Can early precut reduce post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with difficult bile duct cannulation?

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is associated with a variety of adverse events(AEs).One of the most important AEs is post-ERCP pancreatitis(PEP),which is most common in cases of difficult biliary cannulation.Although the precut technique has been reported as a PEP risk factor,recent studies indicate that early precut could reduce PEP,and that precut itself is not a risk factor.AIM To evaluate the safety of the precut technique,especially in terms of PEP.METHODS We conducted a retrospective study,spanning the period from November 2011 through December 2021.It included 1556 patients,aged≥20 years,who underwent their initial ERCP attempt for biliary disease with a naïve papilla at the Kawasaki University General Medical Center.We compared the PEP risk between the early precut and the delayed precut group.RESULTS The PEP incidence rate did not significantly differ between the precut and nonprecut groups.However,the PEP incidence was significantly lower in the early precut group than the delayed precut group(3.5%vs 10.5%;P=0.02).The PEP incidence in the delayed precut group without pancreatic stent insertion(17.3%)was significantly higher compared to other cases(P<0.01).CONCLUSION Our findings indicate that early precut may reduce PEP incidence.If the precut decision is delayed,a pancreatic stent should be inserted to prevent PEP.

External use of mirabilite to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in children:A multicenter randomized controlled trial

BACKGROUND Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography(ERCP).Currently,there is no suitable treatment for post-ERCP pancreatitis(PEP)prophylaxis.Few studies have prospectively evaluated interventions to prevent PEP in children.AIM To assess the efficacy and safety of the external use of mirabilite to prevent PEP in children.METHODS This multicenter,randomized controlled clinical trial enrolled patients with chronic pancreatitis scheduled for ERCP according to eligibility criteria.Patients were randomly divided into the external use of mirabilite group(external use of mirabilite in a bag on the projected abdominal area within 30 min before ERCP)and blank group.The primary outcome was the incidence of PEP.The secondary outcomes included the severity of PEP,abdominal pain scores,levels of serum inflammatory markers[tumor necrosis factor-alpha(TNF-α)and serum interleukin-10(IL-10)],and intestinal barrier function markers[diamine oxidase(DAO),D-lactic acid,and endotoxin].Additionally,the side effects of topical mirabilite were investigated.RESULTSA total of 234 patients were enrolled,including 117 in the external use of mirabilite group and theother 117 in the blank group.The pre-procedure and procedure-related factors were notsignificantly different between the two groups.The incidence of PEP in the external use ofmirabilite group was significantly lower than that in the blank group(7.7%vs 26.5%,P<0.001).The severity of PEP decreased in the mirabilite group(P=0.023).At 24 h after the procedure,thevisual analog scale score in the external use of mirabilite group was lower than that in the blankgroup(P=0.001).Compared with those in the blank group,the TNF-αexpressions weresignificantly lower and the IL-10 expressions were significantly higher at 24 h after the procedurein the external use of mirabilite group(P=0.032 and P=0.011,respectively).There were nosignificant differences in serum DAO,D-lactic acid,and endotoxin levels before and after ERCPbetween the two groups.No adverse effects of mirabilite were observed.CONCLUSIONExternal use of mirabilite reduced the PEP occurrence.It significantly alleviated post-proceduralpain and reduced inflammatory response.Our results favor the external use of mirabilite toprevent PEP in children.

Prophecy about post-endoscopic retrograde cholangiopancreatography pancreatitis:From divination to science

One unresolved issue of endoscopic retrograde cholangiopancreatography(ERCP)is post-ERCP pancreatitis (PEP),which occurs in up to 40%of patients.Identification of risk factors for PEP is especially important in the field of ERCP practice because it may assist physicians in taking protective measures in situations with high risk.A decade ago,Freeman et al meticulously evaluated a large number of potentially relevant risk factors for PEP,which can be divided into patient-relat-ed and procedure-related issues.In this commentary, we summarize this classic article and reevaluate the risk factors for PEP from the current point of view.This is followed by assessment of strategies for prevention of PEP that can be divided into mechanical and pharmacologic methods.

