(ESGE) Guideline: Prophylaxis of post-ERCP ... - ResearchGate

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512 Guidelines Sphincter of Oddi manometry " In patients undergoing pancreatic sphincter of Oddi manometry, use of the standard perfusion catheter without an aspiration port has been shown to increase the risk of PEP compared with modified water perfusion catheters (Evidence level 2++). Pancreatic sphincter of Oddi manometry should be done using a modified triple-lumen perfusion catheter with simultaneous aspiration or a microtransducer catheter (non-water-perfused) (Recommendation grade B). To reduce the risk of possible perfusion-related hydrostatic pancreatic injury, modified perfusion catheters have been developed. These include a modified triple-lumen catheter that allows aspiration of the perfused fluid from the pancreas, a sleeve assembly in which the fluid is reverse-perfused so that perfusate enters the duodenum rather than the pancreatic duct, and a microtransducer catheter that uses solid-state technology [122 – 125]. Excellent correlation of manometry results has been demonstrated between the standard perfusion catheter and the microtransducer catheter as well as the sleeve assembly device [122, 126]. Three RCTs comparing incidence of PEP after using the standard perfusion catheter vs. other catheters have been performed; two of these have found a significantly lower incidence of PEP with the alternative catheter compared with the standard perfusion catheter (3.0 % vs. 23.5%, P=0.01; 3.1% vs. 13.8 %, P < 0.05), and in the third RCT no episodes of PEP occurred [125, 127,128]. 8. Role of pancreatic stent placement for PEP prophylaxis ! " Prophylactic pancreatic stent placement is recommended to prevent PEP in patients who are at high risk for development of PEP. Short, 5-Fr diameter, plastic pancreatic stents are currently recommended. Passage of the stent from the pancreatic duct should be evaluated within 5 to 10 days of placement and retained stents should be promptly removed endoscopically (Evidence level 1+; Recommendation grade A). Two independent meta-analyses on the use of pancreatic stent placement for PEP prophylaxis in patients at high risk for PEP have demonstrated that stent placement significantly reduced the incidence of PEP [20, 129]. The most recent meta-analysis was the most robust because, in addition to the analysis of six prospective controlled studies, it provided separate analysis of the four available RCTs and used intention-to-treat principles (by assuming that patients in whom attempted prophylactic pancreatic stent placement failed actually developed PEP if the clinical outcome was not stated in the original study) [20, 129]. Using this approach, the OR for PEP was 0.44 in the stent group vs. the no-stent group (95 %CI, 0.24 – 0.81; P=0.009), with an absolute risk reduction of 12.0 % (95 %CI, 3.0 – 21.0). A large multicenter RCT (201 patients) was subsequently published and showed a decreased incidence of PEP when prophylactic pancreatic stent placement was performed, regardless of the presence or absence of risk factors for PEP (PEP incidence in the stent and no-stent groups was 3.2 % vs. 13.6 %, respectively; P=0.019) [130]. What is also clear from these studies is that the risk of severe pancreatitis is nearly eliminated following successful placement of a prophylactic pancreatic stent. Different types of plastic stents have been used. Although nasopancreatic catheters were used in early studies, more recent studies have mostly used 3-Fr and 5-Fr diameter pancreatic stents. In two recent RCTs that compared 5-Fr with 3-Fr stents, Dumonceau J-M. et al. Guidelines for PEP prophylaxis … Endoscopy 2010; 42: 503 –515 5-Fr stents proved equivalent to 3-Fr stents in most outcomes, but successful insertion of 5-Fr stents was achieved significantly more often [131, 132]. Straight polyethylene stents measuring 5 Fr in diameter and 2 or 3 cm in length without internal flanges and with one or two external flanges (on the duodenal side) are often used. Using this type of stent, spontaneous elimination at 2 weeks post-ERCP occurred in more than 95% of 200 patients [130, 131]. In the absence of spontaneous migration out of the pancreatic duct at 5–10 days post-ERCP (as determined by plain abdominal X-ray), prompt endoscopic stent removal is recommended because of the increased risk of PEP (RR, 5.2 in patients without vs. with spontaneous stent elimination at 2 weeks) and potential for stent-induced damage to the pancreatic duct [131, 133]. Prophylactic pancreatic stent placement is cost-effective in patients at high risk for PEP, but not in those at average risk [134]. Caution should be used when attempting prophylactic pancreatic stent placement because the incidence of PEP after failed attempts may be as high as 65% [135]. Therefore prophylactic pancreatic stent placement in high-risk patients is cost-effective only if the success rate of pancreatic stent placement is more than 75%. Surveys of physician practices have shown that expert pancreaticobiliary endoscopists from the US and Canada commonly place prophylactic pancreatic stents, but most European endoscopists do not [136, 137]. Findings from the currently most recent survey showed that: (i) endoscopists who did not place prophylactic pancreatic stents cited lack of experience in this technique as the reason; and (ii) measurement of PEP incidence and an annual hospital volume of more than 500 ERCPs were independently associated with the use of prophylactic pancreatic stent placement [137]. 9. Selection of measures for PEP prophylaxis ! " For low-risk ERCPs, periprocedural rectal administration of nonsteroidal anti-inflammatory drugs (NSAIDs) is recommended. For high-risk ERCPs, prophylactic pancreatic stent placement should be strongly considered (Evidence level 1+; Recommendation grade A). In the setting of ERCP the following conditions are considered to represent high risk for PEP: endoscopic ampullectomy (papillectomy), known or suspected SOD, pancreatic sphincterotomy, precut biliary sphincterotomy, pancreatic guide wire-assisted biliary cannulation, endoscopic balloon sphincteroplasty, and presence of more than two of the risk factors listed in ● " Table 1. Procedures and patient conditions that do not fulfill these criteria are considered to represent low risk for PEP. Competing interests: None. Institutions 1 Service of Gastroenterology and Hepatology, Geneva University Hospitals, Geneva, Switzerland 2 Division of Gastroenterology, Casa Sollievo Sofferemza Hospital, IRCCS, San Giovanni Rotondo, Italy 3 Departments of Gastroenterology and Hepato-Pancreatology, Erasme University Hospital, Brussels, Belgium 4 Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital, Milan, Italy 5 Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Medical Center, Rochester, Minnesota, USA Downloaded by: Thieme Verlagsgruppe. Copyrighted material.
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