Romania
| | | | - Ion Sandu
- Academy of Romanian Scientists (AORS), 54 Splaiul Independentei St., Sector 5, 050094 Bucharest, Romania
- Science Department, Interdisciplinary Research Institute, Alexandru Ioan Cuza University of Iasi, 11 Carol I Boulevard, 700506 Iasi, Romania
- Romanian Inventors Forum, 3 Sf. Petru Movilă St., L11, III/3, 700089 Iasi, Romania
| | - Vasile Sandru
- Gastroenterology and Hepatology Clinic, Floreasca Clinical Emergency Hospital, 014461 Bucharest, Romania
| | - Anca Trifan
- Gastroenterology and Hepatology Clinic, “Sf. Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihaela Moscalu
- Department of Preventive Medicine and Interdisciplinarity, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Gabriela Stefanescu
- Gastroenterology and Hepatology Clinic, “Sf. Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
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21
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Predictive factors of postendoscopic retrograde cholangiopancreatography pancreatitis for biliary complications in living-donor liver transplantation recipients. Eur J Gastroenterol Hepatol 2023; 35:359-364. [PMID: 36827529 DOI: 10.1097/meg.0000000000002521] [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: 02/26/2023]
Abstract
OBJECTIVES Endoscopic retrograde cholangiopancreatography (ERCP) has shown great safety and efficacy in the management of post-living-donor liver transplantation (LDLT) biliary complications. Pancreatitis is the most commonest and the most feared complication after ERCP. METHODS We reviewed the data of liver transplant recipients who underwent ERCP for biliary complications after LDLT between 2011 and 2022. RESULTS In total 63 patients underwent ERCP after LDLT. They were targeted to 134 set of ERCP. Pancreatitis occurred in 52 sets (38.8%). We subclassified the patients into two groups, without pancreatitis: 31 patients (49.2%) and with pancreatitis 32 patients (50.8%). A higher incidence of pancreatitis was noticed with the first ERCP set (P = 0.04). Biliary strictures were more noted in the pancreatitis group (P = 0.025). Difficult cannulation requiring precut was more observed in the pancreatitis group (P = 0.007). Also, more frequent sphincterotomy was observed in the pancreatitis group (P = 0.003). Longer hospital stay, more fever, abdominal pain and vomiting were noted in the pancreatitis group (P = 0.001). Higher post-ERCP serum amylase (P = 0.001) and creatinine (P = 0.021), while lower serum calcium (P = 0.21) were noticed in the pancreatitis group. On multivariate analysis, preoperative diabetes, number of biliary anastomoses (single/multiple) and difficult cannulation requiring precut were significant predictors of post-ERCP pancreatitis. CONCLUSION Patient-related risk factors and bedside procedure-related risk factors play an essential role in the development of pancreatitis after ERCP for LDLT recipients. Endoscopists should be mindful by those high-risk patients during ERCP to apply appropriate techniques to prevent the development of this serious complication.
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ERDOĞAN Ç, GÜVEN İE, BAŞPINAR B, KILIÇ ZMY. Evaluation of pancreatic stent and/or suppository indomethacin efficacy in post ERCP pancreatitis prophylaxis: a single center experience. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2023. [DOI: 10.32322/jhsm.1197804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Aim: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a serious complication of ERCP. In this study, we aimed to compare the use of rectal indomethacin, pancreatic stenting or both techniques for prevention of PEP.
Material and Method: Patients who underwent ERCP for the first time due to choledocholithiasis between January 2022 and June 2022 were retrospectively reviewed. The clinical findings, demographics, laboratory records, endoscopic intervention characteristics, whether rectal indomethacin was applied before the procedure, whether pancreatic stent was placed or not were evaluated.
Results: A total of 367 patients who underwent ERCP for the first time were included in the study. The mean age was 61 (28-92) years and 53.4% were female. In 124 (33.8%) patients, involuntary guide-wire insertion into the pancreatic duct occurred during canulation. Pancreatic stent was placed in 82 (22.3%) of the patients. Rectal indomethacin was administered to 288 patients (78.5%), while indomethacin could not be administered in 79 patients (21.5%), because they did not give consent. When patients with involuntarily pancreatic canulation were evaluated, the rate of PEP was 3.6% in the stented group, while it was 15.3% in the stent-free group (p
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Affiliation(s)
- Çağdaş ERDOĞAN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - İbrahim Ethem GÜVEN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - Batuhan BAŞPINAR
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
| | - Zeki Mesut Yalın KILIÇ
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
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23
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Bapaye J, Chandan S, Bhalla V, Shehadah A, Naing LY, Mohan B, Ramai D, Perisetti A, Goyal H, Kassab L, Facciorusso A, Bilal M, Adler DG. Primary needle-knife fistulotomy versus rescue precut: a systematic review and meta-analysis of outcomes. IGIE 2023; 2:44-51. [DOI: 10.1016/j.igie.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2025]
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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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25
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Technical Outcomes in Pediatric Endoscopic Retrograde Cholangiopancreatography: Data from an International Collaborative. J Pediatr Gastroenterol Nutr 2022; 75:755-760. [PMID: 36122368 DOI: 10.1097/mpg.0000000000003612] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Endoscopic retrograde cholangiopancreatography (ERCP) in adults has been extensively studied through multicenter prospective studies. Similar pediatric studies are lacking. The Pediatric ERCP Database Initiative (PEDI) is a multicenter collaborative aiming to evaluate the indications and technical outcomes in pediatric ERCPs. METHODS In this prospective cohort study, data were recorded for pediatric ERCPs performed across 15 centers. A pre-procedure, procedure, 2-week post-procedure follow-up, and adverse event form were completed for each ERCP performed. Univariate and stepwise linear regression was performed to identify factors associated with technically successful procedures and adverse events. RESULTS A total of 1124 ERCPs were performed on 857 patients from May 1, 2014 to May 1, 2018. The median age was 13.5 years [interquartile range (IQR) 9.0-15.7]. Procedures were technically successful in the majority of cases (90.5%) with success more commonly encountered for procedures with biliary indications [odds ratio (OR) 4.2] and less commonly encountered for native papilla anatomy (OR 0.4) and in children <3 years (OR 0.3). Cannulation was more often successful with biliary cannulation (95.9%) compared to pancreatic cannulation via the major papilla (89.6%, P < 0.0001) or minor papilla (71.2%, P < 0.0005). The most commonly identified adverse events included post-ERCP pancreatitis (5%), pain not related to post-ERCP pancreatitis (1.8%), and bleeding (1.2%). Risk factors for the development of each were identified. CONCLUSIONS This large prospective study demonstrates that ERCP is reliable and safe in the pediatric population. It highlights the utility of PEDI in evaluating the technical outcomes of pediatric ERCPs and demonstrates the potential of PEDI for future studies in pediatric ERCPs.
