Endoscopic ultrasound-guided tissue sampling induced pancreatic duct leak resolved by the placement of a pancreatic stent:A case report

BACKGROUND Pancreatic ductal leaks complicated by endoscopic ultrasonography-guided tissue sampling(EUS-TS)can manifest as acute pancreatitis.CASE SUMMARY A 63-year-old man presented with persistent abdominal pain and weight loss.Diagnosis:Laboratory findings revealed elevated carbohydrate antigen 19-9(5920 U/mL)and carcinoembryonic antigen(23.7 ng/mL)levels.Magnetic resonance imaging of the pancreas revealed an approximately 3 cm ill-defined space-occupying lesion in the inferior aspect of the head,with severe encasement of the superior mesenteric artery.Pancreatic ductal adenocarcinoma was confirmed after pathological examination of specimens obtained by EUS-TS using the fanning method.Interventions and outcomes:The following day,the patient experienced severe abdominal pain with high amylase(265 U/L)and lipase(1173 U/L)levels.Computed tomography of the abdomen revealed edematous wall thickening of the second portion of the duodenum with adjacent fluid collections and a suspicious leak from either the distal common bile duct or the main pancreatic duct in the head.Endoscopic retrograde cholangiopancreatography revealed dye leakage in the head of the main pancreatic duct.Therefore,a 5F 7 cm linear plastic stent was deployed into the pancreatic duct to divert the pancreatic juice.The patient’s abdominal pain improved immediately after pancreatic stent insertion,and amylase and lipase levels normalized within a week.Neoadjuvant chemotherapy was then initiated.CONCLUSION Using the fanning method in EUS-TS can inadvertently cause damage to the pancreatic duct and may lead to clinically significant pancreatitis.Placing a pancreatic stent may immediately resolve acute pancreatitis and shorten the waiting time for curative therapy.When using the fanning method during EUSTS,ductal structures should be excluded to prevent pancreatic ductal leakage.

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.

Metal stents placement for refractory pancreatic duct stricture in children

AIM To evaluate the use of fully covered self-expandable metal stents(FCSEMSs) for pancreatic duct strictures in children with chronic pancreatitis.METHODS Eight patients with refractory benign dominant stricture of the main pancreatic duct(MPD) were enrolled through chart reviews between December 2014 and June 2017 in a single center. Endoscopic retrograde cholangiopancreatography(ERCP) with placement of a 6-mm FCSEMS with dual flaps was performed. Endoscopic removal of FCSEMSs was performed with a snare or rat-tooth forceps. All procedures were performed by a pediatric gastroenterologist. For the assessment of outcomes, technical and clinical success, adverse events, and stent patency were evaluated retrospectively.RESULTS The placement and removal of the FCSEMSs were successful in all 8 patients. Five patients were boys and 3 were girls. The median age at initial FCSEMS placement was 12 years(range, 5-18 years). The diameters of all the inserted stents were 6 mm, and the lengths were 4-7 cm. The median indwelling time was 6 mo(range, 3-10 mo). No pancreatic sepsis, pancreatitis, cholestasis, or mortality occurred. There was no proximal and distal migration. All subjects showed a patent stent. On follow-up ERCP, the mean diameter of the stricture improved from 1.1 mm to 2.8 mm(P < 0.05), whereas that of upstream dilation improved from 8.4 mm to 6.3 mm(P < 0.05).CONCLUSION This initial experience showed that temporary FCSEMS placement is feasible and safe for the management of refractory benign MPD stricture in children.

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.