Pancreatic stents for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis should be inserted up to the pancreatic body or tail

AIM To investigate the location to which a pancreatic stent should be inserted to prevent post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis(PEP).METHODS Over a ten-year period at our hospital, 296 patients underwent their first ERCP procedure and had a pancreatic stent inserted; this study included 147 patients who had ERCP performed primarily for biliary investigation and had a pancreatic stent inserted to prevent PEP. We dividedthese patients into two groups: 131 patients with a stent inserted into the pancreatic head(head group) and 16 patients with a stent inserted up to the pancreatic body or tail(body/tail group). Patient characteristics and ERCP factors were compared between the groups.RESULTS Pancreatic amylase isoenzyme(p-AMY) levels in the head group were significantly higher than those in the body/tail group [138.5(7.0-2086) vs 78.5(5.0-1266.5), P = 0.03] [median(range)]. No cases of PEP were detected in the body/tail group [head group, 12(9.2%)]. Of the risk factors for post-ERCP hyperamylasemia(≥ p-AMY median, 131 IU/L), procedure time ≥ 60 min [odds ratio(OR) 2.65, 95%CI: 1.17-6.02, P = 0.02) and stent insertion into the pancreatic head(OR 3.80, 95%CI: 1.12-12.9, P = 0.03) were identified as independent risk factors by multivariate analysis.CONCLUSION Stent insertion up to the pancreatic body or tail reduces the risk of post-ERCP hyperamylasemia and may reduce the risk of PEP.

Is rectal indomethacin effective in preventing of post-endoscopic retrograde cholangiopancreatography pancreatitis?

AIM: To investigate the effectiveness of rectally administered indomethacin in the prophylaxis of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and hyperamylasaemia in a multicentre study.

Post-endoscopic retrograde cholangio-pancreatography pancreatitis:Is time for a new preventive approach?

Acute pancreatitis is the most common serious complication of endoscopic retrograde cholangio-pancre-atography (ERCP) and its incidence may exceed 25% in some high-risk patient subsets. In some patients, pancreatitis may follow a severe course with pancreatic necrosis, multiorgan failure, permanent disability and even death. Hence, approaches which minimize both the incidence and severity of post-ERCP pancreatitis are worth pursuing. Pancreatic stents have been used with some success in the prevention of post-ERCP, while so far pharmacological trials have yielded disappointing results. A recent multicenter, randomized, placebo-controlled, double-blind trial has shown that rectally administered indomethacin is effective in reducing the incidence of post-ERCP pancreatitis, the occurrence of episodes of moderate-to-severe pancreatitis and the length of hospital stay in high-risk patients. These results together with the demonstration that rectal administration of indomethacin is not associated with en-hanced risk of bleeding strongly support the use of this drug in the prophylaxis of post-ERCP pancreatitis.

Effect of precut sphincterotomy on post-endoscopic retrograde cholangiopancreatography pancreatitis:A systematic review and meta-analysis

AIM: To conduct a systemic review and meta-analysis to investigate the role of early precut technique. Multiple randomized controlled trails (RCTs) have reported conflicting results of the early precut sphincterotomy.

Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis

AIM: To investigate the efficacy and safety profile ofpancreatic duct(PD) stent placement for prevention of post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis(PEP). METHODS: We performed a search of MEDLINE, EMBASE, and Cochrane Library to identify randomized controlled clinical trials of prophylactic PD stent placement after ERCP. Rev Man 5 software provided by Cochrane was used for the heterogeneity and efficacy analyses, and a meta-analysis was performed for the data that showed homogeneity. Categorical data are presented as relative risks and 95% confidence intervals(CIs), and measurement data are presented as weighted mean differences and 95%CIs. RESULTS: The incidence rates of severe pancreatitis, operation failure, complications and patient pain severity were analyzed. Data on pancreatitis incidence were reported in 14 of 15 trials. There was no significant heterogeneity between the trials(I2 = 0%, P = 0.93). In the stent group, 49 of the 1233 patients suffered from PEP, compared to 133 of the 1277 patients in the no-stent group. The results of this meta-analysis indicate that it may be possible to prevent PEP by placing a PD stent. CONCLUSION: PD stent placement can reduce postoperative hyperamylasemia and might be an effective and safe option to prevent PEP if the operation indications are well controlled.

