review of literature on clinical pancreatology - The Pancreapedia

treated patients (23/684), without statistical significance (relative risk [RR], 0.58; 95 %confidence interval [CI], 0.22 tgo 1.55). Subsequent sensitivity analysis on trials mainlytargeted at patients with suspicious biliary obstruction showed that the incidences <strong>of</strong> post-ERCP cholangitis were 2.8 percent (12/425) and 5.4 percent (24/441) in the antibiotics andcontrol groups, respectively, and this sensitivity analysis did not support antibiotics'preventive effect (RR, 0.33; 95 % CI, 0.03 to 3.32). Another sensitivity analysis exclusivelyincluding trials with intravenous route <strong>of</strong> antibiotics administration also failed to confirm theprophylactic effect <strong>of</strong> antibiotics (RR, 0.53; 95 % CI, 0.18 to 1.60). It was concluded thatantibiotics cannot significantly prevent ERCP-induced cholangitis in unselected patients andshould not be routinely recommended [214].To determine the prophylactic effect <strong>of</strong> antibiotics on post-endoscopic retrogradecholangiopancreatography (ERCP) cholangitis or sepsis reduction in randomized controlledtrials a search was done in databases including MEDLINE, EMBASE, Cochrane Library, andScience Citation Index updated to June 2007. Main outcome measure was post-ERCPcholangitis or sepsis. Seven trials were identified, and a total <strong>of</strong> 1389 patients were included;post-ERCP cholangitis occurred in 5.8 percent <strong>of</strong> controls (41/705) versus 3.4 percent <strong>of</strong>treated patients (23/684), without statistical significance. Subsequent sensitivity analysis ontrials mainly targeted at patients with suspicious biliary obstruction showed that theincidences <strong>of</strong> post-ERCP cholangitis were 2.8 percent (12/425) and 5.4 percent (24/441) inthe antibiotics and control groups, respectively, and this sensitivity analysis did not supportantibiotics' preventive effect. Another sensitivity analysis exclusively including trials withintravenous route <strong>of</strong> antibiotics administration also failed to confirm the prophylactic effect <strong>of</strong>antibiotics [215].TAP for monitoring post-ERCP-pancreatitisTrypsinogen activation peptide (TAP) is a small peptide <strong>of</strong> 7 to 10 amino acids capable <strong>of</strong>activating trypsinogen into trypsin, and it reflects the amount <strong>of</strong> activated trypsinogen. SerumTAP concentrations determined before and 6 hours after ERCP did not differ probablybecause the half-life <strong>of</strong> TAP is approximately 8 minutes, and this time interval is too long todetect its alteration. Therefore, the primary end point <strong>of</strong> the study was to evaluate the hourlyTAP concentration elevation after ERCP. All consecutive patients who underwentinterventional ERCP from 2005 to 2007 were studied. Post-ERCP acute pancreatitis wasdefined as the appearance <strong>of</strong> typical abdominal pain associated with an increase in serumamylase activity greater than 3 times the upper reference limit. Elevation <strong>of</strong> serum TAPconcentration was estimated in 30 percent <strong>of</strong> patients who developed postprocedural acutepancreatitis. It was enrolled 75 patients (38 men and 37 women). The reasons for which theyunderwent operative ERCP were cholangitis or jaundice in 63 patients (84 %), the need toinsert a biliary stent in 4 (5 %), persistent pain or jaundice in 6 patients (8 %) with recurrentpancreatitis, and the need to insert a pancreatic stent in 2 (3 %). The mean endoscopicprocedure lasted for 45 minutes (range, 15-95 minutes). There was difficult cannulation in 29patients (39 %); Wirsung injection in 40 (53 %); mechanic lithotripsy in 2 (3 %); biliarysphincterotomy in 44 (59 %); major papilla pancreatic sphincterotomy in 6 (8 %); minorpapilla sphincterotomy in 2 (3 %); and insertion <strong>of</strong> endoscopic biliary drainage in 23 (31 %),<strong>of</strong> pancreatic drainage in 6 (8 %), <strong>of</strong> a biliary stent in 17 (23 %), and <strong>of</strong> a pancreatic stent in 3(4 %). Sixty-one patients (81 %) received intravenous gabexate mersilat as a prophylactictreatment to prevent postprocedural ERCP. Postprocedural abdominal pain was recorded at1 hour in 35 patients (47 %), 2 hours in 34 (45 %), 3 hours in 14 (19 %), 4 hours in 8 (11 %),and 6 hours in another 8 (11 %); 6 patients (8 %) had pain for more than 6 hours.Postprocedural acute pancreatitis developed in 13 patients (17 %), and it was in all <strong>of</strong> themclinically mild. The frequency <strong>of</strong> patients with acute pancreatitis who had pain after 2 hours(11/13; 85 %) was significantly higher when compared with patients without acutepancreatitis (23/62; 37 %). Postprocedural acute pancreatitis developed in 20 % (12/61) <strong>of</strong>patients who received gabexate and 7 percent (1/14) <strong>of</strong> those who did not, which was a notsignificant difference. In the 65 patients who completed the study, at basal examination