Comparison of postoperative complications between internal and external pancreatic duct stenting during pancreaticoduodenectomy: a meta-analysis

Background：Two types of pancreatic duct stents are used to improve postoperative outcomes of pancreatic anastomosis.The aim of this meta-analysis was to evaluate and compare the postoperative outcomes of patients with internal or external stenting during pancreaticoduodenectomy（PD）.Methods：We searched Pub Med,EMBASE,the Cochrane Library and Web of Science databases until the end of December,2014.Studies comparing outcomes of external vs.internal stent placement in PD were eligible for inclusion.Included literature was extracted and assessed by two independent reviewers.Results：Seven articles were identified for inclusion：three randomized controlled trials（RCTs）and four observational clinical studies（OCS）.The meta-analyses revealed that use of external stents had advantage on reducing the incidences of pancreatic fistula（PF）in total[odds ratio（OR）=0.69;95%confidence interval（CI）,0.48-0.99;P=0.04],PF in soft pancreas（OR=0.30;95%CI,0.16-0.56;P=0.0002）and delayed gastric emptying（DGE）（OR=0.58;95%CI,0.38-0.89;P=0.01）compared with internal stents.There were no significant differences in other postoperative outcomes between two stenting methods,including postoperative morbidity（OR=0.93;95%CI,0.39-2.23;P=0.88）,overall mortality（OR=0.70;95%CI,0.22-2.25;P=0.55）,and intra-abdominal collections（OR=0.67;95%CI,0.26-1.71;P=0.40）.Conclusions：Based upon this meta-analysis,the use of external pancreatic stents might have potential benefit in reducing the incidence of PF and DGE.Due to the limited number of original studies,more RCTs are needed to further support our result and clarify the issue.

Chronic pancreatic pain successfully treated by endoscopic ultrasound-guided pancreaticogastrostomy using fully covered self-expandable metallic stent

One of the most common symptoms presenting in patients with chronic pancreatitis is pancreatic-type pain.Obstruction of the main pancreatic duct in chronic pancreatitis can be treated by a multitude of therapeutic approaches,ranging from pharmacologic,endoscopic and radiologic treatments to surgical interventions.When the conservative treatment approaches fail to resolve symptomatic cases,however,endoscopic retrograde pancreatography with pancreatic duct drainage is the preferred second approach,despite its well-recognized drawbacks.When the conventional transpapillary approach fails to achieve the necessary drainage,the patients may benefit from application of the less invasive endoscopic ultrasound(EUS)-guided pancreatic duct interventions.Here,we describe the case of a 42-year-old man who presented with severe abdominal pain that had lasted for 3 mo.Computed tomography scanning showed evidence of chronic obstructive pancreatitis with pancreatic duct stricture at genu.After conventional endoscopic retrograde pancreaticography failed to eliminate the symptoms,EUS-guided pancreaticogastrostomy(PGS)was applied using a fully covered,self-expandable,10-mm diameter metallic stent.The treatment resolved the case and the patient experienced no adverse events.EUS-guided PGS with a regular biliary fully covered,self-expandable metallic stent effectively and safely treated pancreatictype pain in chronic pancreatitis.

Endoscopic ultrasound-guided pancreaticogastrostomy for symptomatic pancreatic duct obstruction caused by migrated pancreatic stent

Endoscopic pancreatic stenting has been widely used in various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been recognized. Especially, proximal stent migration presents a serious condition because of subsequent pancreatic duct obstruction, impaired drainage, ductal dilation, and pancreatic pain. Although endoscopic retrieval is the preferred treatment for proximally migrated pancreatic stents, it is not always successful, resulting in conversion to surgery. To date, endoscopic ultrasound-guided pancreatic duct drainage(EUS-PD) has never been reported for treatment of pancreatic duct obstruction caused by proximally migrated pancreatic stent. We herein describe a case of pancreatic duct rupture and obstruction caused by proximally migrated pancreatic stent that was successfully treated by EUS-guided pancreaticogastrostomy while keeping the former stent in situ after failed endoscopic retrograde cholangiopancreatography. We believe that this report adds to the increasing evidence of symptomatic pancreatic duct obstruction being successfully treated by EUS-PD.

