Endoscopy 2003; 35(11): 913-919
DOI: 10.1055/s-2003-43483
DDW Report 2003
© Georg Thieme Verlag Stuttgart · New York

Endoscopic Retrograde Cholangiopancreatography Topics

E.  L.  Fogel1
  • 1Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
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Publikationsverlauf

Publikationsdatum:
07. November 2003 (online)

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

  • 1 Rabenstein T, Fischer B, Wiesner V. et al . Low molecular weight heparin does not prevent acute post-ERCP pancreatitis [abstract].  Gastrointest Endosc. 2003;  57 AB189
  • 2 Kaffes A, Alrubaie A, Ding S. et al . A prospective, randomized, double-blind, placebo-controlled trial of transdermal glyceryl trinitrate in technical success of ERCP and the prevention of post-ERCP pancreatitis: preliminary results [abstract].  Gastrointest Endosc. 2003;  57 AB191
  • 3 Macintosh D, Love J, Abraham N. Endoscopic sphincterotomy using pure-cut current does not reduce the risk of post-ERCP pancreatitis: a prospective randomized trial [abstract].  Gastrointest Endosc. 2003;  57 AB189
  • 4 Matsumoto H, Kawanishi N, Araki M. et al . Does shortened duration of balloon dilatation reduce the incidence of pancreatitis and elevation of serum amylase after endoscopic papillary balloon dilatation for extracting bile duct stones? Preliminary results of a prospective randomized trial [abstract].  Gastrointest Endosc. 2003;  57 AB195
  • 5 Boerma D, Rauws E A, Keulemans Y C. et al . Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomized trial.  Lancet. 2002;  360 761-765
  • 6 Ryan E E, Ryan M E. Should cholecystectomy follow endoscopic removal of common duct stones? [abstract].  Gastrointest Endosc. 2003;  57 AB194
  • 7 Byrne M F, Mitchell R M, Gerke H. et al . The fate of patients who undergo ”preoperative” ERCP to clear known or suspected bile duct stones [abstract].  Gastrointest Endosc. 2003;  57 AB194
  • 8 Yamato T, Yamaguchi Y, Imao Y. et al . Long-term benefit of endoscopic papillary balloon dilation for common bile duct stone removal [abstract].  Gastrointest Endosc. 2003;  57 AB192
  • 9 Sasahira N, Komatsu Y, Nakai Y. et al . Long-term follow-up after endoscopic papillary balloon dilation for patients with cholecystocholedocholithiasis [abstract].  Gastrointest Endosc. 2003;  57 AB196
  • 10 Moon J, Cha S, Cheon Y. et al . Endoscopic treatment of difficult bile duct stones using a new balloon catheter for electrohydraulic lithotripsy without cholangioscopic control [abstract].  Gastrointest Endosc. 2003;  57 AB188
  • 11 Cho Y, Cha S, Bhandari S. et al . Clinical usefulness and safety of FREDDY (frequency-doubled double-pulsed YAG laser) technology for removal of bile duct stones [abstract].  Gastrointest Endosc. 2003;  57 AB81
  • 12 Minami A, Sugiyama Y, Sakurai A. Expandable metallic stent-assisted biliary lithotripsy in patients with Billroth II gastrectomy and the papilla on the inner rim or deep within a diverticulum [abstract].  Gastrointest Endosc. 2003;  57 AB188
  • 13 Seitz U, Ponnudurai R, Seewald S. et al . Mirizzi’s syndrome: can endoscopy provide successful treatment? [abstract].  Gastrointest Endosc. 2003;  57 AB194
  • 14 Pfau P R, Kochman M L, Lewis J D. et al . Endoscopic management of postoperative biliary complications in orthotopic liver transplantation.  Gastrointest Endosc. 2000;  52 55-63
