Systematic review and meta-analysis on the prophylactic role of non-steroidal anti-inflammatory drugs to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis

AIM: To critically appraise the published randomized, controlled trials on the prophylactic effectiveness of the non-steroidal anti-inflammatory drugs(NSAIDs), in reducing the risk of post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis. METHODS: A systematic literature search(MEDLINE, Embase and the Cochrane Library, from inception of the databases until May 2015) was conducted to identify randomized, clinical trials investigating the role of NSAIDs in reducing the risk of post-ERCP pancreatitis. Random effects model of the meta-analysis was carried out, and results were presented as odds ratios(OR) with corresponding 95%CI.RESULTS: Thirteen randomized controlled trials on 3378 patients were included in the final meta-analysis. There were 1718 patients in the NSAIDs group and 1660 patients in non-NSAIDs group undergoing ERCP. The use of NSAIDs(through rectal route or intramuscular route) was associated with the reduced risk of post-ERCP pancreatitis [OR, 0.52(0.38-0.72), P = 0.0001]. The use of pre-procedure NSAIDs was effective in reducing approximately 48% incidence of post-ERCP pancreatitis, number needed to treat were 16 with absolute risk reduction of 0.05. But the risk of post-ERCP pancreattis was reduced by 55% if NSAIDs were administered after procedure. Similarly, diclofenac was more effective(55%) prophylactic agent compared to indomethacin(41%).CONCLUSION: NSAIDs seem to have clinically proven advantage of reducing the risk of post-ERCP pancreatitis.

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.

Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis using pancreatic stents: A review of efficacy, diameter and length

Although endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure for the diagnosis and treatment of pancreaticobiliary diseases, post-ERCP pancreatitis (PEP) is the most frequent adverse event that can sometimes be fatal. However, prophylactic pancreatic stent (PS) insertion has been performed to prevent PEP in high-risk patients. In some randomized controlled trials (RCTs) and meta-analyses, the efficacy of prophylactic PS insertion has been shown to prevent PEP. In addition, several types of stents have been used to decrease PEP. In this review, we introduce the details of these RCTs and meta-analyses and reveal the specifications for stent placement, for example, the stent diameter and length and the pancreatic region into which the stent should be inserted.

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.

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.

NSAIDs for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography:Ready for prime time?

Acute pancreatitis is the most common and the most fearful complication of endoscopic retrograde cholangiopancreatography (ERCP).Prevention of post-ERCP pancreatitis has therefore been of great interest to endoscopists performing ERCP procedures.So far,only pancreatic duct stenting during ERCP and rectal administration of a non-steroidal anti-inflammatory drug (NSAID) prior to or immediately after ERCP have been consistently shown to be effective for prevention of post-ERCP pancreatitis.This commentary focuses on a short discussion about the rates,mechanisms,and risk factors for post-ERCP pancreatitis,and effective means for its prevention with emphasis on the use of NSAIDs including a recent clinical trial published in The New England Journal of Medicine by Elmunzer et al.

Role of nonsteroidal anti-inflammatory drugs in the prevention of post-ERCP pancreatitis:a meta-analysis

BACKGROUND: The role of prophylactic nonsteroidal anti-inflammatory drugs (NSAIDs) for reduction of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) is debated. We performed a meta-analysis of all published randomized controlled trials to evaluate the efficacy of NSAIDs in the prevention of post-ERCP pancreatitis. DATA SOURCES: Searches were conducted in the databases PubMed, EMBASE and the Cochrane Library. Six randomized clinical trials that fulfilled the inclusion criteria and addressed the clinical questions of this analysis were further assessed. Data were extracted by two independent observers according to predetermined criteria. RESULTS: The risk of pancreatitis was lower in the NSAID group than in the placebo, group (OR: 0.46, 95% CI: 0.32 to 0.65, P < 0.0001). Two hours after ERCP, prophylactic administration of NSAIDs was associated with a lower serum amylase level (WMD: -91.09,95% CI: -149.78 to -32.40, P=0.002), but there was no difference in mean 24-hour serum amylase values (WMD: -379.00, 95% CI: -805.75 to 47.76, P=0.08). No deaths or NSAID-related complications were noted. CONCLUSIONS: Prophylactic administration of NSAIDs can reduce the incidence of post-ERCP pancreatitis; this administration in patients undergoing ERCP is recommended. Further randomized controlled trials are required before its introduction into routine care.

endoscopic 以后后退 cholangiopancreatography 复杂并发症: 他们怎么能被避免？

Endoscopic retrograde cholangiopancreatography(ERCP) has a significant complication rate which can be lowered by adopting technical variations of proven beneficial effect and prophylactic maneuvers such as pancreatic stenting during ERCP or periprocedural non-steroidal anti-inflammatory drug administration.However,adoption of these prophylactic maneuvers by endoscopists is not uniform.In this editorial we discuss the beneficial effects of the aforementioned maneuvers.

