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.

The outcomes and safety of patients undergoing endoscopic retrograde cholangiopancreatography combining a single-use cholangioscope and a single-use duodenoscope:A multicenter retrospective international study

Background: Duodenoscope-related multidrug-resistant organism(MDRO) infections raise concerns. Disposable duodenoscopes have been recently introduced in the market and approved by regulatory agencies with the aim to reduce the risk of endoscopic retrograde cholangiopancreatography(ERCP) associated infections. The aim of this study was to evaluate the outcome of procedures performed with single-use duodenoscopes in patients with clinical indications to single-operator cholangiopancreatoscopy. Methods: This is a multicenter international, retrospective study combining all patients who underwent complex biliopancreatic interventions using the combination of a single-use duodenoscope and a single-use cholangioscope. The primary outcome was technical success defined as ERCP completion for the intended clinical indication. Secondary outcomes were procedural duration, rate of cross-over to reusable duodenoscope, operator-reported satisfaction score(1 to 10) on performance rating of the single-use duodenoscope, and adverse event(AE) rate. Results: A total of 66 patients(26, 39.4% female) were included in the study. ERCP was categorized according to ASGE ERCP grading system as 47(71.2%) grade 3 and 19(28.8%) grade 4. The technical success rate was 98.5%(65/66). Procedural duration was 64(interquartile range 15-189) min, cross-over rate to reusable duodenoscope was 1/66(1.5%). The satisfaction score of the single-use duodenoscope classified by the operators was 8.6 ± 1.3 points. Four patients(6.1%) experienced AEs not directly related to the single-use duodenoscope, namely 2 post-ERCP pancreatitis(PEP), 1 cholangitis and 1 bleeding.Conclusions: Single-use duodenoscope is effective, reliable and safe even in technically challenging procedures with a non-inferiority to reusable duodenoscope, making these devices a viable alternative to standard reusable equipment.

Splenic subcapsular hematoma following endoscopic retrograde cholangiopancreatography:A case report and review of literature

BACKGROUND Splenic injury following endoscopic retrograde cholangiopancreatography(ERCP)is a rare complication.The literature contains around 30 articles reporting various degrees of splenic injuries resulting from ERCP since the first report of splenic rupture after ERCP in 1989.CASE SUMMARY This report describes a case of splenic hematoma and stent displacement in a 69-year-old male patient who developed these conditions 7 days after undergoing ERCP and stenting.The patient had bile duct stenosis caused by a malignant tumor that was obstructing the bile duct.The diagnosis was confirmed by epigastric computed tomography and magnetic resonance cholangiopancreatography.The patient was successfully treated with percutaneous transhepatic cholangial drainage,endoscopic pyloric stent placement,and conservative management.The causes of splenic injury following ERCP are discussed.CONCLUSION ERCP has the potential to cause splenic injury.If a patient experiences symptoms such as abdominal pain,decreased blood pressure,and altered hematology after the procedure,it's important to be thoroughly investigated for postoperative bleeding and splenic injury.

Acute cholangitis with Achromobacter xylosoxidans bacteremia after endoscopic retrograde cholangiopancreatography in hilar cholangiocarcinoma:A case report

BACKGROUND Achromobacter xylosoxidans is a Gram-negative opportunistic aerobe,usually causing nosocomial infections in immunocompromised patients with manifestations including bacteremia,pneumonia,and catheter-related infections.However,A.xylosoxidans have not yet been reported to cause biliary system infections.CASE SUMMARY A 72-year-old woman presented to the outpatient department of our hospital with a chief complaint of jaundice.Computed tomography of her abdomen revealed the presence of a mass of approximately 2.4 cm in the hilar portion of the common hepatic duct,consistent with hilar cholangiocarcinoma.We performed endoscopic retrograde cholangiopancreatography(ERCP)to decompress the obstructed left and right intrahepatic ducts(IHDs)and placed 10 cm and 11 cm biliary stents in the left and right IHDs,respectively.However,the day after the procedure,the patient developed post-ERCP cholangitis as the length of the right IHD stent was insufficient for proper bile drainage.The blood culture of the patient tested positive for A.xylosoxidans.Management measures included the replacement of the right IHD stent(11 cm)with a longer one(12 cm)and administering culturedirected antibiotic therapy,solving the cholangitis-related complications.After the cholangitis had resolved,the patient underwent surgery for hilar cholangiocarcinoma and survived for 912 d without recurrence.CONCLUSION A.xylosoxidans-induced biliary system infections are extremely rare.Clinical awareness of physicians and endoscopists is required as this rare pathogen might cause infection after endoscopic procedures.