New 14-mm diameter Niti-S biliary uncovered metal stent for unresectable distal biliary malignant obstruction

AIM To investigate whether an uncovered self-expandable metal stent(UCSEMS) with a large diameter could prevent recurrent biliary obstruction(RBO).METHODS Thirty-eight patients with malignant biliary obstruction underwent treatment with an UCSEMS with a 14-mm diameter(Niti-S 14). Retrospectively, we evaluated technical and functional success rate, RBO rate, time to RBO, survival time, and adverse events in these patients.RESULTS Stent placement success and functional success were achieved in all patients. Two patients(5.3%) had RBO due to tumor ingrowth or overgrowth. The median time to RBO was 190(range, 164-215) d. The median survival time was 120(range, 18-502) d. The 6-mo non-RBO rate was 91%. Other adverse events other than RBO occurred as follows: Acute cholecystitis, post-ERCP pancreatitis, hemobilia, and fever without exacerbation of liver injury, and liver abscess in 4(10.3%), 3(7.9%), 2(5.3%), 1(2.6%), and 1(2.6%), respectively. Migration of the stents was not observed.CONCLUSION Niti-S 14 is considered to be a preferable metal stent because of a low rate of RBO with no migration.

Placement of a fully covered self-expandable metal stent in a young patient with chronic pancreatitis

Plastic stent insertion is a treatment option for pancreatic duct stricture with chronic pancreatitis.However, recurrent stricture is a limitation after removing the plastic stent.Self-expandable metal stents have long diameters and patency.A metal stent has become an established management option for pancreatic duct stricture caused by malignancy but its use in benign stricture is still controversial.We introduce a young patient who had chronic pancreatitis and underwent several plastic stent insertions due to recurrent pancreatic duct stricture.His symptoms improved after using a fully covered self-expandable metal covered stent and there was no recurrence found at follow-up at the outpatient department.

One-step palliative treatment method for obstructive jaundice caused by unresectable malignancies by percutaneous transhepatic insertion of an expandable metallic stent

AIM： To describe a simple one-step method involving percutaneous transhepatic insertion of an expandable metal stent （EMS） used in the treatment of obstructive jaundice caused by unresectable malignancies. METHODS： Fourteen patients diagnosed with obstructive jaundice due to unresectable malignancies were included in the study. The malignancies in these patients were a result of very advanced carcinoma or old age. Percutaneous transhepatic cholangiography was performed under ultrasonographic guidance. After a catheter with an inner metallic guide was advanced into the duodenum, an EMS was placed in the common bile duct, between a point 1 cm beyond the papilla of Vater and the entrance to the hepatic hilum. In cases where it was difficult to span the distance using just a single EMS, an additional stent was positioned. A drainage catheter was left in place to act as a hemostat. The catheter was removed after resolution of cholestasis and stent patency was confirmed 2 or 3 d post-procedure. RESULTS： One-step insertion of the EMS was achieved in all patients with a procedure mean time of 24.4 min. Out of the patients who required 2 EMS, 4 needed a procedure time exceeding 30 min. The mean time for removal of the catheter post-procedure was 2.3 d. All patients died of malignancy with a mean follow-up time of 7.8 mo. No stent-related complication or stent obstruction was encountered. CONCLUSIONS： One-step percutaneous transhepaticinsertion of EMS is a simple procedure for resolving biliary obstruction and can effectively improve the patient＇s quality of life.

Pancreatic guidewire placement for achieving selective biliary cannulation during endoscopic retrograde cholangio-pancreatography

AIM: To investigate the frequency and risk factors for acute pancreatitis after pancreatic guidewire placement (P-GW) in achieving cannulation of the bile duct during endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: P-GW was performed in 113 patients in whom cannulation of the bile duct was difficult. The success rate of biliary cannulation, the frequency and risk factors of post-ERCP pancreatitis, and the frequency of spontaneous migration of the pancreatic duct stent were investigated. RESULTS: Selective biliary cannulation with P-GW was achieved in 73% of the patients. Post-ERCP pancreatitis occurred in 12% (14 patients: mild, 13; moderate, 1). Prophylactic pancreatic stenting was attempted in 59% of the patients. Of the 64 patients who successfully underwent stent placement, three developed mild pancreatitis (4.7%). Of the 49 patients without stent placement, 11 developed pancreatitis (22%: mild, 10; moderate, 1). Of the five patients in whom stent placement was unsuccessful, two developed mild pancreatitis. Univariate and multivariate analyses revealed no pancreatic stenting to be the only significant risk factor for pancreatitis. Spontaneous migration of the stent was observed within two weeks in 92% of the patients who had undergone pancreatic duct stenting.CONCLUSION: P-GW is useful for achieving selective biliary cannulation. Pancreatic duct stenting after P-GW can reduce the incidence of post-ERCP pancreatitis, which requires evaluation by means of prospective randomized controlled trials.