  • 15 Sossenheimer M, Slivka A, Carr-Locke D. Management of extrahepatic biliary disease after orthotopic liver transplantation: review of the literature and results of a multicenter survey.  Endoscopy. 1996;  28 565-571
  • 16 Rerknimitr R, Sherman S, Fogel E L. et al . Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy.  Gastrointest Endosc. 2002;  55 224-231
  • 17 Aqul B A, Loeb D, Bonatti H. et al . Nature of extra-hepatic anastomotic biliary lesion post-orthotopic liver transplantation (OLT) predicts outcome of endoscopic intervention (EI) [abstract].  Gastrointest Endosc. 2003;  57 AB191
  • 18 Popli R K, Brady P G. Prophylactic stent placement after orthotopic liver transplantation to prevent biliary complications [abstract].  Gastrointest Endosc. 2003;  57 AB191
  • 19 Davids P H, Rauws E A, Coene P P. et al . Endoscopic stenting for postoperative biliary strictures.  Gastrointest Endosc. 1992;  38 12-18
  • 20 Pandolfi M, Spada C, Mutignani M. et al . Biliary strictures after laparoscopic cholecystectomy (BSALC): long-term results of endoscopic management with increasing number of stents [abstract].  Gastrointest Endosc. 2003;  57 AB81
  • 21 Gyökeres T, Burai M, Pap A. Multiple stents in the management of the postoperative benign biliary duct strictures [abstract].  Gastrointest Endosc. 2003;  57 AB205
  • 22 Seitz U, Vadeyar H, Soehendra N. Prolonged patency with a new-design Teflon biliary prosthesis.  Endoscopy. 1994;  26 478-482
  • 23 Catalano M F, Geenen J E, Lehman G A. et al . ”Tannenbaum” Teflon stents versus traditional polyethylene stents for treatment of malignant biliary stricture.  Gastrointest Endosc. 2002;  55 354-358
  • 24 England R E, Martin D F, Morris J. et al . A prospective randomised multicenter trial comparing 10 Fr Teflon Tannenbaum stents with 10 Fr polyethylene Cotton-Leung stents in patients with malignant common duct strictures.  Gut. 2000;  46 395-400
  • 25 Van Berkel A M, Huibregtse I, Bergman J. et al . A prospective randomized study of Tannenbaum-type Teflon-coated stents versus polyethylene stents for distal malignant biliary obstruction [abstract].  Gastrointest Endosc. 2003;  57 AB200
  • 26 Huibregtse K, Cheng J, Coene P P. et al . Endoscopic placement of expandable metal stents for biliary strictures: a preliminary report on experience with 33 patients.  Endoscopy. 1989;  21 280-282
  • 27 Rossi P, Bezzi M, Salvatori F M. et al . Clinical experience with covered Wallstents for biliary malignancies: 23-month follow-up.  Cardiovasc Intervent Radiol. 1997;  20 441-447
  • 28 Rossi P, Bezzi M, Rossi M. et al . Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients.  J Vasc Interv Radiol. 1994;  5 279-285
  • 29 Huibregtse K, Carr-Locke D L, Cremer M. et al . Biliary stent occlusion: a problem solved with self-expanding metal stents? European Wallstent Study Group.  Endoscopy. 1992;  24 391-394
  • 30 Yuasa K, Bayuga S J, Zauber A G. et al . Covered versus uncovered self-expanding metal endobiliary stents for malignant obstruction [abstract].  Gastrointest Endosc. 2003;  57 AB199
  • 31 Nakai Y, Isayama H, Komatsu Y. et al . Covered Wallstent for the management of malignant biliary obstruction: preliminary results [abstract].  Gastrointest Endosc. 2003;  57 AB199
  • 32 Isayama H, Komatsu Y, Tsujino T. et al . A prospective randomized study of ”covered” versus ”uncovered” Diamond stent for the management of distal malignant biliary obstruction: final report [abstract].  Gastrointest Endosc. 2003;  57 AB197