Clinical usefulness and current problems of pancreatic duct stenting for preventing post-ERCP pancreatitis

Endoscopic retrograde cholangiopancreatography(ERCP) is an endoscopic procedure with high frequency of accidental symptoms, and particularly some patients who develop and aggravate pancreatitis due to the procedure may need treatment of surgery or die. Various attempts were performed so far to prevent post-ERCP pancreatitis, however, it is impossible to completely prevent pancreatitis at this time because there are various factors for occurrence of post-ERCP pancreatitis.One of the most frequent causes of post-ERCP pancreatitis is considered to be congestion of pancreatic juice associated with duodenal papilledema after examination or treatment. Recently it is often reported that use of a pancreatic duct stent may prevent occurrence of pancreatitis which occurs because of an increased inner pressure of the pancreatic duct caused by congestion of pancreatic juice associated with duodenal papilledema. However, there are some patients who develop pancreatitis even if treated with the pancreatic duct stent, thus further clarification of the pathology and advancement of the prophylactic method will be needed.

ERCP术后胰腺炎的预防策略

胰腺炎是内镜逆行胰胆管造影(ERCP)术后最常见和最严重的并发症之一。目前,非甾体类抗炎药物(吲哚美辛栓或双氯芬栓)纳肛和预防性胰管支架植入是行之有效的ERCP术后胰腺炎(PEP)预防措施。优化ERCP围手术期管理(术前风险评估,术中风险控制,术后积极治疗),可有效降低PEP风险。

不同方法预防ERCP术后胰腺炎效果的Meta分析

目的 系统评价不同方法预防ERCP术后胰腺炎（PEP）的效果.方法 以endoscopic retrograde cholangiopancreatography、ERCP、post-ERCP pancreatitis、pancreatitis、pancreatic duct stent、non-steroid anti-inflammatory drugs、indometacin、diclofenac、protease inhibitors、nafamostat、ulinastatin、gabexate、somatostain、内镜逆行胰胆管造影、内镜逆行胰胆管造影术后胰腺炎、胰腺炎、胰管支架置入、非甾体类抗炎药、吲哚美辛、双氯芬酸、抑酶剂、萘莫司他、乌司他丁、加贝酯、生长抑素为检索词检索PubMed、EMBASE、Cochrane Library、中国期刊全文数据库、中国生物医学文献数据库等数据库.检索时间为2000年1月至2014年1月.最终纳入研究预防PEP效果的相关随机对照试验,再由2名研究者独立筛查文献和提取数据,并进行文献质量评价.采用RevMan 5.0软件进行Meta分析.数据采用优势比（OR）及95％可信区间（95％ CI）表示.采用I2对异质性进行分析.结果 共纳入符合标准的文献27篇,累计样本量8 293例,其中实验组[含胰管支架置入组、非甾体类抗炎药（NSAIDs）组、萘莫司他组、乌司他丁组、加贝酯组、生长抑素长期（静脉输注＞6 h）输注组、生长抑素短期（静脉输注≤6 h）输注组、生长抑素静脉团注组]患者4 701例,对照组（采用无胰管支架置入或安慰剂对比）患者3 592例.Meta分析结果显示：与对照组比较,胰管支架置入组、NSAIDs组、萘莫司他组、生长抑素长期输注组和生长抑素静脉团注组患者PEP发生率显著降低,差异有统计学意义（OR =0.18,0.45,0.31,0.33,0.25,95％ CI：0.09～0.35,0.33 ～0.61,0.19 ～0.52,0.20 ～0.56,0.11 ～0.55,P＜0.05）.结论 胰管支架置入、NSAIDs、萘莫司他、静脉输注生长抑素＞6h和静脉团注生长抑素能有效预防PEP的发生.