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DOI: 10.1055/a-2407-9651
A novel ultrasound-based algorithm for the detection of pancreatic stents placed for prophylaxis of post-ERCP pancreatitis: a prospective trial
Evaluation eines ultraschallgestützten Algorithmus zur Erkennung von prophylaktischen Pankreas-Stents zur Vermeidung einer Pankreatitis nach ERCP: eine prospektive Studie Clinical Trial: Registration number (trial ID): NCT04546867, Trial registry: ClinicalTrials.gov (http://www.clinicaltrials.gov/), Type of Study: Prospective, interventional Mono-Center Study
Abstract
Purpose
Before removal of retained pancreatic stents placed during endoscopic retrograde cholangiopancreatography to avoid post-ERCP pancreatitis, imaging is recommended. The aim of the present study was to evaluate a new ultrasound-based algorithm.
Materials and Methods
Patients who received a pancreatic stent for PEP prophylaxis were included. Straight 5Fr (0.035inch) 6cm stents with an external flap that were visualized by ultrasound were removed endoscopically with no further imaging. If the ultrasound result reported the stent to be dislodged or was inconclusive, X-ray imaging was performed. The endpoints were positive and negative predictive value, specificity, sensitivity, and contingency coefficient between ultrasound and X-ray and/or endoscopy.
Results
88 patients were enrolled in the present study. X-ray was performed in 23 (26%) patients. Accordingly, the ultrasound algorithm saved an X-ray examination in 65 cases, leading to a reduction of 74%. Stents were retained in 67 patients (76%) and visualized correctly by ultrasound in 54 patients with a sensitivity of 81%. The positive predictive value was 83%. The specificity was 48%, because ultrasound described 10/21 dislodged stents correctly. The negative predictive value was 43%, since 10/23 stents were correctly classified by ultrasound as dislodged. In 11 patients (13%), esophagogastroduodenoscopy was performed even though the pancreatic stent was already dislodged.
Conclusion
A novel ultrasound-based algorithm reduced the need for X-ray imaging by three quarters. To avoid unnecessary endoscopic examinations, the algorithm should be implemented with a learning phase and procedures should be performed by experienced examiners. An important limitation might be stent length since shorter stents might be more difficult to visualize by ultrasound.
Zusammenfassung
Hintergrund
Aktuell wird vor der Entfernung von prophylaktisch gelegten Pankreas-Stents nach einer endoskopischen retrograden Cholangiopankreatikografie eine Bildgebung empfohlen. Ziel der vorliegenden Studie war es, einen neuen ultraschallbasierten Algorithmus zu evaluieren.
Material und Methoden
Eingeschlossen wurden Patienten nach prophylatischer Pankreas-Stent-Anlage. Gerade 5 Fr-Stents (0,035 inches) mit 6cm Länge vom externen Flansch, die mittels Ultraschall sichtbar waren, wurden endoskopisch ohne weitere Bildgebung entfernt. Wenn das Ultraschall-Ergebnis den Stent als disloziert beschrieb, wurde eine Röntgenaufnahme durchgeführt. Die Endpunkte waren der positive und negative Vorhersagewert, die Spezifität, Sensitivität und der Kontingenzkoeffizient zwischen Ultraschall und Röntgen und/oder Endoskopie.
Ergebnisse
88 Patienten wurden in die Studie eingeschlossen. Bei 23 (26%) Patienten musste eine Röntgenaufnahme durchgeführt werden. Entsprechend hat der Ultraschall-Algorithmus in 65 Fällen (74%) eine Röntgenuntersuchung eingespart. Stents waren bei 67 Patienten (76%) verblieben und wurden bei 54 Patienten korrekt mit einer Sensitivität von 81% mittels Ultraschall visualisiert. Der positive Vorhersagewert betrug 83%. Die Spezifität betrug 48%, da der Ultraschall 10/21 dislozierte Stents korrekt beschrieb. Der negative Vorhersagewert betrug 43%, da 10/23 Stents korrekt als disloziert klassifiziert wurden. Bei 11 Patienten (13%) wurde eine Ösophagogastroduodenoskopie durchgeführt, obwohl der Pankreas-Stent bereits disloziert war.
Fazit
Ein ultraschallbasierter Algorithmus reduzierte den Bedarf an Röntgen-Bildgebung um 3/4. Um unnötige endoskopische Untersuchungen zu vermeiden, sollte der Algorithmus mit einer Lernphase implementiert und das Verfahren von erfahrenen Untersuchern durchgeführt werden. Eine wichtige Einschränkung könnte die Länge der Stents sein, da kürzere Stents mit Ultraschall schwieriger zu visualisieren sein könnten.
Publication History
Received: 17 March 2024
Accepted after revision: 30 July 2024
Accepted Manuscript online:
02 September 2024
Article published online:
25 September 2024
© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
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References
- 1 Yachimski PS, Ross A. The Future of Endoscopic Retrograde Cholangiopancreatography. Gastroenterology 2017; 153: 338-344 DOI: 10.1053/j.gastro.2017.06.015. (PMID: 28647354)
- 2 Andriulli A, Loperfido S, Napolitano G. et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007; 102: 1781-1788 DOI: 10.1111/j.1572-0241.2007.01279.x. (PMID: 17509029)
- 3 Kochar B, Akshintala VS, Afghani E. et al. Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials. Gastrointest Endosc 2015; 81: 143-149.e9 DOI: 10.1016/j.gie.2014.06.045.