  • 33 Fogel E L, deBellis M, McHenry L. et al . Effectiveness of a new long cytology brush in the evaluation of malignant biliary obstruction: preliminary results of a prospective study [abstract].  Gastrointest Endosc. 2003;  57 AB198
  • 34 Rizvi S, Quadri A, Catalano M F. et al . Diagnostic yield of Howell needle biopsy for biliary and pancreatic strictures [abstract].  Gastrointest Endosc. 2003;  57 AB200
  • 35 Howell D A, Lukens F J, Shah R J. et al . What is the true yield of tissue sampling at ERCP? [abstract].  Gastrointest Endosc. 2003;  57 AB196
  • 36 Topazian M, Hong-Curtis J, Li J. et al . Predictors of outcome in post-cholecystectomy pain [abstract].  Gastrointest Endosc. 2003;  57 AB201
  • 37 Park S H, McHenry L, Fogel E L. et al . The symptomatic improvement (SI) outcome to assess long-term outcome of endoscopic dual pancreatobiliary sphincterotomy (DES) in patients with manometry-documented sphincter of Oddi dysfunction (SOD) and normal pancreatogram. [abstract].  Gastrointest Endosc. 2003;  57 AB201
  • 38 Varadarajulu S, Payne K M, Hawes R H. et al . Frequency of sphincter of Oddi dysfunction in patients with previously normal sphincter of Oddi manometry studies [abstract].  Gastrointest Endosc. 2003;  57 AB82
  • 39 Park S H, McHenry L, Fogel E L. et al . Suspected sphincter of Oddi dysfunction (SOD): manometric re-evaluation on the untreated sphincter after medical treatment only (MTX) or biliary endoscopic sphincterotomy (BES) alone [abstract].  Gastrointest Endosc. 2003;  57 AB212
  • 40 Rizvi S, Quadri A, Geenen J E. et al . Comparison of endoscopic and radiologic treatment of symptomatic pancreatic pseudocysts [abstract].  Gastrointest Endosc. 2003;  57 AB210
  • 41 Catalano M F, Linder J D, Bukeirat F A. et al . Endoscopic therapy of symptomatic pseudocysts using combined transpapillary and cyst enterostomy techniques [abstract].  Gastrointest Endosc. 2003;  57 AB211
  • 42 Dumonceau J M, Vahedi K, Delhaye M. et al . Extracorporeal shock-wave lithotripsy (ESWL) alone compared to ESWL plus endoscopic pancreatic drainage in chronic pancreatitis associated with ductal stones [abstract].  Gastrointest Endosc. 2003;  57 AB87
  • 43 Singh P, Sivak M V, Agarwal D. et al . Prophylactic pancreatic stenting for prevention of post-ERCP acute pancreatitis: a meta-analysis of controlled trials [abstract].  Gastrointest Endosc. 2003;  57 AB89
  • 44 Fogel E L, Varadarajulu S, Sherman S. et al . Prophylactic pancreatic duct stenting in patients with suspected sphincter of Oddi dysfunction but normal sphincter of Oddi manometry [abstract].  Gastrointest Endosc. 2003;  57 AB88
  • 45 Raju G S, Gomez G, Xiao S Y. et al . Short-term pancreatic stenting leads to a rapid onset of inflammation, fibrosis, and acinar loss [abstract].  Gastrointest Endosc. 2003;  57 AB88
  • 46 Rashdan A, Fogel E L, McHenry L. et al . Pancreatic ductal changes following small-diameter, long-length, unflanged pancreatic duct stent placement [abstract].  Gastrointest Endosc. 2003;  57 AB213
  • 47 Seifert H, Schmitt W, Kreitmair C. et al . GEPARD: German study on endoscopic pancreatic retroperitoneal debridement of necroses and abscesses [abstract].  Gastrointest Endosc. 2003;  57 AB101

E. L. Fogel, M. D.

Division of Gastroenterology/Hepatology, Indiana University Medical Center ·

550 North University Boulevard · Suite 4100 · Indianapolis, IN 46202 · USA

Fax: + 1-317-278-0164 ·

eMail: efogel@iupui.edu