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The aim of this study was to assess the influence of patient body weight on the clinical effect of 100 mg diclofenac administered as a single dose for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).All patients subjected to endoscopic retrograde cholangiopancreatography (ERCP) from 2009 to 2014 were evaluated for inclusion. In total, 772 patients were included of whom 378 (49%) received diclofenac prophylaxis.In the diclofenac prophylaxis group, body weight was higher in patients with PEP (mean ± SD: 82 ± 18 kg) than in patients without PEP (74 ± 18 kg) (p = 0.029). In patients not receiving prophylaxis, body weight was not associated with the occurrence of PEP (mean ± SD: 77 ± 18 vs 75 ± 18 kg, respectively, p = 0.450). In an adjusted analysis, higher patient body weight was inversely associated with the clinical effect of 100 mg diclofenac for the prophylaxis of PEP.High patient body weight was associated with a reduced effect of 100 mg diclofenac for prophylaxis of PEP.

Endoscopic papillary balloon dilatation (EPBD) is useful for decreasing early complications of endoscopic retrograde cholangio-pancreatography (ERCP), including bleeding, biliary infection, and perforation, but it is generally avoided in Western countries because of a relatively high reported incidence of post-ERCP pancreatitis (PEP). However, as the efficacy of endoscopic papillary large-balloon dilatation (EPLBD) becomes widely recognized, EPBD is attracting attention. Here we investigate whether EPBD is truly a risk factor for PEP, and seek safer and more effective EPBD procedures by reviewing past studies. We reviewed thirteen randomised control trials comparing EPBD and endoscopic sphincterotomy (EST) and ten studies comparing direct EPLBD and EST. Three randomized controlled trials of EPBD showed significantly higher incidence of PEP than EST, but no study of EPLBD did. Careful analysis of these studies suggested that longer and higher-pressure inflation of balloons might decrease PEP incidence. The paradoxical result that EPBD with small-calibre balloons increases PEP incidence while EPLBD does not may be due to insufficient papillary dilatation in the former. Insufficient dilatation could cause the high incidence of PEP through the use of mechanical lithotripsy and stress on the papilla at the time of stone removal. Sufficient dilation of the papilla may be useful in preventing PEP.

Anesthetic related fatality is rare in this time and age in young patients who are ASA II (American Society of Anesthesiologists). Our patient had a very unfortunate anesthetic mortality due to aspiration of bilious vomit. A posthumous diagnosis of post Endoscopic Retrograde Cholangio-pancreatography (ERCP) pancreatitis leading to ileus was missed before surgery. There is a brief literature search about perils of bile aspiration, post ERCP pancreatitis and why pancreatitis is a lethal combination with acute respiratory distress syndrome (ARDS).

[No abstract available]

Post-ERCP pancreatitis (PEP) is one of the most feared complications of ERCP. Despite being mild in most cases, severe cases of PEP can lead to significant morbidity and even mortality. Many studies have looked at identifying high-risk features related to both the patient and the ERCP procedure itself that may impact on rates of PEP. Strategies that have been demonstrated to decrease the incidence and severity of PEP include aggressive hydration, prophylactic pancreatic duct stenting, and administration of rectal indomethacin. Although these measures have improved clinical outcomes, the best method of preventing PEP is to properly select patients for ERCP by having a solid indication so that unnecessary procedures can be avoided.

Nuzhat A. Ahmad, Philadelphia, PA Darren M. Brenner, Chicago, IL Andrew T. Chan, Boston, MA Francis K. L. Chan, Hong Kong, China Lin Chang, Los Angeles, CA Tsutomu Chiba, Kyoto, Japan Massimo Colombo, Milan, Italy B. Joseph Elmunzer, Ann Arbor, MI Timothy B. Gardner, Lebanon, NH Lauren B. Gerson, Stanford, CA Colin W. Howden, Chicago, IL W. Ray Kim, Rochester, MN Paul Y. Kwo, Indianapolis, IN Edward V. Loftus, Rochester, MN Josep M. Llovet, New York, NY Julian Panes, Barcelona, Spain Sameer Saini, Ann Arbor, MI Shiv K. Sarin, New Delhi, India Shamita B. Shah, Stanford, CA Amit Singal, Dallas, TX Jan Tack, Leuven, Belgium Michael L. Volk, Ann Arbor, MI Akbar Waljee, Ann Arbor, MI Kenneth K. Wang, Rochester, MN Alex Ford, Leeds, United Kingdom Joel Rubenstein, Ann Arbor, MI Alastair J. M. Watson, Norwich, UK