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Ak Ç, Aykut H, Pala E, Sayar S, Tarikçi Kiliç E, Adali G, Kahraman R, Öztürk O, Özdil K. Post-ERCP Complication Analysis of an Experienced Center. Surg Laparosc Endosc Percutan Tech 2022; 32:707-713. [PMID: 36468895 DOI: 10.1097/sle.0000000000001113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 09/13/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND/AIM Post-ERCP pancreatitis (PEP), post-sphincterotomy bleeding (PSB), and Post-ERCP perforation are the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). Identification of risk factors for post-ERCP complications is critical for postoperative follow-up. This study aimed to evaluate the most common post-ERCP complication risk factors in an experienced center. METHODS/DESIGN The sample consisted of 1288 patients with naive papillae. Demographic characteristics, patient-related risk factors, procedure-related risk factors and postoperative complications were recorded. RESULTS Patients had a mean age of 61.5±18.4 years. The prevalence of PEP, PSB, and post-ERCP perforation was 7.9%, 11.9%, and 0.5%, respectively. Among patient-related factors, female sex (OR 1.672 95% Cl 1.046 to 2.672) and narrowing of the choledochal diameter (OR 2.910 95% Cl 1.830 to 4.626) were associated with PEP. From procedure-related factors; precut sphincterotomy (OR 2.172 95% Cl 1.182 to 3.994), difficult cannulation (OR 5.110 95% Cl 2.731 to 9.560), pancreatic cannulation (OR 5.692 95% Cl 0.994 to 32.602) and postprocedure residual stone (OR 2.252 95% Cl 1.403 to 3.614) were found to be associated with PEP. The successful procedure (OR 0.378 95% Cl 0.204 to 0.699) had a protective effect on PEP. Choledocholithiasis indication (OR 3.594 95% Cl 1.444 to 8.942) and small papilla (OR 2.042 95% Cl 1.170 to 3.562) were associated with the development of PSB. Choledochal stenosis, periampullary-diverticulum, oral anticoagulant, and oral antiaggregant use were not associated with the development of PSB. Of the patients with post-ERCP perforation, 85.7% had difficult cannulation, 57.1% had precut sphincterotomy, and 28.6% had periampullary-diverticulum. CONCLUSION Female sex, biliary stricture, precut sphincterotomy, difficult cannulation, pancreatic cannulation, and postoperative residual stone were associated with PEP. Choledocholithiasis indication and the presence of small papilla were associated with PSB.
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Affiliation(s)
| | - Hüseyin Aykut
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
| | - Emin Pala
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
| | - Süleyman Sayar
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
| | - Ebru Tarikçi Kiliç
- Health Sciences University Umraniye Training and Research Hospital, Department of Anesthesiology, Istanbul, Turkey
| | - Gupse Adali
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
| | - Resul Kahraman
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
| | - Oğuzhan Öztürk
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
| | - Kamil Özdil
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
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Sakai H, Iwai N, Sakagami J, Okuda T, Ohara T, Hattori C, Taniguchi M, Oka K, Hara T, Tsuji T, Komaki T, Kagawa K, Dohi O, Yasuda H, Konishi H, Itoh Y. Rectal administration of low-dose diclofenac does not reduce post-endoscopic retrograde cholangiopancreatography pancreatitis: a propensity score matching analysis. Surg Endosc 2022; 37:2698-2705. [PMID: 36443561 DOI: 10.1007/s00464-022-09718-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 10/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a popular technique; however, post-ERCP pancreatitis (PEP) remains a major adverse event. The administration of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) is reportedly effective in preventing PEP. However, the recommended dose varies and the efficacy of low-dose rectal NSAIDs remains unclear. Therefore, we decided to investigate the effectiveness of low-dose rectal diclofenac on PEP prevention, using propensity score matching. METHODS This single-center retrospective study included 401 patients who underwent ERCP between July 2015 and March 2020. After December 2016, we administered rectal diclofenac within 30 min before the ERCP procedure as widely as possible. Patients were divided into those who did (diclofenac group) and did not (control group) receive rectal diclofenac. Patients weighing ≥ 50 kg were administered a 50 mg dose, while those weighing < 50 kg were administered a 25 mg dose. The incidence and severity of PEP in the two groups were assessed by propensity score matching analysis. RESULTS Among 401 patients undergoing ERCP, 367 fulfilled the inclusion criteria. Overall, 187 patients received rectal diclofenac (diclofenac group) and 180 did not (control group). After propensity score matching, 105 pairs were selected for evaluation. Overall, seven (6.7%) patients in the diclofenac group and 10 (9.5%) in the control group developed PEP (P = 0.45). Moderate or severe PEP occurred in four (3.8%) patients in the diclofenac group and six (5.7%) in the control group (P = 0.52). CONCLUSIONS The administration of low-dose rectal diclofenac could not reduce the incidence and severity of PEP.
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Affiliation(s)
- Hiroaki Sakai
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Naoto Iwai
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan.
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Junichi Sakagami
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Takashi Okuda
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Tomoya Ohara
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Chie Hattori
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Masashi Taniguchi
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Kohei Oka
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Tasuku Hara
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Toshifumi Tsuji
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Toshiyuki Komaki
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Keizo Kagawa
- Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan
| | - Osamu Dohi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroaki Yasuda
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hideyuki Konishi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Xu X, Guan L, Wu Y, Ke H, Zhao Y, Liu P. One hundred most cited articles related to Endoscopic retrograde cholangiopancreatography: A bibliometric analysis. Front Surg 2022; 9:1005771. [PMID: 36439532 PMCID: PMC9681810 DOI: 10.3389/fsurg.2022.1005771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) has developed over the past few decades into a reliable technology for diagnostic and therapeutic purposes. Through a bibliometric analysis, this research attempted to evaluate the characteristics of the top 100 articles on ERCP that had the most citations. Methods We extracted pertinent publications from the Web of Science Core Collection (WoSCC) on July 9, 2022. The top 100 ERCP articles with the most citations were identified and analyzed. The following data were extracted: publication year, country/region, organization, total citation times, annual citation times, research type and research field, etc. To implement the network’s visual analysis, a bibliographic coupling network based on keywords was built using the VOSviewer 1.6.17 program. Results The journal with the most publications were GASTROINTESTINAL ENDOSCOPY, with 45 articles. Most of the top 100 articles came from the United States (n = 47) and Italy (n = 14). Indiana University and the University of Amsterdam were among the most important institutions in ERCP research. ML Freeman of the University of Minnesota contributed the highest number (n = 9) and the most highly cited paper. The age of the paper and article type is closely related to citation frequency. Of the 100 most-cited articles, clinical application in the field of ERCP has focused on three aspects: diagnosis, treatment, and complications. Clinical use of ERCP has shifted from diagnosis to treatment. Post-ERCP pancreatitis is the focus of attention, and the clinical application of technically complex therapeutic ERCP is the future development trend. Conclusion This study lists the most influential articles in ERCP by exposing the current state of the field, and showing the evolution of research trends to provide perspective for the future development of ERCP.