Preoperative gastric retention in endoscopic retrograde cholangiopancreatography

We comment on the article by Jia et al,in the World Journal of Gastrointestinal Surgery.We focus mainly on the factors that impair gastric motility and cause gastric retention in the pre-operative setting of endoscopic retrograde cholan-giopancreatography(ERCP).ERCP is a complex endoscopic therapeutic proce-dure,which demands great skill from the endoscopist but also has recognized complications.Gastric retention impairs the endoscopist’s visibility but also increases the risk of complications,such as aspiration pneumonia.Therefore,identifying the factors that predispose to gastric retention alerts the endoscopists of the possible risks and enables them to take evasive action.The authors in the current study by Jia et al developed and validated a predictive model,which in-corporates five different factors,i.e.,gender,primary disease,jaundice,opioid use,and gastrointestinal obstruction,which were found to influence gastric retention.This model was shown to have a high predictive value to accurately identify pa-tients at risk for gastric retention before a therapeutic ERCP.

Impact of frailty on endoscopic retrograde cholangiopancreatography outcomes in nonagenarians:A United States national experience

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is an essential therapeutic tool for biliary and pancreatic diseases.Frail and elderly patients,especially those aged≥90 years are generally considered a higher-risk population for ERCP-related complications.AIM To investigate outcomes of ERCP in the Non-agenarian population(≥90 years)concerning Frailty.METHODS This is a cohort study using the 2018-2020 National Readmission Database.Patients aged≥90 were identified who underwent ERCP,using the international classification of diseases-10 code with clinical modification.Johns Hopkins’s adjusted clinical groups frailty indicator was used to classify patients as frail and non-frail.The primary outcome was mortality,and the secondary outcomes were morbidity and the 30 d readmission rate related to ERCP.We used univariate and multivariate regression models for analysis.RESULTS A total of 9448 patients were admitted for any indications of ERCP.Frail and non-frail patients were 3445(36.46%)and 6003(63.53%)respectively.Indications for ERCP were Choledocholithiasis(74.84%),Biliary pancreatitis(9.19%),Pancreatico-biliary cancer(7.6%),Biliary stricture(4.84%),and Cholangitis(1.51%).Mortality rates were higher in frail group[adjusted odds ratio(aOR)=1.68,P=0.02].The Intra-procedural complications were insigni-ficant between the two groups which included bleeding(aOR=0.72,P=0.67),accidental punctures/lacerations(aOR=0.77,P=0.5),and mechanical ventilation rates(aOR=1.19,P=0.6).Post-ERCP complication rate was similar for bleeding(aOR=0.72,P=0.41)and post-ERCP pancreatitis(aOR=1.4,P=0.44).Frail patients had a longer length of stay(6.7 d vs 5.5 d)and higher mean total charges of hospitalization($78807 vs$71392)compared to controls(P<0.001).The 30 d all-cause readmission rates between frail and non-frail patients were similar(P=0.96).CONCLUSION There was a significantly higher mortality risk and healthcare burden amongst nonagenarian frail patients undergoing ERCP compared to non-frail.Larger studies are warranted to investigate and mitigate modifiable risk factors.