Potential risk factors for nonalcoholic steatohepatitis related to pancreatic secretions following pancreaticoduodenectomy

AIM: To identify risk factors for nonalcoholic steatohepatitis following pancreaticoduodenectomy, with a focus on factors related to pancreatic secretions. METHODS: The medical records of 228 patients who had a pancreaticoduodenectomy over a 16-mo period were reviewed retrospectively. The 193 patients who did not have fatty liver disease preoperatively were included in the final analysis. Hepatic steatosis was diagnosed using the differences between splenic and hepatic attenuation and liver-to-spleen attenuation as measured by non-enhanced computed tomography. RESULTS: Fifteen patients (7.8%) who showed postoperative hepatic fatty changes were assigned to Group A, and the remaining patients were assigned to Group B. Patient demographics, preoperative laboratory findings (including levels of C-peptide, glucagon, insulin and glucose tolerance test results), operation types, and final pathological findings did not differ significantly between the two groups; however, the frequency of pancreatic fistula (P = 0.020) and the method of pancreatic duct stenting (P = 0.005) showed significant differences between the groups. A multivari- ate analysis identified pancreatic fistula (HR = 3.332, P = 0.037) and external pancreatic duct stenting (HR = 4.530, P = 0.017) as independent risk factors for the development of postoperative steatohepatitis. CONCLUSION: Pancreatic fistula and external pancreatic duct stenting were identified as independent risk factors for the development of steatohepatitis following pancreaticoduodenectomy.

Continuing episodes of pain in recurrent acute pancreatitis: Prospective follow up on a standardised protocol with drugs and pancreatic endotherapy

AIM To assess the outcomes of drug therapy(DT)followed by pancreatic endotherapy for continuing painful episodes in recurrent acute pancreatitis.METHODS DT comprised of pancreatic enzymes and antioxidants failing which,endotherapy(ET;pancreatic sphincterotomy and stent placement)was done.The frequency of pain,its visual analogue score(VAS),quality of life(Qo L),serum C peptide and faecal elastase were compared between baseline and after 1 year of follow up in all patients and in the two subgroups on DT and ET.Response was defined as at least 50%reduction in the severity of pain to below a score of 5.RESULTS Of the thirty nine patients analysed,21(53.9%)responded to DT and 18(46.1%)underwent ET.The VAS for pain(7.0±2.0 vs 1.3±2.5,P<0.001)and the number of days with pain per month decreased[1.0(1.0,2.0)vs 1.0(0.0,1.0),P<0.001],and the Qo L scores[55.0(44.0,66.0)vs 38.0(32.00,51.00),P<0.01]improved significantly during follow up.Similar significant improvements were seen in patients in the subgroups of DT and ET except for Qo L in ET.The serum C-peptide(P=0.001)and FE(P<0.001)levels improved significantly in the entire group and in the two subgroups of patients except for the C peptide levels in patients on DT.CONCLUSION A standardised protocol of DT,followed by ET decreased the intensity and frequency of pain in recurrent acute pancreatitis,enhanced Qo L and improved pancreatic function.