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Affiliation(s)
- Xuan Xu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- First Clinical Medical College, Nanchang University, Nanchang, China
| | - Lulu Guan
- First Clinical Medical College, Nanchang University, Nanchang, China
| | - Yao Wu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huajing Ke
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuanbin Zhao
- Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Pi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Department of Gastroenterology, The People’s Hospital of Longhua, Shenzhen, China
- Correspondence: Pi Liu
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Double guide-wire technique versus transpancreatic biliary sphincterotomy for difficult biliary cannulation: Real life experience from a referral center. Dig Liver Dis 2022; 54:1548-1553. [PMID: 35931625 DOI: 10.1016/j.dld.2022.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/19/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND During ERCP for biliary indication, when a difficult bile duct (BD) cannulation occurs, with unintended access to the main pancreatic duct (PD), both double guidewire technique (DGW) and transpancreatic biliary sphincterotomy (TPBS) can be performed. We aimed to compare the technical success and adverse events (AEs) rate of these techniques. METHODS A retrospective analysis of patients with naïve papillae referred to the Pancreas Institute of Verona from January 2016 and July 2021 to undergo ERCP for biliary indications was performed. RESULTS Overall, 202 patients (53.5% males, mean age 67.2 years) were evaluated (96 DGW, 106 TPBS). Malignant biliary stricture was the most common ERCP indication (78.2%). The rate of success in deep biliary cannulation was significantly higher in the DGW group (94.8%) compared to TPBS (79.2%) at the first attempt (p = 0.001). This result was also confirmed in the subgroup of patients with malignant distal stricture (72/77, 93.5% vs 63/80, 78.8%, p = 0.01). No significant difference in AEs rate, particularly in PEP incidence was found between the two groups. CONCLUSIONS DGW demonstrated a higher success rate and similar safety profile compared with TPBS in difficult biliary cannulation. Based on this retrospective study, DGW should be preferred over TPBS in case of unintended PD cannulation. Further prospective studies are needed to confirm our results.
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Niu M, Zhang X, Song P, Li L, Wen L. Intraductal pressure in experimental models of acute and chronic pancreatitis in mice. Pancreatology 2022; 22:917-924. [PMID: 35989220 DOI: 10.1016/j.pan.2022.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Pancreatic intraductal pressure is related to the development of pancreatitis, including post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis. In this study, we investigate pancreatic intraductal pressure in various mouse models of acute and chronic pancreatitis. METHODS Post-ERCP pancreatitis was induced by retrograde infusion of normal saline or radiocontrast at the constant rate of 10 or 20 μL/min. Obstructive pancreatitis was induced by ligation of the pancreatic duct followed by a single injection of caerulein and the changes of intraductal pressure were recorded in day 3 for obstructive acute pancreatitis and day 14 for obstructive chronic pancreatitis. Non-obstructive pancreatitis was induced by repetitive intraperitoneal injections of caerulein. The changes of intraductal pressure were recorded right after the last caerulein injection for non-obstructive acute pancreatitis and after the completion of 4-week caerulein injections for non-obstructive chronic pancreatitis. RESULTS Elevated pancreatic intraductal pressure was observed in both normal saline and radiocontrast infusion groups and was furtherly indicated that was positively correlated with the viscosity of solution but not genders. In the models of obstructive pancreatitis, a rise in intraductal pressure was observed in both acute and chronic pancreatitis; whereas in the models of non-obstructive pancreatitis, a rise in intraductal pressure was only observed in chronic, but not acute pancreatitis. CONCLUSIONS During ERCP, the elevations in pancreatic intraductal pressure are induced by increasing rate or viscous solution of infusion. During different forms of experimental acute and chronic pancreatitis, obstructive or non-obstructive etiologies of pancreatitis also induces the elevations in pancreatic intraductal pressure.
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Affiliation(s)
- Mengya Niu
- Department of Gastroenterology and Shanghai Key Laboratory of Pancreatic Disease, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Xiuli Zhang
- Department of Gastroenterology and Shanghai Key Laboratory of Pancreatic Disease, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pengli Song
- Department of Gastroenterology and Shanghai Key Laboratory of Pancreatic Disease, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liang Li
- Department of Gastroenterology and Shanghai Key Laboratory of Pancreatic Disease, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Wen
- Department of Gastroenterology and Shanghai Key Laboratory of Pancreatic Disease, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.
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Muacevic A, Adler JR. Exploring the Association Between Paralytic Ileus and Endoscopic Retrograde Cholangiopancreatography Complications Using the National Inpatient Sample Database. Cureus 2022; 14:e30319. [PMID: 36407216 PMCID: PMC9661870 DOI: 10.7759/cureus.30319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2022] [Indexed: 01/25/2023] Open
Abstract
Introduction Paralytic ileus (PI) is often seen in critically ill hospitalized patients. Those with pancreaticobiliary diseases will require endoscopic retrograde cholangiopancreatography (ERCP) for management. Here, we will explore the association between patients with paralytic ileus who underwent ERCP and post-procedural complications, which has not been done before. Methods Patients who underwent ERCP between 2007 and 2017 in the National Inpatient Sample database were selected. Cases were matched 1:1 by age, gender, race, and the Elixhauser comorbidity index for patients with and without pre-procedural paralytic ileus. Primary outcomes were associations between paralytic ileus and length of stay, payor status, and average total charges. Secondary outcomes were associations between paralytic ileus and post-ERCP complications (infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage), and overall mortality. The Chi-squared analysis was used to compare categorical data, and the independent t-test was used for continuous data. Regression analysis was used to assess primary and secondary outcomes. Results Of 2,008,217 hospitalized patients from 2007 to 2017, 43,643 patients had paralytic ileus and 43,859 patients did not, before undergoing ERCP. There were no differences in age, gender, race, or the Elixhauser comorbidity index. The differences in the length of stay, payor status, and total charges were significant (p<0.001). Patients with paralytic ileus had increased risks of post-ERCP infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage, and overall mortality (p<0.001). Conclusions Patients hospitalized with paralytic ileus who underwent ERCP had a longer length of stay, higher total charges, and were less compensable. They also had increased risks for post-ERCP infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage, and overall mortality, which can be from critical illness and the systemic inflammatory response.
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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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Post-ERCP Pancreatitis: Prevention, Diagnosis and Management. Medicina (B Aires) 2022; 58:medicina58091261. [PMID: 36143938 PMCID: PMC9502657 DOI: 10.3390/medicina58091261] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/21/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) carries a post-ERCP pancreatitis (PEP) rate of 2–10%, which could be as high as 30–50% in high-risk cases. PEP is severe in up to 5% of cases, with potential for life-threatening complications, including multi-organ failure, peripancreatic fluid collections, and death in up to 1% of cases. The risk of PEP is potentially predictable and may be modified with pharmacological measures and endoscopist technique. This review covers the definition, epidemiology and risk factors for PEP, with a focus on the latest evidence-based medical and endoscopic strategies to prevent and manage PEP.
