Endoscopic Retrograde Cholangiopancreatography Topics

Post-ERCP Pancreatitis

While advances in pancreaticobiliary therapeutics continue to be made, endoscopists are too frequently reminded of the inherent risks of endoscopic retrograde cholangiopancreatography (ERCP). Prevention of postprocedural complications was the focus of several abstracts this year. While pharmacological prevention of post-ERCP pancreatitis has largely been disappointing, two abstracts reported results from well-designed, randomized, placebo-controlled trials evaluating heparin and transdermal glyceryl trinitrate.

In a multicenter trial from Germany, Rabenstein and colleagues [1] randomly assigned 458 patients to receive either low-molecular-weight heparin (LMWH; Certoparin 3000 IU s. c.) or placebo, 2 h before and 22 h after ERCP. The two groups were comparable with regard to patient and procedural risk factors for pancreatitis. Overall, pancreatitis occurred in 38 of 448 patients (8.5 %), with one death. There was no benefit in the treatment group compared to placebo, based on the incidence (LMWH: 18 of 221 vs. placebo: 20 of 227; P = 0.87) or the severity of pancreatitis observed. Pain scores and amylase values at 24 h also did not differ significantly between the groups. Bleeding was seen in two patients (one mild, one moderate), both of whom received LMWH.

Kaffes and colleagues [2] from Australia evaluated the role of transdermal glyceryl trinitrate (GTN) in 222 patients, based on the premise that GTN relaxes the sphincter of Oddi in animals and humans, and earlier data had suggested that GTN reduces post-ERCP pancreatitis rates. In their study, the patch (GTN/placebo) was placed on the patient 60 min before the ERCP and removed the next morning. The groups were matched for age, sex, and indication for the procedure. There were 11 cases of pancreatitis observed overall: eight of 103 in the placebo group vs. three of 99 in the GTN group (P = 0.14). However, among patients with sphincter of Oddi dysfunction, the incidence of pancreatitis was five of nine in the placebo group vs. one of 11 in the GTN group (P = 0.04). The incidence of headache leading to early removal of the patch was higher in the GTN arm (13 cases vs. one case; P = 0.001). These results suggest that glyceryl trinitrate may reduce post-ERCP pancreatitis rates, particularly in high-risk patients - a conclusion also reached by others in smaller studies. However, confirmatory trials are needed before we can embrace this agent as a reliable prophylactic agent against post-ERCP pancreatitis.

It has been suggested that the use of pure-cut electrical current for endoscopic sphincterotomy (ES) may reduce the incidence of post-ERCP pancreatitis. In a well-designed trial, Macintosh et al. [3] in Halifax randomly assigned 246 patients to ES with 30-W pure-cut current (116 patients) or 30-W blend-2 current (130 patients). While the overall incidence of pancreatitis was 6.9 % (17 of 246), there was a nonsignificant trend towards an increased incidence of pancreatitis in the pure-cut group (7.8 % vs. 6.1 %, P = 0.6203). Three patients in each group developed delayed bleeds. While the results of this study differ from earlier reports, possible confounding factors (patient and procedure characteristics) are unavailable from the abstract and await full publication.

Endoscopic papillary balloon dilation for the removal of bile duct stones carries an increased risk of pancreatitis compared to ES. Matsumoto and colleagues [4] in Japan studied the effects of a shortened balloon dilation period on pancreatitis rates and amylase levels in 33 patients who were randomly assigned to two different dilation protocols. In all patients, the balloon was inflated to its maximum diameter of 8 mm with a pressure of 8 atm (ca. 800 kPa). The balloon was deflated immediately after inflation to its maximum diameter in 16 patients, whereas in the remaining 17 patients, the inflated balloon was maintained in position for 2 min. While there was no difference in postprocedural amylase levels (elevated in 15 of 33 patients overall), only one patient in each group developed mild pancreatitis, limiting the validity of any conclusions drawn. Further studies with this potentially promising technique are awaited.

All of these studies support the notion that post-ERCP pancreatitis is not yet avoidable. Careful patient selection and appropriate informed consent remain mandatory. The only ”sure way” to avoid this complication is to avoid performing the ERCP.

References

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