Metallic biliary stents for malignant obstructive jaundice:a review

Affecting 8-10 patients per 100000population,pancreatic cancer is the primary causeof malignant obstructive jaundice and is thepresenting feature in over three quarters of thesepatients.Unfortunately,using modern imagingtechniques,such as endoscopic ultrasound orpancreatic protocol computed tomography withvascular reconstruction,80%-90% proveunrescctable for cure.Historically,this jaundicewas treated surgically with biliary bypass.Over

Endoscopic multiple metal stenting for the treatment of enteral leaks near the biliary orifice: A novel effective rescue procedure

Between April 2013 and October 2015, 6 patients developed periampul ary duodenal or jejunal/biliary leaks after major abdominal surgery. In all patients, percutaneous drainage of the collection or re-operation with primary surgical repair was attempted at first but failed. A fully covered enteral metal stent was placed in all patients to seal the leak. Subsequently, we cannulated the common bile duct and, in some cases, and the main pancreatic duct inserting hydrophilic guidewires through the stent after dilating the stent mesh with a dilatation balloon or breaking the meshes with Argon Plasma Beam. Finally, we inserted a fully covered biliary metal stent to drain the bile into the lumen of the enteral stent. In cases of normal proximal upper gastrointestinal anatomy, a pancreatic plastic stent was also inserted. Oral food intake was initiated when the abdominal drain outflow stopped completely. Stent removal was scheduled four to eight weeks later after a CT scan to confirm the complete healing of the fistula and the absence of any perilesional residual fluid collection. The leak resolved in five patients. One patient died two days after the procedure due to severe, pre-existing, sepsis. The stents were removed endoscopically in four weeks in four patients. In one patient we experiencedstent migration causing small bowel obstruction. In this case, the stents were removed surgically. Four patients are still alive today. They are still under follow-up and doing well. Bilio-enteral fully covered metal stenting with or without pancreatic stenting was feasible, safe and effective in treating postoperative enteral leaks near the biliopancreatic orifice in our small series. This minimally invasive procedure can be implemented in selected patients as a rescue procedure to repair these challenging leaks.

可降解药物洗脱消化道支架的研究进展与前景

背景:目前消化道支架的临床应用较为普遍,常规的自膨胀金属及塑料支架存在易移位、取出困难、术后再狭窄等问题,可降解药物洗脱消化道支架凭借生物可降解、术后再狭窄率低等优点成为消化道支架研究的热点。目的:总结可降解药物洗脱消化道支架的研究进展,对可降解药物洗脱消化道支架的前景作出展望。方法:检索中国知网、万方、Pub Med、Web of Science数据库中1994年1月至2024年3月发表的相关文献,中文检索词为“可降解,药物洗脱支架,食管支架,胆道支架,胰管支架,肠道支架,消化道支架”,英文检索词为“biodegradable,drug-eluting stent,esophageal stent,biliary stent,pancreatic duct stent,intestinal stent,gastrointestinal stent”,最终纳入64篇文献进行综述分析。结果与结论:(1)可降解药物洗脱消化道支架以生物可降解材料为主体,搭载并局部洗脱不同治疗目的的药物,发挥物理支撑及药物治疗双重作用。通过调整支架材料性质、改进制造工艺及辅助手段可以加快或减缓支架降解速度,满足临床需求。药物洗脱技术以药物涂层、纳米颗粒、聚合物载药膜等为载药平台,使药物精准释放,提高病变部位局部药物浓度,减少药物损耗及毒性药物的全身吸收量。(2)可降解药物洗脱消化道支架主要为一种或多种功能性药物结合可生物降解聚合物、金属或纳米纤维材料。可用的功能性药物分为抗炎抗增生类、抗肿瘤类、溶石类、酶抑制剂类。(3)维持支架机械性能稳定和精准控释药物是可降解药物洗脱消化道支架现阶段需要解决的问题,开发新型可降解消化道支架,研究新型载药及释药方式、制造工艺和辅助手段是未来研究方向。

胰管支架置入术预防ERCP术后胰腺炎的Meta分析

目的评价胰管支架置入术预防高危患者内镜逆行胰胆管造影术后胰腺炎（PEP）的作用。方法通过计算机文献检索Cochrane图书馆（1970-2015.8）、Pub Med（1966-2015.8）、EMBASE（1966-2015.8）和中国生物医学文献资料库（1978-2015.8）,查找胰管支架置入术预防PEP的随机对照试验及其参考文献。由2名研究者独立选择实验、提取资料和评估方法学质量,采用Cochrane协作网提供的Rev Man 5.3软件进行统计分析。结果共纳入23篇文献,包括2556例患者。Meta分析结果显示：与对照组比较,使用胰管支架可以有效预防高危患者发生PEP（RR=0.34,95%CI：0.27～0.43,P〈0.00001）,并可有效减轻PEP的严重程度（RR=0.18,95%CI：0.08～0.42,P〈0.0001）。结论胰管支架能够预防高危患者PEP的发生,并可以减轻PEP的严重程度。