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Zhang R, Liu J, Li H, Zeng Q, Wu S, Tian H. Evaluation of therapeutic efficacy, safety and economy of ERCP and LTCBDE in the treatment of common bile duct stones. Front Physiol 2022; 13:949452. [PMID: 36091409 PMCID: PMC9452837 DOI: 10.3389/fphys.2022.949452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: This study further compared the endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic transcystic common bile duct exploration (LTCBDE) approaches in the treatment of common bile duct stones (CBDS) from the perspective of efficacy, safety and economy.Methods: The therapeutic efficacy and safety of ERCP and LTCBDE approaches were retrospectively compared. Cost-effectiveness analysis of clinical economics was performed to analyze and evaluate the two approaches.Results: There was no significant difference in the success rate of surgery and bile stone residue between ERCP and LTCBDE group. The incidence of postoperative complications in ERCP group was significantly higher than that in the LTCBDE group; while the incidence of pancreatitis in the ERCP group was significantly higher than that in the LTCBDE group. There was no significant difference in biliary infection, bile leakage and sepsis between ERCP and LTCBDE groups. In terms of cost, the costs of surgery and nursing were significantly lower, the costs of treatment and sanitary materials were significantly higher in the ERCP group than that in the LTCBDE group. There was no significant difference in the costs of medical examination, laboratory test, medicine cost and total cost between ERCP group and LTCBDE group. The total length of hospital stay, length of hospital stay before surgery and duration of surgery in the ERCP group were significantly lower than that in the LTCBDE group; there was no significant difference in length of hospital stay after surgery between the ERCP and LTCBDE group. The cost-effectiveness ratio of ERCP group was 34171.25, and the cost-effectiveness of LTCBDE group was 34524.25. The incremental cost-effectiveness ratio (ICER) of the two groups was 51415.Conclusion: ERCP and LTCBDE approaches had similar therapeutic efficacy in the treatment of CBDS. The safety of LTCBDE approach is superior to that of ERCP approach for the treatment of CBDS. ERCP approach is more economical in the treatment of CBDS than LTCBDE approach.
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Affiliation(s)
- Renjie Zhang
- Department of Hepatobiliary Surgery, Shenzhen Traditional Chinese Medicine Hospital/The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Jialin Liu
- Department of Hepatobiliary Surgery, Shenzhen Traditional Chinese Medicine Hospital/The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Huizhen Li
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Qingteng Zeng
- Department of Hepatobiliary Surgery, Shenzhen Traditional Chinese Medicine Hospital/The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Shenfeng Wu
- Department of Hepatobiliary Surgery, Shenzhen Traditional Chinese Medicine Hospital/The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Hengyu Tian
- Department of Hepatobiliary Surgery, Shenzhen Traditional Chinese Medicine Hospital/The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
- *Correspondence: Hengyu Tian,
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Maharshi S, Sharma SS. Response. Gastrointest Endosc 2022; 96:167-168. [PMID: 35715121 DOI: 10.1016/j.gie.2022.03.016] [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: 03/12/2022] [Accepted: 03/17/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Sudhir Maharshi
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Shyam Sunder Sharma
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
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Laparo-Endoscopic Rendez-Vous in the Treatment of Cholecysto-Choledocolithiasis in the Pediatric Population. J Pediatr Gastroenterol Nutr 2022; 74:819-822. [PMID: 35258502 DOI: 10.1097/mpg.0000000000003444] [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: 12/10/2022]
Abstract
OBJECTIVES The incidence of choledocolithiasis is reported to be increasing in children. As for the adult population, several different therapeutic strategies have been described, however it is unclear which of those should be considered the gold standard. There is evidence-based literature in adults that supports a combined "rendez-vous" endoscopic retrograde cholangiopancreatography-laparoscopic cholecystectomy technique. This allows management of the choledocholithiasis during the same anesthetic episode as the cholecystectomy. By contrast, there are just two case reports in children reporting this approach. The aim of this study is to report our experience with this technique in a series of children with choledocholithiasis. METHODS All patients who underwent the "rendez-vous technique" at our institution between 2009 and 2020 were reviewed and evaluated for outcomes and complications. RESULTS Eleven children with cholecysto-choledocholithiasis were evaluated: the procedure was successful in 10 whereas in one patient it was aborted due to technical difficulties. All patients resolved their clinical condition without major complications. CONCLUSION To our knowledge, this is the first consistent series of "rendez-vous technique" in the pediatric population, proving its feasibility and safety.
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Fujita Y, Hirono S, Kawai M, Okada KI, Miyazawa M, Kitahata Y, Ueno M, Hayami S, Kobayashi R, Yanagisawa A, Yamaue H. Malignant potential and specific characteristics of pure main duct type intraductal papillary mucinous neoplasm. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1054-1061. [PMID: 34933794 DOI: 10.1016/j.ejso.2021.11.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/03/2021] [Accepted: 11/29/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND As the malignant potential of main duct (MD-) type intraductal papillary mucinous neoplasm (IPMN) has been discussed together with Mixed-type in most previous studies, the malignant potential of pure MD-type IPMN remains unclear. This study evaluated the specific characteristics and predictors of high-grade dysplasia (HGD) and invasive intraductal papillary mucinous carcinoma (IPMC) for pure MD-type IPMN. METHODS From 1,100 patients with IPMN, this study includes 387 patients that underwent surgery. We evaluated the specific characteristics of pure MD-type IPMN by comparing clinicopathological factors between MD-type (n = 79) and branch duct (BD-) type (n = 146) or Mixed-type IPMN (n = 162), and predictors of HGD/invasive IPMC in pure MD-type IPMN. RESULTS The rate of HGD/invasive IPMC was significantly higher in MD-type than in BD-type (70.9 vs. 48.6%, P = 0.001), although there was no difference between MD-type and Mixed-type IPMNs (P = 0.343). Recurrence-free survival (RFS) and disease-specific survival (DSS) of patients with MD-type were better than those of patients with Mixed-type (P = 0.008 and P = 0.009, respectively). There were no significant differences in RFS, overall survival, and DSS between patients with MD-type and patients with BD-type IPMNs. Multivariate analysis showed two independent predictors of HGD/invasive IPMC in MD-type IPMN; mural nodule height ≥5 mm (P = 0.025, odds ratio [OR]; 16.949) and carcinoembryonic antigen (CEA) level in the pancreatic juice obtained by preoperative endoscopic retrograde pancreatography ≥50 ng/ml (P = 0.039, OR; 9.091). CONCLUSIONS Measurement of mural nodule height and CEA in the pancreatic juice might be useful in determining surgical indication for pure MD-type IPMN, although further studies for confirmation are essential.
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Affiliation(s)
- Yoichi Fujita
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Seiko Hirono
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan.
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Ken-Ichi Okada
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Motoki Miyazawa
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Yuji Kitahata
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Masaki Ueno
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Shinya Hayami
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Ryohei Kobayashi
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Akio Yanagisawa
- Department of Pathology, Japanese Red Cross Kyoto Daiichi Hospital, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
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Takada T, Isaji S, Mayumi T, Yoshida M, Takeyama Y, Itoi T, Sano K, Iizawa Y, Masamune A, Hirota M, Okamoto K, Inoue D, Kitamura N, Mori Y, Mukai S, Kiriyama S, Shirai K, Tsuchiya A, Higuchi R, Hirashita T. JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:1057-1083. [PMID: 35388634 DOI: 10.1002/jhbp.1146] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND In preparing the Japanese (JPN) guidelines for the management of acute pancreatitis 2021, the committee focused the issues raised by the results of nationwide epidemiological survey in 2016 in Japan METHOD: In addition to a systematic search using the previous JPN guidelines, papers published from January 2014 to September 2019 were searched for the contents to be covered by the guidelines based on the concept of GRADE system. RESULTS Thirty-six clinical questions (CQ) were prepared in 15 subject areas. Base on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast-enhanced CT grade had a high fatality rate and that little prognosis improvement after 2 weeks of disease onset was not obtained, we emphasized the importance of Pancreatitis Bundles, which was shown to be effective in improving prognosis, and the CQ sections for local pancreatic complications had been expanded to ensure adoption of a step-up approach. Furthermore, on the facts that enteral nutrition for severe acute pancreatitis was not started early within 48 hours of admission and that unnecessary prophylactic antibiotics was used in almost all cases, we emphasized early enteral nutrition in small amounts even if gastric feeding is used and no prophylactic antibiotics in mild pancreatitis. CONCLUSION All the members of the committee have put a lot of effort into preparing the extensively revised guidelines in the hope that more people will have a common understanding and that better medical care will be spread.