Antioxidant therapy in acute,chronic and post-endoscopic retrograde cholangiopancreatography pancreatitis:An updated systematic review and meta-analysis

AIM:To investigate the efficacy and adverse effects of antioxidant therapy in acute pancreatitis(AP),chronic pancreatitis(CP) and post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP).METHODS:Pub Med,Scopus,Google Scholar,Cochrane library database,and Evidence-based medicine/clinical trials published before August 2014 were searched. Clinical and laboratory outcomes of randomized trials of antioxidant therapy in patients with AP,CP and PEP were included. The methodological quality of the trials was assessed by the Jadad score based on the description of randomization,blinding,and dropouts(withdrawals). The results of the studies were pooled and meta-analyzed to provide estimates of the efficacy of antioxidant therapy.RESULTS:Thirty four trials out of 1069 potentially relevant studies with data for 4898 patients wereeligible for inclusion. Antioxidant therapy significantly reduced the length of hospital stay in AP patients {mean difference-2.59 d(95%CI:-4.25-(-0.93)],P = 0.002}. Although,antioxidant therapy had no significant effect on serum C reactive protein(CRP) after 5-7 d in AP patients [mean difference-9.57(95%CI:-40.61-21.48,P = 0.55],it significantly reduced serum CRP after 10 d {mean difference-45.16 [95%CI:-89.99-(-0.33)],P = 0.048}. In addition,antioxidant therapy had no significant effect on CP-induced pain [mean difference-2.13(95%CI:-5.87-1.6),P = 0.26]. Antioxidant therapy had no significant effects on the incidence of all types of PEP [mean difference 1.05(95%CI:0.74-1.5),P = 0.78],severe PEP [mean difference 0.92(95%CI:0.43-1.97),P = 0.83],moderate PEP [mean difference 0.82(95%CI:0.54-1.23),P = 0.33],and mild PEP [mean difference 1.33(95%CI:0.99-1.78),P = 0.06]. Furthermore,while antioxidant therapy had no significant effect on serum amylase after less than 8 h sampling [mean difference-20.61(95%CI:-143.61-102.39),P = 0.74],it significantly reduced serum amylase close to 24-h sampling {mean difference-16.13 [95%CI:-22.98-(-9.28)],P < 0.0001}.CONCLUSION:While there is some evidence to support antioxidant therapy in AP,its effect on CP and PEP is still controversial.

Impact of changing our cannulation method on the incidenceof post-endoscopic retrograde cholangiopancreatography pancreatitis after pancreatic guidewire placement