Endoscopic ultrasound-guided biliary drainage vs percutaneous transhepatic biliary drainage for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography failure

In a recent issue of the World Journal of Gastrointestinal Surgery,a meta-analysis investigated the safety and efficacy of electrocautery-enhanced lumen-apposing metal stent(ECE-LAMS)implantation for managing malignant biliary obstruction following failed endoscopic retrograde cholangiopancreatography.This manusc-ript endeavors to offer a comprehensive look at the progression of endoscopic ultrasound-guided biliary drainage(EUS-BD)technologies,weighing their merits and drawbacks against traditional percutaneous methods.Several meta-analyses and randomized controlled trials have compared the performance of EUS-BD and percutaneous transhepatic cholangiodrainage(PTCD).These studies revealed that the technical success rate,clinical success rate,and adverse events were similar between EUS-BD and PTCD.Nevertheless,given that most of these studies preda-te 2015,the safety and effectiveness of novel EUS-BD techniques,including ECE-LAMS,compared with those of percutaneous biliary drainage remain elusive.Further investigation is imperative to ascertain whether these novel EUS-BD techniques can safely and efficaciously replace conventional percutaneous thera-peutic approaches.

Recognition and management of stent malposition in the portal vein during endoscopic retrograde cholangiopancreatography:A case report

BACKGROUND Portal vein injury is an uncommon complication of endoscopic retrograde cholangiopancreatography(ERCP),for which stent malpositioning in the portal vein is very rare and can lead to fatal events.We report a case of biliary stent migration to the portal vein and a novel method for its safe removal under the guidance of portal angiography.Moreover,we reviewed the literature and summarized reports on the identification and management of this condition.CASE SUMMARY A 59-year-old woman with pancreatic cancer presented with abdominal pain and a high fever 20 days after the placement of two plastic biliary stents under the guidance of ERCP.Blood cultures and laboratory tests revealed sepsis,which was treated with antibiotics.A contrast-enhanced computed tomography scan revealed that one of the biliary stents in the main portal vein was malpositioned.To safely remove the stent,portal angiography was performed to visualize the portal vein and to allow the management of any bleeding.The two stents were removed without obvious bleeding,and an uncovered self-expanding metal stent was placed in the common bile duct for drainage.The patient had an uneventful 6-month follow-up period,except for self-resolving portal vein thrombosis.CONCLUSION The combination of endoscopic and angiographic techniques allowed uneventful management of stent malposition in the portal vein.

Systemic air embolism associated with endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is a key procedure for diagnosing and treating biliary and pancreatic disorders.Although effective,it carries risks,including rare but severe complications such as air embolism.CASE SUMMARY We report a case of a 58-year-old man who developed extensive air embolism during ERCP.He previously underwent a Whipple procedure and experienced a sudden drop in vital signs and loss of consciousness.Immediate intervention with hyperbaric oxygen therapy and supportive care led to gradual recovery.Imaging confirmed widespread air embolism,which resolved with continued treatment.CONCLUSION Air embolism is a rare,critical complication of ERCP,especially in patients with prior surgery such as pancreaticoduodenectomy.Early detection and prompt treatment,including hyperbaric oxygen therapy,are crucial for favorable out-comes.

Failed biliary cannulation: Clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography

AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP. RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary can- nulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identif iable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 nave pa-pilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or postERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017). CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.

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.

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.

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.

Pancreatitis after endoscopic retrograde cholangiopancreatography:A narrative review

Acute post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP)is a feared and potentially fatal complication that can be as high as up to 30%in high-risk patients.Pre-examination measures,during the examination and after the examination are the key to technical and clinical success with a decrease in adverse events.Several studies have debated on the subject,however,numerous topics remain controversial,such as the effectiveness of prophylactic medications and the amylase dosage time.This review was designed to provide an update on the current scientific evidence regarding PEP available in the literature.