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Affiliation(s)
- Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Shuji Isaji
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, School of Medicine, International University of Health & Welfare, Chiba, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Takao Itoi
- Department. of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yusuke Iizawa
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Fukuoka, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Hospital, Ishikawa, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Chiba, Japan
| | - Yasuhisa Mori
- Department of Surgery I, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Shuntaro Mukai
- Department. of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, Gifu, Japan
| | - Kunihiro Shirai
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
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Tse F, Liu J, Yuan Y, Moayyedi P, Leontiadis GI. Guidewire-assisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Cochrane Database Syst Rev 2022; 3:CD009662. [PMID: 35349163 PMCID: PMC8963249 DOI: 10.1002/14651858.cd009662.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cannulation techniques have been recognized as being important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, considerable controversy exists about the usefulness of the guidewire-assisted cannulation technique for the prevention of PEP. OBJECTIVES To assess the effectiveness and safety of the guidewire-assisted cannulation technique compared to the conventional contrast-assisted cannulation technique for the prevention of PEP in people undergoing diagnostic or therapeutic ERCP for biliary or pancreatic diseases. SEARCH METHODS For the previous version of this review, we searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL and major conference proceedings, up to February 2012, with no language restrictions. An updated search was performed on 26 February 2021 for the current version of this review. Two clinical trial registries, clinicaltrials.gov and WHO ICTRP, were also searched in this update. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing the guidewire-assisted cannulation technique versus the contrast-assisted cannulation technique in people undergoing ERCP. DATA COLLECTION AND ANALYSIS Two review authors conducted study selection, data extraction, and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test (P < 0.10) and I² statistic (> 50%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, publication type, risk of bias, use of precut sphincterotomy, inadvertent guidewire insertion or contrast injection of the pancreatic duct (PD), use of a PD stent, cannulation device, and trainee involvement in cannulation. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects) and per-protocol analysis. MAIN RESULTS 15 RCTs comprising 4426 participants were included. There was moderate heterogeneity among trials for the outcome of PEP (P = 0.08, I² = 36%). Meta-analyses suggest that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique (RR 0.51, 95% CI 0.36 to 0.72, 15 studies, moderate-certainty evidence). In addition, the guidewire-assisted cannulation technique may result in an increase in primary cannulation success (RR 1.06, 95% CI 1.01 to 1.12, 13 studies, low-certainty evidence), and probably reduces the need for precut sphincterotomy (RR 0.79, 95% CI 0.64 to 0.96, 10 studies, moderate-certainty evidence). Compared to the contrast-assisted cannulation technique, the guidewire-assisted cannulation technique may result in little to no difference in the risk of post-sphincterotomy bleeding (RR 0.87, 95% CI 0.49 to 1.54, 7 studies, low-certainty evidence) and perforation (RR 0.93, 95% CI 0.11 to 8.23, 8 studies, very low-certainty evidence). Procedure-related mortality was reported by eight studies, and there were no cases of deaths in both arms (moderate-certainty evidence). Subgroup analyses suggest that the heterogeneity for the outcome of PEP could be explained by differences in trial design. The results were robust in sensitivity analyses. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique. There is low-certainty evidence that the guidewire-assisted cannulation technique may result in an increase in primary cannulation success. There is low- and very low-certainty evidence that the guidewire-assisted cannulation technique may result in little to no difference in the risk of bleeding and perforation. No procedure-related deaths were reported. Therefore, the guidewire-assisted cannulation technique appears to be superior to the contrast-assisted cannulation technique considering the certainty of evidence and the balance of benefits and harms. However, the routine use of guidewires in biliary cannulation will be dependent on local expertise, availability, and cost. Future research should assess the effectiveness and safety of the guidewire-assisted cannulation technique in the context of other pharmacologic or non-pharmacologic interventions for the prevention of PEP.
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Affiliation(s)
- Frances Tse
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, Hamilton, Canada
| | - Jasmine Liu
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Yuhong Yuan
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
| | - Paul Moayyedi
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, Hamilton, Canada
| | - Grigorios I Leontiadis
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, Hamilton, Canada
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Park CH, Chung MJ, Park DH, Min S, Park SW. Impact of pancreatic fat on the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis. Surg Endosc 2022; 36:5734-5742. [PMID: 35099627 DOI: 10.1007/s00464-022-09070-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 01/20/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND STUDY AIMS Fatty pancreas is a potential risk factor for acute pancreatitis; however, whether it is also a risk factor for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) has not been evaluated. We aimed to determine the impact of fatty pancreas on the development of PEP. METHODS We analyzed the data of patients who underwent abdominal computed tomography (CT) scan and sequential therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Fatty change in the pancreas was evaluated based on pancreatic attenuation of unenhanced image on CT scan. The risk of fatty pancreas for the development of PEP was evaluated using a logistic regression model. RESULTS Of a total of 858 patients included in the study, 354 (41.3%) had fatty pancreas, while 504 (58.7%) did not have fatty pancreas. PEP developed in 28 patients (7.9%) in the fatty pancreas group and in 13 patients (2.6%) in the no fatty pancreas group. Fatty pancreas was significantly associated with the development of PEP (odds ratio [OR] [95% confidence interval [CI]] 2.38 [1.16-4.87]). A history of acute pancreatitis, female sex, difficult cannulation, and endoscopic papillary balloon dilation were also risk factors for the development of PEP. The risk for moderate-to-severe PEP development tended to be higher in the fatty pancreas group than in the no fatty pancreas group (OR [95% CI] 5.61 [0.63-49.62]). CONCLUSIONS Fatty pancreas is a significant risk factor for the development of PEP. Clinicians need to be aware of the risk of fatty pancreas for the development of PEP prior to performing ERCP.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Republic of Korea
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Da Hae Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Republic of Korea
| | - Seonjeong Min
- Department of Radiology, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Gyeonggi-do, Republic of Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Republic of Korea.