AIM： To clarify whether the incidence of post-endoscopic retrograde cholangiopancreatography （ERCP） pancreatitis （PEP） after pancreatic guidewire placement （PGW） can be reduced by using a different cannulation method. METHODS： BebNeen April 2001 and October 2009, PGW was performed in 142 patients with native papilla to overcome difficult biliary cannulation. Our cannulation method for ERCP was changed from contrast injection （CI） using a single-lumen catheter （April 2001-May 2008） to wire-guided cannulation （WGC） using a double-lumen catheter （June 2008-October 2009）. The CI protocol was also changed during the study period： in the first period it was used for routine pancreatography for detecting small pancreatic cancer （April 2001-November 2002）, whereas in the second period it was not （December 2002-May 2008）. In PGW with CI using a single- lumen catheter, the contrast medium in the catheter lumen was injected into the pancreatic duct. The success rate of biliary cannulation, the incidence of PEP according to the cannulation method, and the impact of CI using a single-lumen catheter on PEP in comparison with WGC using a double-lumen catheter were investigated.RESULTS： CI with routine pancreatography, CI without routine pancreatography, and WGC were performed in 27 patients, 77 patients and 38 patients, respectively. Routine pancreatography did not contribute to the early diagnosis of pancreatic cancer in our study period. In CI without routine pancreatography and WGC, diagnostic pancreatography was performed in 17 patients and no patients, respectively. The success rate of biliary cannulation by PGW alone was 69%, and the final success rate was increased to 80.3% by the addition of consecutive maneuvers or a second ERCP. PEP occurred in 22 patients （15.5%）, and the severity was mild in all cases. When analyzed according to cannulation method, the incidence of PEP was 37.0% （10/27） in the patients who underwent CI with routine pancreatography, 14.3% （11/77） in those who underwent CI without routine pancreatography, and 2.6% （1/38） in those who underwent WGC. In all patients who underwent CI using a singlelumen catheter, the incidence of PEP was 20% （21/104）, which was significantly higher than that in WGC using a double-lumen catheter. In univariate and multivariate analysis, CI using a single-lumen catheter showed a high, statistically significant, odds ratio for PEP after PGW. CONCLUSION： The practice of a cannulation method involving the use of a double-lumen catheter minimizes the CI dose administered to the pancreatic duct and reduces the incidence of PEP after PGW.

Suppository naproxen reduces incidence and severity of post-endoscopic retrograde cholangiopancreatography pancreatitis: Randomized controlled trial

AIM: To determine the efficacy of rectally administered naproxen for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).METHODS: This double-blind randomized control trial conducted from January 2013 to April 2014 at the Gastrointestinal and Liver Diseases Research Center in Rasht, Iran. A total of 324 patients were selected from candidates for diagnostic or therapeutic ERCP by using the simple sampling method. Patients received a single dose of Naproxen (500 mg; n = 162) or a placebo (n = 162) per rectum immediately before ERCP. The overall incidence of PEP, incidence of mild to severe PEP, serum amylase levels and adverse effects were measured. The primary outcome measure was the development of pancreatitis onset of pain in the upper abdomen and elevation of the serum amylase level to &#x0003e; 3 &#x000d7; the upper normal limit (60-100 IU/L) within 24 h after ERCP. The severity of PEP was classified according to the duration of therapeutic intervention for PEP: mild, 2-3 d; moderate 4-10 d; and severe, &#x0003e; 10 d and/or necessitated surgical or intensive treatment, or contributed to death.RESULTS: PEP occurred in 12% (40/324) of participants, and was significantly more frequent in the placebo group compared to the naproxen group (P &#x0003c; 0.01). Of the participants, 25.9% (84/324) developed hyperamylasemia within 2 h of procedure completion, among whom only 35 cases belonged to the naproxen group (P &#x0003c; 0.01). The incidence of PEP was significantly higher in female sex, in patients receiving pancreatic duct injection, more than 3 times pancreatic duct cannulations, and ERCP duration more than 40 min (Ps &#x0003c; 0.01). There were no statistically significant differences between the groups regarding the procedures or factors that might increase the risk of PEP, sphincterotomy, precut requirement, biliary duct injection and number of pancreatic duct cannulations. In the subgroup of patients with pancreatic duct injection, the rate of pancreatitis in the naproxen group was significantly lower than that in the placebo (6 patients vs 23 patients, P &#x0003c; 0.01, RRR = 12%, AR = 0.3, 95%CI: 0.2-0.6). Naproxen reduced the PEP in patients with &#x02265; 3 pancreatic cannulations (P &#x0003c; 0.01, RRR = 25%, AR = 0.1, 95%CI: 0.1-0.4) and an ERCP duration &#x0003e; 40 min (P &#x0003c; 0.01, RRR = 20%, AR = 0.9, 95%CI: 0.4-1.2).CONCLUSION: Single dose of suppository naproxen administered immediately before ERCP reduces the incidence of PEP.