- 4 Choudhary A, Bechtold ML, Arif M. et al. Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review. Gastrointest Endosc 2011; 73: 275-282 DOI: 10.1016/j.gie.2010.10.039. (PMID: 21295641)
- 5 Mazaki T, Mado K, Masuda H. et al. Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis. J Gastroenterol 2014; 49: 343-355 DOI: 10.1007/s00535-013-0806-1. (PMID: 23612857)
- 6 Denzer U, Beilenhoff U, Eickhoff A. et al. S2k-Leitlinie Qualitätsanforderungen in der gastrointestinalen Endoskopie, AWMF Register Nr. 021–022. Erstauflage 2015. Z Gastroenterol 2015; 53: E1-E227 DOI: 10.1055/s-0041-109598.
- 7 Chandrasekhara V, Khashab MA, Muthusamy VR. et al. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85: 32-47 DOI: 10.1016/j.gie.2016.06.051.
- 8 Mine T, Morizane T, Kawaguchi Y. et al. Clinical practice guideline for post-ERCP pancreatitis. J Gastroenterol 2017; 52: 1013-1022 DOI: 10.1007/s00535-017-1359-5. (PMID: 28653082)
- 9 Dumonceau JM, Kapral C, Aabakken L. et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 127-149 DOI: 10.1055/a-1075-4080. (PMID: 31863440)
- 10 Dumonceau JM, Andriulli A, Elmunzer BJ. et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – updated June 2014. Endoscopy 2014; 46: 799-815 DOI: 10.1055/s-0034-1377875. (PMID: 25148137)
- 11 Chahal P, Tarnasky PR, Petersen BT. et al. Short 5Fr vs long 3Fr pancreatic stents in patients at risk for post-endoscopic retrograde cholangiopancreatography pancreatitis. Clin Gastroenterol Hepatol 2009; 7: 834-839 DOI: 10.1016/j.cgh.2009.05.002. (PMID: 19447196)
- 12 Afghani E, Akshintala VS, Khashab MA. et al. 5-Fr vs. 3-Fr pancreatic stents for the prevention of post-ERCP pancreatitis in high-risk patients: a systematic review and network meta-analysis. Endoscopy 2014; 46: 573-580 DOI: 10.1055/s-0034-1365701. (PMID: 24830399)
- 13 Dultz G, Gerber L, Zeuzem S. et al. Prolonged retention of prophylactic pancreatic stents is not associated with increased complications. Pancreatology 2019; 19: 39-43 DOI: 10.1016/j.pan.2018.11.011.
- 14 Smith MT, Sherman S, Ikenberry SO. et al. Alterations in pancreatic ductal morphology following polyethylene pancreatic stent therapy. Gastrointest Endosc 1996; 44: 268-275 DOI: 10.1016/S0016-5107(96)70163-3. (PMID: 8885345)
- 15 Rashdan A, Fogel EL, McHenry L. et al. Improved stent characteristics for prophylaxis of post-ERCP pancreatitis. Clinical Gastroenterology and Hepatology 2004; 2: 322-329 DOI: 10.1016/S1542-3565(04)00062-X. (PMID: 15067627)
- 16 Michael FA, Gerber L, Weiler N. et al. Transabdominal ultrasonography to reduce the burden of X-ray imaging in prophylactic pancreatic stent localization after ERCP-A prospective trial. United European Gastroenterol J 2021; 9: 469-477 DOI: 10.1002/ueg2.12063. (PMID: 33887119)
- 17 Moffatt DC, Coté GA, Fogel EL. et al. Acute pancreatitis after removal of retained prophylactic pancreatic stents. Gastrointest Endosc 2011; 73: 980-986 DOI: 10.1016/j.gie.2011.01.012. (PMID: 21521566)
- 18 Ashida R, Tanaka S, Yamanaka H. et al. The Role of Transabdominal Ultrasound in the Diagnosis of Early Stage Pancreatic Cancer: Review and Single-Center Experience. Diagnostics (Basel) 2018; 9 DOI: 10.3390/diagnostics9010002. (PMID: 30587766)
- 19 Dietrich CF, Jenssen C. Modern ultrasound imaging of pancreatic tumors. Ultrasonography 2019; 39: 105-113 DOI: 10.14366/usg.19039. (PMID: 31962384)
- 20 Engjom T, Sangnes DA, Havre RF. et al. Diagnostic Accuracy of Transabdominal Ultrasound in Chronic Pancreatitis. Ultrasound in Medicine & Biology 2017; 43: 735-743 DOI: 10.1016/j.ultrasmedbio.2016.11.020. (PMID: 28108042)
- 21 Erchinger FG, Dimcevski G, Engjom T. et al. Transabdominal ultrasonography of the pancreas: basic and new aspects. Imaging in Medicine 2011; 3: 411-422 DOI: 10.2217/iim.11.36.
- 22 Ben-Menachem T, Decker GA, Early DS. et al. Adverse events of upper GI endoscopy. Gastrointest Endosc 2012; 76: 707-718 DOI: 10.1016/j.gie.2012.03.252. (PMID: 22985638)
- 23 Titare PU, Sonawane BD, Tembhekar NG. et al. A STUDY OF DIAGNOSTIC ACCURACY AND UTILITY OF ULTRASOUND IN THE ASSESSMENT OF BILIARY STENT. jemds 2015; 4: 13624-13630 DOI: 10.14260/jemds/2015/1948.