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Park SW, Jang SI, Chung MJ, Cho JH, Bang S. [Comparison of Clinical Performance and Safety between Domestic New Pull-type Triple-lumen Sphincterotome and Conventional Sphincterotome: A Prospective Multicenter Trial]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:22-30. [PMID: 35086969 DOI: 10.4166/kjg.2021.147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/03/2022]
Abstract
Background/Aims Sphincterotomes are essential for endoscopic sphincterotomy (EST) and can also be used for cannulation in ERCP. A domestic new pull-type sphincterotome (Optimos™, Taewoong, Goyang, Korea) provides acceptable technical feasibility and safety, but there are no comparison results. Thus, this study compared the clinical performance and safety of Optimos™ sphincterotome to a conventional sphincterotome (CleverCut3™, Olympus, Tokyo, Japan) in patients who underwent ERCP. Methods From April 2021 to July 2021, a randomized prospective comparative study was conducted on 104 consecutive patients who underwent ERCP in three medical centers. The primary endpoint was the clinical performance and safety of sphincterotomes during ERCP. Results One hundred and four patients were assigned randomly to the Optimos™ group (n=51) or CleverCut3™ group (n=53). All demographic characteristics did not differ between the groups except the BMI. The technical success rate for cannulation, performance of EST, and total procedure time were similar in the two groups. The adverse events did not differ, even though two cases of post-ERCP pancreatitis occurred in CleverCut3™. On the other hand, in questionnaire analysis, CleverCut™ showed a better user's convenience (median [interquartile range] 4.0 [3.0-4.0] vs. 3.0 [3.0-4.0], p=0.013) and manipulability (median [interquartile range], 4.0 [3.0-4.0] vs. 3.0 [3.0-4.0], p=0.039) than Optimos™, even though the other profiles did not reveal any differences. Conclusions New domestic pull-type sphincterotome can offer comparable clinical performance and safety profiles to conventional sphincterotome, but it needs refinements to increase the user's convenience and manipulability. Further improvement and innovation will be required to advance domestic medical devices.
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Affiliation(s)
- Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Sung Ill Jang
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cho
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Complications of Endoscopic Retrograde Cholangiopancreatography in Patients With Previous Bariatric Surgery: A National Inpatient Sample Analysis, 2007-2013. J Clin Gastroenterol 2022; 56:81-87. [PMID: 33405433 DOI: 10.1097/mcg.0000000000001483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/22/2020] [Indexed: 12/10/2022]
Abstract
BACKGROUND Bariatric surgery (BS) has been proven to be effective in the treatment of obesity and weight-related diseases, but the anatomic changes after BS make endoscopic retrograde cholangiopancreatography (ERCP) technically challenging. This study aims to assess the safety and clinical outcomes of ERCP in patients with previous BS. MATERIALS AND METHODS The National Inpatient Sample from 2007 to 2013 was queried for hospitalizations of adults over 18 years of age with procedure diagnoses of ERCP. Those with prior BS were selected as cases and those without BS as controls. Case-control matching at a ratio of 1 case to 2 controls was performed based on sex, age, race, comorbidities, and obesity. The primary outcomes were inpatient mortality and ERCP-related complications. Multivariate regression analysis was used to identify independent risk factors associated to the primary outcomes. RESULTS A total of 1,068,862 weighted hospitalizations with ERCP procedure codes were identified. Of these, 6689 with BS were selected as cases, and 13,246 were matched as controls. The reason for hospital admission was most often biliary stone disease (60.7% vs. 55.5%), followed by malignancy (3.5% vs. 12.1%) and cholangitis (7.7% vs. 4.5%) with and without BS, P<0.05. The BS group had lower rates of post-ERCP pancreatitis (0.1% vs. 1.3%), cholecystitis (0.1% vs. 0.3%), bleeding (1.0% vs. 1.4%), and inpatient mortality (0.2% vs. 0.5%), but had higher rates of cholangitis (5.0% vs. 3.7%) and systemic infections (6.2% vs. 4.8%), all P<0.05. CONCLUSIONS BS group had lower post-ERCP pancreatitis, cholecystitis and bleeding while had more cholangitis, and systemic infection compared with those without BS. Also, BS was independently associated with reduced inpatient mortality after adjusted for age, race, and comorbidity.
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Bang JY, Hawes R, Varadarajulu S. Endoscopic biliary drainage for malignant distal biliary obstruction: Which is better - endoscopic retrograde cholangiopancreatography or endoscopic ultrasound? Dig Endosc 2022; 34:317-324. [PMID: 34748675 PMCID: PMC9299777 DOI: 10.1111/den.14186] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/03/2021] [Accepted: 11/05/2021] [Indexed: 12/13/2022]
Abstract
Presently, following endoscopic ultrasound (EUS)-guided biopsy, an endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stenting is performed for palliation of malignant distal biliary obstruction (MDBO). However, technical failure and postprocedure pancreatitis are limitations to ERCP. Endoscopic ultrasonography-guided biliary drainage (EUS-BD) after a failed ERCP has a 90% technical success rate and has been shown to be superior when compared to percutaneous methods, making EUS an increasingly recognized option for biliary drainage. Supporting this approach, findings from recently concluded randomized trials suggest that the safety profile and technical outcomes for EUS-BD are comparable or even superior to that of ERCP for primary biliary decompression in patients with MDBO. Also, EUS-BD is increasingly being utilized in patients with altered surgical anatomy in lieu of percutaneous techniques and balloon-assisted enteroscopy. A growing body of evidence supports the notion that, in the future, EUS may become the primary modality by which biliary decompression is undertaken in the majority of patients with MDBO. The roadmap to this eventuality may require further optimization of procedural techniques, technological innovations, and cost reduction.
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Affiliation(s)
| | - Robert Hawes
- Digestive Health InstituteOrlando HealthOrlandoUSA
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Thiruvengadam NR, Saumoy M, Schneider Y, Attala S, Triggs J, Lee P, Kochman ML. A Cost-Effectiveness Analysis for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Prophylaxis in the United States. Clin Gastroenterol Hepatol 2022; 20:216-226.e42. [PMID: 34481952 DOI: 10.1016/j.cgh.2021.08.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common adverse event after endoscopic retrograde cholangiopancreatography, and is responsible for substantial morbidity and health care expenditures of at least $200 million. Therapies for PEP prevention include pancreatic stent placement (PSP), rectal indomethacin, sublingual nitrates, and aggressive lactated Ringer's hydration. Our objective was to determine which PEP prophylactic strategies are cost effective. METHODS We developed 2 separate decision trees to evaluate PEP prophylactic strategies. The first, in high-risk patients, compared rectal indomethacin, PSP, PSP with indomethacin, sublingual nitrates, aggressive hydration with lactated Ringer's, and no prophylaxis. The second, in average-risk patients, compared rectal indomethacin, sublingual nitrates, aggressive hydration, and no prophylaxis. We used incidence rates, transition probabilities, and costs from publications and public data sources. Outcome measures were reported as incremental cost-effectiveness ratios, with a willingness-to-pay (WTP) threshold of $100,000/quality-adjusted life years (QALYs). RESULTS Compared with no prophylaxis, all strategies were cost effective at a WTP of $100,000 in preventing PEP in high-risk patients. When directly compared with each other, rectal indomethacin was the cost-effective strategy in high-risk patients ($31,589/QALYs). In average-risk patients, indomethacin and sublingual nitrates were cost effective at a WTP of $100,000/QALYs compared with no prophylaxis. When directly compared with each other, rectal indomethacin was the cost-effective strategy ($53,016/QALYs). CONCLUSIONS Rectal indomethacin was the cost-effective strategy for preventing PEP in both average-risk and high-risk patients undergoing endoscopic retrograde cholangiopancreatography. All strategies were cost effective when compared with no prophylaxis in high-risk patients, whereas all strategies except for aggressive hydration with lactated Ringer's were cost effective in average-risk patients. Further studies are needed to improve the utilization of PEP prevention strategies.