Risk factors for the development of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with asymptomatic common bile duct stones

BACKGROUND Previous studies have revealed that patients with asymptomatic common bile duct(CBD)stones are at a high risk of developing post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP).However,no studies to date have addressed the risk factors for PEP in patients with asymptomatic CBD stones.AIM To examine the risk factors for PEP in patients with asymptomatic CBD stones.METHODS Using medical records of three institutions in Japan for 6 years,we identified a total of 1135 patients with choledocholithiasis including 967 symptomatic patients and 168 asymptomatic patients with native papilla who underwent therapeutic ERCP.We performed univariate and multivariate analyses to examine the risk factors for PEP in the 168 patients with asymptomatic CBD stones.RESULTS The overall incidence rate of PEP in all the patients with during study period was 4.7%(53/1135).Of the 168 patients with asymptomatic CBD stones,24(14.3%)developed PEP.In univariate analysis,precut sphincterotomy(P=0.009)and biliary balloon sphincter dilation(P=0.043)were significant risk factors for PEP.In multivariate analysis,precut sphincterotomy(P=0.002,95%CI:2.2-27.8,odds ratio=7.7),biliary balloon sphincter dilation(P=0.015,95%CI:1.4-17.3,odds ratio=4.9),and trainee endoscopists(P=0.048,95%CI:1.01-8.1,odds ratio=2.9)were significant risk factors for PEP.CONCLUSION ERCP for asymptomatic CBD stones should be performed by experienced endoscopists.When performing precut sphincterotomy or biliary balloon sphincter dilation in patients with asymptomatic CBD stones,the placement of a prophylactic pancreatic stent is strongly recommended to prevent PEP.

Balloon dilation itself may not be a major determinant of post-endoscopic retrograde cholangiopancreatography pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) is the essential first modality for common bile duct (CBD) stone therapy. The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sphincterotomy (EST). Stone removal after papillary stretching using balloon dilation instead of the conventional method has been widely adopted. There are many reports regarding endoscopic papillary balloon dilation (EPBD) utilizing a small balloon (&#x0003c; 10 mm) instead of EST for the removal of small CBD stones. In contrast, two cases of mortality due to post-ERCP pancreatitis (PEP) were reported after an EPBD clinical trial in the Western world, and the psychological barrier caused by these incidences hinders the use of this technique in Western countries. Endoscopic papillar large balloon dilation (EPLBD), which is used to treat large CBD stones, was not widely adopted when first introduced due to concerns about perforation and severe pancreatitis from the use of a large balloon (12-20 mm). However, as experience with this procedure accumulates, the occurrence of PEP with EPLBD is confirmed to be much lower than with EPBD. This report reviews whether EPBD and EPLBD, two procedures that use balloon dilation but differ in terms of indications and concept, contribute to the occurrence of PEP.

Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis by pancreatic duct stenting using a loop-tipped guidewire

AIM: To examine whether it is possible to prevent the occurrence of post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis in patients experiencing difficulties with selective biliary duct cannulation by pancreatic duct stenting using a looptipped guidewire.METHODS: Procedure success rate, frequency of unintended insertion of the guidewire into side branches of the pancreatic duct, and incidence of procedural accidents were examined using a loop-tipped guidewire(Group A, 20 patients), and a conventional straighttype guidewire(Group B, 20 patients).RESULTS: The success rate of the procedure was 100% in both groups. Unintended insertion of the guidewire into a side branch of the pancreatic duct occurred 0.056 ± 0.23(0-1) times in Group A and 2.3 ±1.84(0-5) times in Group B; thus, unintended insertion of the guidewire into a side branch of the pancreatic duct was seen significantly less frequently in Group A. There were no procedural accidents in Group A, whereas pancreatitis occurred in one Group B patient; however, the difference between the two groups was not statistically significant. The serum amylase level after ERCP was 257.15 ± 136.4(88-628) IU/L in Group A, and 552.05 ± 534.57(101-2389) IU/L in Group B, showing a significantly lower value in Group A. Hyperamylasemia was found in two patients(10%) in Group A, and nine(45%) in Group B, showing a significantly lower value in Group A.CONCLUSION: The results suggest that in patients who experience difficulties with biliary cannulation, the use of a loop-tipped guidewire for pancreatic duct stenting may assist with the prevention of post-ERCP pancreatitis, and thereby to a reduction of the risk of post-ERCP pancreatitis or hyperamylasemia.