Split-dose or hybrid nonsteroidal anti-inflammatory drugs and Nacetylcysteine therapy for prevention of post-retrograde cholangiopancreatography pancreatitis

BACKGROUND Despite significant technical and training improvements, the incidence of postendoscopic retrograde cholangiopancreatography(ERCP) pancreatitis(PEP) has not significantly dropped. Although many studies have evaluated the efficacy of various agents, e.g. nonsteroidal anti-inflammatory drugs, octreotide,antioxidants, administered via various dosages, routes(oral, intrarectal or parenteral), and schedules(before or after the procedure), the results have been conflicting.AIM To evaluate efficacy of three pharmacologic prophylactic methods for prevention of PEP.METHODS In this prospective, single-center randomized trial, patients who underwent firsttime ERCP for choledocholithiasis were randomly assigned to three groups. The first group received 600 mg N-acetylcysteine 15 min prior to ERCP, and perrectum administration of 50 mg indomethacin both prior to and after completion of the ERCP. The second group was administered only the 50 mg indomethacin per-rectum both prior to and after the ERCP. The third group was administeredper-rectum 100 mg indomethacin only after the ERCP, representing the control group given the guideline-recommended regimen. The primary end-point was PEP prevention.RESULTS Among the total 211 patients evaluated during the study, 186 fulfilled the inclusion criteria and completed the protocol. The percentages of patients who developed PEP in each of the three groups were not significantly different(χ2 =2.793, P = 0.247). Among the acute PEP cases, for all groups, 14 patients developed mild pancreatitis(77.77%) and 4 moderate. No severe cases of PEP occurred, and in all PEP cases the resolution was favorable. No adverse events related to the medications(digestive hemorrhage, rectal irritation, or allergies)occurred.CONCLUSION The efficacies of split-dose indomethacin and combined administration(Nacetylcysteine with indomethacin) for preventing PEP were similar to that of the standard regimen.

Innovations and techniques for balloon-enteroscopeassisted endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy

Endoscopic retrograde cholangiopancreatography(ERCP) remains challenging in patients who have undergone surgical reconstruction of the intestine.Recently,many studies have reported that balloonenteroscope-assisted ERCP(BEA-ERCP) is a safe and effective procedure.However,further improvements in outcomes and the development of simplified procedures are required.Percutaneous treatment,Laparoscopy-assisted ERCP,endoscopic ultrasoundguided anterograde intervention,and open surgery are effective treatments.However,treatment should be noninvasive,effective,and safe.We believe that these procedures should be performed only in difficult-to-treat patients because of many potential complications.BEA-ERCP still requires high expertiselevel techniques and is far from a routinely performed procedure.Various techniques have been proposed to facilitate scope insertion(insertion with percutaneous transhepatic biliary drainage(PTBD) rendezvous technique,Short type single-balloon enteroscopes with passive bending section,Intraluminal injection of indigo carmine,CO2 inflation guidance),cannulation(PTBD or percutaneous transgallbladder drainage rendezvous technique,Dilation using screw drill,Rendezvous technique combining DBE with a cholangioscope,endoscopic ultrasound-guided rendezvous technique),and treatment(overtube-assisted technique,Short type balloon enteroscopes) during BEA-ERCP.The use of these techniques may allow treatment to be performed by BEA-ERCP in many patients.A standard procedure for ERCP yet to be established for patients with a reconstructed intestine.At present,BEA-ERCP is considered the safest and most effective procedure and is therefore likely to be recommended as firstline treatment.In this article,we discuss the current status of BEA-ERCP in patients with surgically altered gastrointestinal anatomy.

Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is a valuable therapeutic technique for pancreatobiliary diseases,and its application in the elderly is no longer limited.However,a higher incidence of procedure difficulty and periprocedural adverse events might be expected in elderly patients due to the presence of other medical disorders and the poor general condition of this population.AIM To evaluate the incidence,causes,and management of difficult biliary cannulation during ERCP in elderly patients and the role of difficult cannulation as a risk factor for adverse events.METHODS A total of 614 patients who underwent ERCP during the study period were prospectively studied and divided into two groups based on their age.One hundred and forty-six patients were aged 80 years or older and 468 patients were aged less than 80 years.The primary outcome measurements were cannulation difficulty,cannulation success rate,ERCP procedure time,and related adverse events.RESULTS There was no difference in the incidence of difficult cannulation among the two groups(32.9%vs 34.4%,P=0.765),as well as in the cannulation success rate(96.6%vs 96.8%,P=0.54).The cannulation techniques were shown to be safe and efficient in achieving successful cannulation.Logistic regression analysis showed that patients aged 80 years or older were not associated with increased adverse events;however,difficult cannulation cases[adjusted odds ratio(AOR)=3.478;95%confidence interval(CI):1.877-6.442;P<0.001]and patients with Charlson Comorbidity Index≥2(AOR=1.824;95%CI:0.993-3.349;P=0.045)were more likely to develop adverse events.In contrast,other factors including age≤65(AOR=3.460;95%CI:1.511-7.922;P=0.003),female gender(AOR=2.362;95%CI=1.089-5.124;P=0.030),difficult cannulation(AOR=4.527;95%CI:2.078-9.860;P<0.001),and patients with cholangitis(AOR=3.261;95%CI:1.204-8.832;P=0.020)were strongly associated with a higher rate of post-ERCP pancreatitis.CONCLUSION Advanced age has not been proved to be a risk factor for difficult cannulation,and secondary cannulation techniques can be safely and efficaciously utilized in this group.Patients with a Charlson Comorbidity Index≥2 and difficult cannulation are associated with an increased overall adverse events rate,while age≥80 years is not.

Endoscopic retrograde cholangiopancreatography in the treatment of pancreaticopleural fistula in children

BACKGROUND Pancreaticopleural fistula(PPF)is a rare disease,especially in children.Conservative treatment and surgery are traditional therapies,but surgery is invasive.The emergence of endoscopic retrograde cholangiopancreatography(ERCP)has provided a new noninvasive treatment for PPF and may become the first choice for children with PPF.AIM To explore the treatment response to ERCP for PPF in children.METHODS Seven children with PPF were hospitalized in the Gastroenterology Department of Beijing Children’s Hospital from December 2007 to May 2019.Data on these seven patients’clinical characteristics,diagnosis,treatments,and outcomes were analyzed,and their treatment responses following surgery and ERCP were compared.The correlation between the length of hospital stay and conservative treatment was analyzed.Peer-reviewed articles written in English and Chinese published from January 2009 to December 2019 were obtained from various open data sources and reviewed.RESULTS The seven patients comprised three boys and four girls with a mean age of 6.57±3.26 years.The main symptoms were chest tightness and pain(n=4),intermittent fever(n=3),dyspnea(n=3),and abdominal pain(n=1),and all patients had bloody pleural effusion.All seven patients were diagnosed with PPF by magnetic resonance cholangiopancreatography,and all were initially treated conservatively for a mean of 34.67±22.03 d with a poor response.Among five patients who underwent ERCP,one required surgery because of intubation failure;thus,the success rate of ERCP was 80%.Two patients were successfully treated with surgery(100%).The postoperative hospital stay of the two patients treated by surgery was 20 and 30 d,respectively(mean of 25 d),and that of the four patients treated by ERCP ranged from 12 to 30 d(mean of 19.25±8.85 d).The recovery time after ERCP was short[time to oral feeding,4-6 d(mean,5.33±1.15 d);duration of closed thoracic drainage,2-22 d(mean,13.3 d)].Analysis of previous cases of PPF published worldwide during the past decade showed that the treatment success rate of ERCP is not lower than that of surgery.There was no significant difference in the postoperative hospital stay between surgery(16±10.95 d)and ERCP(18.7±6.88 d,P>0.05).A positive linear correlation was found between the overall hospital stay and ERCP intervention time(R2=0.9992).CONCLUSION ERCP is recommended as the first-choice treatment for PPF in children.ERCP should be performed as early as possible if conditions permit.

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.

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.