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Affiliation(s)
- Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California; Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Endoscopic Innovation, Research and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Monica Saumoy
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Sara Attala
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph Triggs
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Peter Lee
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael L Kochman
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Endoscopic Innovation, Research and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Suzuki A, Uno K, Nakase K, Mandai K, Endoh B, Chikugo K, Kawakami T, Suzuki T, Nakai Y, Kusumoto K, Itokawa Y, Inatomi O, Bamba S, Mizumoto Y, Tanaka K. Post-endoscopic retrograde cholangiopancreatography pancreatitis assessed using criteria for acute pancreatitis. JGH Open 2021; 5:1391-1397. [PMID: 34950783 PMCID: PMC8674548 DOI: 10.1002/jgh3.12687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/10/2022]
Abstract
Background and Aim International consensus on the definition and classification of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has been reached. However, the diagnosis and severity of PEP are often assessed according to the diagnostic criteria and classification for acute pancreatitis (AP). This study determined the incidence, severity, and risk factors of PEP diagnosed according to the diagnostic criteria and classification for AP in a large cohort. Methods This prospective, multicenter, observational cohort study conducted at five high-volume centers included 1932 patients who underwent ERCP-related procedures. The incidence, severity, and risk factors for PEP were evaluated. Results PEP occurred in 142 patients (7.3%); it was mild in 117 patients (6.0%) and severe in 25 patients (1.3%). According to the Cotton criteria, PEP occurred in 87 patients (4.5%); it was mild in 54 patients (2.8%), moderate in 20 patients (1.0%), and severe in 13 patients (0.7%). In the multivariate analysis, female sex (odds ratio [OR] 2.239; 95% confidence interval [CI] 1.546-3.243), naïve papilla (OR 3.047; 95% CI 1.803-5.150), surgically-altered gastrointestinal anatomy (OR 2.538; 95% CI 1.342-4.802), procedure time after reaching the papilla (OR 1.009; 95% CI 1.001-1.017), pancreatic duct injection (OR 2.396; 95% CI 1.565-3.669), and intraductal ultrasonography (OR 1.641; 95% CI 1.024-2.629) were independent risk factors. Conclusion According to the diagnostic criteria and classification for AP, the incidence of PEP was higher than that according to the Cotton criteria and the severity of PEP tended to be severe.
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Affiliation(s)
- Azumi Suzuki
- Department of Gastroenterology Kyoto Second Red Cross Hospital Kyoto Japan.,Present address: Department of Gastroenterology Hamamatsu Medical Center Shizuoka Japan
| | - Koji Uno
- Department of Gastroenterology Kyoto Second Red Cross Hospital Kyoto Japan
| | - Kojiro Nakase
- Department of Gastroenterology Kyoto Second Red Cross Hospital Kyoto Japan.,Present address: Department of Gastroenterology Kyoto Okamoto Memorial Hospital Kyoto Japan
| | - Koichiro Mandai
- Department of Gastroenterology Kyoto Second Red Cross Hospital Kyoto Japan
| | - Bunji Endoh
- Department of Gastroenterology National Hospital Organization Kyoto Medical Center Kyoto Japan
| | - Koki Chikugo
- Department of Gastroenterology National Hospital Organization Kyoto Medical Center Kyoto Japan.,Present address: Center for Gastroenterology Teine Keijinkai Hospital Sapporo Japan
| | - Takumi Kawakami
- Department of Gastroenterology Japanese Red Cross Kyoto Daiichi Hospital Kyoto Japan.,Present address: Department of Gastroenterology Municipal Tsuruga Hospital Fukui Japan
| | - Takahiro Suzuki
- Department of Gastroenterology Japanese Red Cross Kyoto Daiichi Hospital Kyoto Japan.,Present address: Suzuki Naika Iin Kyoto Japan
| | - Yoshitaka Nakai
- Digestive Disease Center, Department of Gastroenterology and Hepatology Kyoto Katsura Hospital Kyoto Japan
| | - Kiyonori Kusumoto
- Digestive Disease Center, Department of Gastroenterology and Hepatology Kyoto Katsura Hospital Kyoto Japan
| | - Yoshio Itokawa
- Digestive Disease Center, Department of Gastroenterology and Hepatology Kyoto Katsura Hospital Kyoto Japan
| | - Osamu Inatomi
- Division of Gastroenterology, Department of Medicine Shiga University of Medical Science Otsu Japan
| | - Shigeki Bamba
- Division of Gastroenterology, Department of Medicine Shiga University of Medical Science Otsu Japan
| | - Yoshinori Mizumoto
- Department of Gastroenterology National Hospital Organization Kyoto Medical Center Kyoto Japan
| | - Kiyohito Tanaka
- Department of Gastroenterology Kyoto Second Red Cross Hospital Kyoto Japan
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Pulvirenti R, Tognon C, Bisoffi S, Ghidini F, De Corti F, Fascetti Leon F, Antoniello LM, Gamba P. Innovative Techniques Associated with Traditional Abdominal Surgery in Complex Pediatric Cases: A Tertiary Center Experience. CHILDREN-BASEL 2021; 8:children8100898. [PMID: 34682163 PMCID: PMC8534733 DOI: 10.3390/children8100898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/20/2022]
Abstract
Pediatric abdominal surgery is constantly evolving, alongside the advent of new surgical technologies. A combined use of new tools and traditional surgical approaches can be useful in the management of complex cases, allowing less invasive procedures and sometimes even avoiding multiple interventions. This combination of techniques has implications even from the anesthetic point of view, especially in post-operative pain control. Thereby, tertiary level centres, including highly-specialized professionals and advanced equipment, can maximize the effectiveness of treatments to improve the final outcomes. Our paper aims to present some possible combinations of techniques recently used at our institution to provide a one-session, minimally invasive treatment within different areas of abdominal surgery.
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Affiliation(s)
- Rebecca Pulvirenti
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
- Correspondence: ; Tel.: +39-347-369-6172
| | - Costanza Tognon
- Anesthesiology Pediatric Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy;
| | - Silvia Bisoffi
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
| | - Filippo Ghidini
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
| | - Federica De Corti
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
| | - Luca Maria Antoniello
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
| | - Piergiorgio Gamba
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
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Icacan G, Onalan E, Yucesoy M. Comparison of stent and indomethacin suppository efficacy in the prevention of acute pancreatitis after ERCP. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021178. [PMID: 34487093 PMCID: PMC8477098 DOI: 10.23750/abm.v92i4.10962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 11/23/2022]
Abstract
Objective: We aimed to compare stent and indomethacin suppository efficacy in the prevention of acute pancreatitis after ERCP. Materials and Methods: 76 high-risk patients undergoing ERCP were included in the study. The patients were divided into three groups as indomethacin group, stent group and control group. Indomethacin group (n = 32) received 100 mg rectal indomethacin immediately after ERCP. A 5F pancreatic stent was applied to the stent group (n = 16) during ERCP. No prophylaxis was given to the control group (n = 28). Results: There was no difference between the groups in terms of age and gender. ERCP pancreatitis was seen in 9.2% (7/76) of the patients. The incidence of ERCP-induced pancreatitis (PEP) was 3.1% (1/32) in the indomethacin group and 21.4% (6/28) in the control group. PEP was not seen in the stent group (0/16). The incidence of PEP was significantly lower in the indomethacin group than in the control group (p = 0.043). However, no significant difference was found between the stent and control groups, stent and indomethacin groups in terms of PEP frequency (p = 0.072, p: 0.90 respectively). Conclusion: According to the results of our study, rectal indomethacin administration decreased the frequency of PEP in high-risk patients. However, there was no significant difference in PEP prophylaxis between the stent and indomethacin groups.