Combination of two-hour post-endoscopic retrograde cholangiopancreatography amylase levels and cannulation times is useful for predicting post-endoscopic retrograde cholangiopancreatography pancreatitis

AIM To estimate the efficacy of 2 h post-endoscopic retrograde cholangiopancreatography(ERCP) serum amylase levels and other factors for predicting postERCP pancreatitis.METHODS This was a retrospective,single-center cohort study of consecutive patients who underwent ERCP from January 2010 to December 2013.Serum amylase levels were measured 2 h post-procedure,and patient- and procedure-related pancreatitis(PEP) risk factors wereanalyzed using a logistic model.RESULTS A total of 1520 cases(average age 72 ± 12 years,60% male) were initially enrolled in this study,and 1403 cases(725 patients) were ultimately analyzed after the exclusion of 117 cases.Fifty-five of these cases developed PEP.We established a 2 h serum amylase cutoff level of two times the upper limit of normal for predicting PEP.Multivariate analysis revealed that a cannulation time of more than 13 min [odds ratio(OR) 2.28,95%CI:1.132-4.651,P=0.0210] and 2 h amylase levels greater than the cutoff level(OR=24.1,95%CI:11.56-57.13,P<0.0001) were significant predictive factors for PEP.Forty-seven of the 55 patients who developed PEP exhibited 2 h amylase levels greater than the cutoff level(85%),and six of the remaining eight patients who developed PEP(75%) required longer cannulation times.Only 2 of the 1403 patients(0.14%) who developed PEP did not exhibit concerning 2 h amylase levels or require longer cannulation times.CONCLUSION These findings indicate that the combination of 2 h post-ERCP serum amylase levels and cannulation times represents a valuable marker for identifying patients at high risk for PEP.

High total Joule heat increases the risk of post-endoscopic submucosal dissection electrocoagulation syndrome after colorectal endoscopic submucosal dissection

BACKGROUND We hypothesized that thermal damage accumulation during endoscopic submucosal dissection(ESD)causes the pathogenesis of post-ESD electrocoagulation syndrome(PECS).AIM To determine the association between Joule heat and the onset of PECS.METHODS We performed a retrospective cohort study in patients who underwent colorectal ESD from May 2013 to March 2021 in Japan.We developed a novel device that measures swift coagulation time with a sensor adjacent to the electrosurgical coagulation unit foot switch,which enabled us to calculate total Joule heat.PECS was defined as localized abdominal pain(visual analogue scale≥30 mm during hospitalization or increased by≥20 mm from the baseline)and fever(temperature≥37.5 degrees or white blood cell count≥10000μ/L).Patients exposed to more or less than the median Joule heat value were assigned to the high and low Joule heat groups,respectively.Statistical analyses included Mann-Whitney U and chisquare tests and logistic regression and receiver operating characteristic curve(ROC)analyses.RESULTS We evaluated 151 patients.The PECS incidence was 10.6%(16/151 cases),and all patients were followed conservatively and discharged without severe complications.In multivariate analysis,high Joule heat was an independent PECS risk factor.The area under the ROC curve showing the correlation between PECS and total Joule heat was high[0.788(95%confidence interval:0.666-0.909)].CONCLUSION Joule heat accumulation in the gastrointestinal wall is involved in the onset of PECS.ESD-related thermal damage to the peeled mucosal surface is probably a major component of the mechanism underlying PECS.

Indomethacin for post-endoscopic retrograde cholangiopancreatography pancreatitis prophylaxis:Is it the magic bullet?