国内胰管支架置入预防内镜逆行胰胆管造影术后胰腺炎的Meta分析

目的系统评价国内胰管支架置入术对内镜逆行胰胆管造影（ERCP）术后胰腺炎（PEP）的预防效果及安全性。方法计算机检索从建库至2015年5月中国知网、万方数据库、中国学术期刊全文数据库、中国生物医学文献数据库、维普（VIP）、PubMed、Medline数据库等,收集国内胰管支架置入预防PEP的临床随机对照试验。由2名研究者按纳入、排除标准独立选择,提取资料,并对纳入文献进行质量方法学评估,使用RevMan5.2软件进行Meta分析。结果共纳入9项研究1 025例患者。Meta分析结果显示,试验组可降低PEP的发生率（OR=0.20,95%CI0.13~0.32,P〈0.01;NNT=6）及重度PEP的发生率（OR=0.16,95%CI 0.05~0.53,P=0.003;NNT=25）,高淀粉酶血症发生率的判定共纳入2项研究,包括试验组86例和对照组79例,试验组术后高淀粉酶血症发生率明显低于对照组（OR=0.33,95%CI 0.16~0.70,P=0.004,NNT=5）。结论国内胰管支架置入术可降低PEP和重度。PEP的发生率,可能是预防PEP的有效方法。

胰十二指肠切除术胰管支撑管应用的Meta分析

目的 评价胰十二指肠切除术中胰管支撑管应用的实际价值.方法 采用Meta分析方法检索1980年1月至2012年1月间发表的有关胰十二指肠切除术胰管支撑管应用的临床对照试验（包括随机和非随机研究）.按照入选和排除标准,有7项临床试验纳入研究,提取所需数据,用RevMan5.1软件进行分析.结果 胰十二指肠切除术胰管支撑管应用与对照组相比,术后胰漏（OR=0.88,95%CI：0.58～1.35）,胃排空障碍（OR=1.08,95%CI：0.63～1.86）,围手术期死亡（OR=0.63,95% CI：0.24～1.61）及术后总的并发症率（OR=1.03,95%CI：0.75～1.43）差异均无统计学意义.结论 胰十二指肠切除术胰管支撑管的应用并没有从根本上改善术后并发症的发生.

Analysis of the risk factors for severity in post endoscopic retrograde cholangiopancreatography pancreatitis: The indication of prophylactic treatments

To determine the risk factors of severe post endoscopic retrograde cholangiopancreatography pancreatitis (sPEP) and clarify the indication of prophylactic treatments. METHODSAt our hospital, endoscopic retrograde cholangiopancreatography (ERCP) was performed on 1507 patients from May 2012 to December 2015. Of these patients, we enrolled all 121 patients that were diagnosed with post endoscopic retrograde PEP. Fourteen of 121 patients diagnosed as sPEP were analyzed. RESULTSForty-one patients had contrast media remaining in the pancreatic duct after completion of ERCP. Seventy-one patients had abdominal pain within three hours after ERCP. These were significant differences for sPEP (P < 0.05). The median of Body mass index, the median time for ERCP, the median serum amylase level of the next day, past histories including drinking and smoking, past history of pancreatitis, sphincter of Oddi dysfunction, whether emergency or not, expertise of ERCP procedure, diverticulum nearby Vater papilla, whether there was sphincterotomy or papillary balloon dilation, pancreatic duct cannulation, use of intra-ductal ultrasonography enforcement, and transpapillary biopsies had no significant differences with sPEP. CONCLUSIONContrast media remaining in the pancreatic duct and the appearance of abdominal pain within three hours after ERCP were risk factors of sPEP.