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Affiliation(s)
- Gamze Icacan
- Fırat University, Deparment of Nephrology, Faculty of Medicine, Elazığ,Turkey.
| | - Erhan Onalan
- Department of Internal Medicine, Faculty of Medicine, Firat Univeristy, 23000, Elazig, Turkey.
| | - Mehmet Yucesoy
- Erciyes University, Deparment of Internal Medicine, Faculty of Medicine, Kayseri,Turkey.
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48
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Ru N, Qian YY, Zhu JH, Chen H, Zou WB, Hu LH, Pan J, Guo JY, Li ZS, Liao Z. Post-ESWL and post-ERCP pancreatitis in patients with chronic pancreatitis: Do they share the same risks? JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:778-787. [PMID: 34242478 DOI: 10.1002/jhbp.1013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/13/2021] [Accepted: 06/12/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic intervention combined with extracorporeal shock wave lithotripsy (ESWL) is recommended as the first line therapy for large pancreatic stones, yet both can cause adverse events. The aim of the study was to identify the risk factors for post-procedural pancreatitis. METHODS Consecutive patients with chronic pancreatitis and pancreatic stones treated with both ESWL and subsequent endoscopic retrograde cholangiopancreatography (ERCP) from October 2016 to December 2019 were prospectively enrolled. Multivariate logistic analyses were performed to detect risk factors for post-ESWL and post-ERCP pancreatitis (PEP). RESULTS A total of 714 patients (507 males, 45.60 ± 12.52 years) were included in this study. A total of 80 patients (11.2%) developed post-ESWL pancreatitis,while 33 patients (4.6%) suffered from PEP. Steatorrhea (P = .018), multiple stones (P = .043), and stones located at the head combined with the body or tail of the pancreas (P = .015) were identified as independent protective factors for post-ESWL pancreatitis. The history of acute exacerbations (P = .013), post-ESWL pancreatitis (P < .001) and stricture dilation during ERCP (P = .002) were identified as risk factors for PEP. CONCLUSIONS More attention should be paid to patients with post-ESWL pancreatitis, as well as a history of acute exacerbations and stricture dilation during ERCP to prevent PEP. (ClincialTrials.gov number, NCT04619511).
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Affiliation(s)
- Nan Ru
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China.,National Clinical Research Center for Digestive Diseases, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Yang-Yang Qian
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China.,National Clinical Research Center for Digestive Diseases, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Jia-Hui Zhu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China.,National Clinical Research Center for Digestive Diseases, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Hui Chen
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China.,National Clinical Research Center for Digestive Diseases, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Wen-Bin Zou
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China.,National Clinical Research Center for Digestive Diseases, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China.,National Clinical Research Center for Digestive Diseases, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Jun Pan
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China.,National Clinical Research Center for Digestive Diseases, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Ji-Yao Guo
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China.,National Clinical Research Center for Digestive Diseases, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China.,National Clinical Research Center for Digestive Diseases, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Zhuan Liao
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China.,National Clinical Research Center for Digestive Diseases, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, Shanghai, China
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49
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Park CH, Park SW, Yang MJ, Moon SH, Park DH. Pre- and post-procedure risk prediction models for post-endoscopic retrograde cholangiopancreatography pancreatitis. Surg Endosc 2021; 36:2052-2061. [PMID: 34231067 DOI: 10.1007/s00464-021-08491-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/28/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common serious adverse event. Given recent endoscopic advances, we aimed to develop and validate a risk prediction model for PEP using the latest clinical database. METHODS We analyzed the data of patients with naïve papilla who underwent endoscopic retrograde cholangiopancreatography (ERCP). Pre-ERCP and post-ERCP risk prediction models for PEP were developed using logistic regression analysis. Patients were classified into low- (0 points), intermediate- (1-2 points), and high-risk (≥ 3 points) groups according to point scores. RESULTS We included 760 and 735 patients in the derivation and validation cohorts, respectively. The incidence of PEP was 5.5% in the derivation cohort and 3.9% in the validation cohort. Age ≤ 65 (1 point), female sex (1 point), acute pancreatitis history (2 points), malignant biliary obstruction (2 points [pre-ERCP model] or 1 point [post-ERCP model]), and pancreatic sphincterotomy (2 points, post-ERCP model only) were independent risk factors. In the validation cohort, the high-risk group (≥ 3 points) had a significantly higher risk of PEP compared to the low- or intermediate-risk groups under the post-ERCP risk prediction model (low: 2.0%; intermediate: 3.4%; high: 18.4%), while there was no significant between-group difference under the pre-ERCP risk prediction model (low: 2.2%; intermediate: 3.8%; high: 6.9%). CONCLUSIONS We developed and validated pre-ERCP and post-ERCP risk prediction models. In the latter, the high-risk group had a higher risk of PEP development than the low- or intermediate-risk groups. Our study findings will help clinicians stratify patient risk for the development of PEP.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Republic of Korea.
| | - Min Jae Yang
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Sung Hoon Moon
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Da Hae Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Republic of Korea
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50
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Gallo C, Boškoski I, Matteo MV, Orlandini B, Costamagna G. Training in endoscopic retrograde cholangio-pancreatography: a critical assessment of the broad scenario of training programs and models. Expert Rev Gastroenterol Hepatol 2021; 15:675-688. [PMID: 33599177 DOI: 10.1080/17474124.2021.1886078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Endoscopic Retrograde Cholangio-Pancreatography (ERCP) applications are rapidly evolving toward increasingly complex therapeutic approaches alongside with technological innovations. There are no globally agreed indications on the ERCP training path, which often requires too much time and does not always guarantee adequate skills.Areas covered: Frequency and difficulty of execution are the main objective criteria on which to draw up a training program: novel trainees should approach ERCP first through the simplest and most frequent procedures. An extensive use of training models would reduce the patient's performer-related risks. Amongst a wide variety of models, mechanical simulators have received large approval. In fact, they can be best-suited to each trainee's learning curve thanks to their precision and safety and by virtue of the unlimited repeatability of their use. However, more solid evidences are still needed.Expert opinion: Hands-on ERCP training should systematically employ mechanical simulators at least in the early stages of the learning process. An implementation of these models through sensors that objectively detect abnormalities in the movements would provide detailed feedbacks and deeper awareness. Simulators might also be useful for expert endoscopists to refine their skills. Rapid prototyping and 3D printing might be the way to create customized training models for successful training programs.
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Affiliation(s)
- Camilla Gallo
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
| | - Maria Valeria Matteo
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
| | - Beatrice Orlandini
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
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