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography(ERCP).Pancreatic duct stent insertion after ERCP has been widely accepted as the standard of care for the prevention of this complication in high-risk patients.Unfortunately,the placement of pancreatic stents requires higher level of endoscopic expertise and is not always feasible due to anatomic considerations.Therefore,effective non-invasive pharmacologic prophylaxis remains appealing,particularly if it is inexpensive,easily administered,has a low risk side effect profile and is widely available.There have been multiple studies evaluating potential pharmacologic candidates for post-ERCP pancreatitis(PEP) prophylaxis,most of them yielding disappointing results.A recently published large,multicenter,randomized controlled trial reported that in high risk patients a single dose of rectal indomethacin administered immediately after the ERCP significantly decreased the incidence of PEP compare to placebo.

Usefulness of serum lipase for early diagnosis of post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND Post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP)is new onset acute pancreatitis after ERCP.This complication is sometimes fatal.As such,PEP should be diagnosed early so that therapeutic interventions can be carried out.Serum lipase(s-Lip)is useful for diagnosing acute pancreatitis.However,its usefulness for diagnosing PEP has not been sufficiently investigated.AIM This study aimed to retrospectively examine the usefulness of s-Lip for the early diagnosis of PEP.METHODS We retrospectively examined 4192 patients who underwent ERCP at our two hospitals over the last 5 years.The primary outcomes were a comparison of the areas under the receiver operating characteristic(ROC)curves(AUCs)of s-Lip and serum amylase(s-Amy),s-Lip and s-Amy cutoff values based on the presence or absence of PEP in the early stage after ERCP via ROC curves,and the diagnostic properties[sensitivities,specificities,positive predictive values(PPV),and negative predictive value(NPV)]of these cutoff values for PEP diagnosis.RESULTS Based on the eligibility and exclusion criteria,804 cases were registered.Over the entire course,PEP occurred in 78 patients(9.7%).It occurred in the early stage after ERCP in 40 patients(51.3%)and in the late stage after ERCP in 38 patients(48.7%).The AUCs were 0.908 for s-Lip[95%confidence interval(CI):0.880-0.940,P<0.001]and 0.880 for s-Amy(95%CI:0.846-0.915,P<0.001),indicating both are useful for early diagnosis.By comparing the AUCs,s-Lip was found to be significantly more useful for the early diagnosis of PEP than s-Amy(P=0.023).The optimal cutoff values calculated from the ROC curves were 342 U/L for s-Lip(sensitivity,0.859;specificity,0.867;PPV,0.405;NPV,0.981)and 171 U/L for s-Amy(sensitivity,0.859;specificity,0.763;PPV,0.277;NPV,0.979).CONCLUSION S-Lip was significantly more useful for the early diagnosis of PEP.Measuring s-Lip after ERCP could help diagnose PEP earlier;hence,therapeutic interventions can be provided earlier.

Best practices for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Acute pancreatitis is of one the most common gastroenterology-related indications for hospital admissions worldwide.With the widespread reliance on endoscopic retrograde cholangiopancreatography(ERCP)for the management of pancreaticobiliary conditions,post-ERCP pancreatitis(PEP)has come to represent an important etiology of acute pancreatitis.Despite many studies aiming to better understand the pathogenesis and prevention of this iatrogenic disorder,findings have been heterogeneous,and considerable variation in clinical practice exists.Herein,we review the literature regarding PEP with the goal to raise awareness of this entity,discuss recent data,and present evidence-based best practices.We believe this manuscript will be useful for gastrointestinal endoscopists as well as other specialists involved in the management of patients with PEP.

Comment on “Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis”

I read with interest an article "Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis" by Fan and colleagues in World J Gastroenterol 2015;21(24): 7577-7583. Although I appreciate their work, I have found problems with the data extracted and analyzed by the authors, and will give my comment in this letter. It would be valuable if the authors could provide an accurate estimation of their extracted data.