Complications occur after 5% to 10% of endoscopic retrograde cholangiopancreatography (ERCP), including diagnostic and therapeutic procedures, and may range from minimal to severe and life threatening. Risk factors for post-ERCP pancreatitis include patient- as well as procedure-related variables, placing a premium on patient selection as well as details of technique. Placement of prophylactic pancreatic stents is effective in reducing risk of pancreatitis after ERCP and is the primary strategy for prevention of this complication once ERCP is undertaken. Newer data suggest that rectal nonsteroidal anti-inflammatory drugs are also effective at reducing risk of post-ERCP pancreatitis. Bleeding after sphincterotomy is primarily related to coagulation defects, but can almost always be treated by endoscopic hemostatic techniques. Perforation can involve bowel wall, sphincterotomy, or be caused by a guidewire; early recognition and management are key to satisfactory outcomes. There is an increasing role for endoscopic closure of perforations using stents, clips, and closure devices. Endoscopist experience is reflected in complication rates. With careful attention to patient selection and details of technique, complications of ERCP can be minimized.

Recently non-steroidal anti-inflammatory drugs have seemed to reduce the frequency of post-ERCP pancreatitis in some prospective controlled trials, but the results have to be confirmed by further studies. Aim: to evaluate the efficacy of rectally administered indomethacin for the reduction of incidence of post-ERCP pancreatitis. Method: A prospective randomized placebo-controlled study was conducted in 228 patients who underwent ERCP. Patients were randomized to receive a suppository containing 100 mg indomethacin or an inert placebo 10 mins before ERCP. Patients were evaluated clinically and biochemically by using serum amylase levels measured 24 h after the procedure. Results: Pancreatitis and hyperamylasemia occurred more frequently in the placebo group, but the difference was not significant. In respect to the rate of pancreatitis, this tendency could particularly be observed in females, in patients older than 60 years and in patients with BMI lower than 25; however, it completely failed in cases with pancreatic duct filling or in those with pancreatic EST. Conclusions: Rectal indomethacin given before ERCP did not prove to be statistically effective in the reduction of the incidence of post-procedure pancreatitis. Further, controlled multicenter studies are required to assess safely the potential efficacy of indomethacin in the prevention of pancreatitis following ERCP. Orv. Hetil., 2012, 153, 990–996.

Endoscopic retrograde cholangio-pancreatography (ERCP) is one of the most technically challenging procedures in therapeutic endoscopy; difficulties in biliary cannulation and post-ERCP pancreatitis are still significant problems. Deep cannulation of Vater's papilla may fail in up to 5% of cases; selective biliary cannulation reportedly fails in 15-35% of cases, even in experienced hands; repeated and prolonged attempts at cannulation increase the risk of post-procedure pancreatitis. Therefore, cannulation technique plays a pivotal role in successful cannulation and occurrence of post-procedure pancreatitis. This review presents and discusses the techniques that can be used for achieving biliary cannulation after an initial failure and for minimizing the risk of pancreatitis, including guide wire assisted technique, needle knife precutting, trans-pancreatic sphincterotomy, and pancreatic stenting.

Efforts to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis have been largely unsuccessful. Cyclo-oxygenase-2 enzyme-mediated inflammatory pathway has been suggested in the pathophysiology of acute pancreatitis. Glyceryl trinitrate (GTN) might prevent post-ERCP pancreatitis by relaxing the sphincter of Oddi.To evaluate the efficacy of valdecoxib, a cyclo-oxygenase-2 inhibitor, and GTN transdermal patch for the prevention of post-ERCP pancreatitis.Patients undergoing first ERCP procedure from October 2003 to August 2005 were randomized to receive either 20 mg intravenous valdecoxib or GTN patch (10 mg/h) at the start of ERCP, or assigned to control group. The study followed CONSORT guidelines. Primary outcome measure was frequency of post-ERCP pancreatitis in the 3 groups.A total of 380 patients were randomized; 121 patients in valdecoxib (group 1), 124 in GTN (group 2), and 126 in the control arm (group 3) were analyzed. There was no difference in the frequency of post-ERCP pancreatitis between the groups (12 each in groups 1 and 2, and 13 in group 3; P=0.986). None of the patients had severe pancreatitis. The frequency of post-ERCP pain and amylase levels were also similar in the 3 groups (P=0.769 and P=0.947, respectively). Pancreatic duct cannulation, cholecystectomy, difficult cannulation, and pre-cut were risk factors for pancreatitis on univariate analysis. On multivariate analysis, pancreatic duct cannulation was the only independent risk factor for pancreatitis (P≤0.001; odds ratio 5.67; 95% confidence interval: 2.76-11.63).Valdecoxib and GTN were not effective for the prevention of post-ERCP pancreatitis.

BACKGROUND: Placement of prophylactic pancreatic stents (PPS) is a method proven to reduce the rate and severity of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk patients; however, PPS do not eliminate the risk completely. Early PPS dislodgement may occur prematurely and contribute to more frequent or severe PEP.OBJECTIVE: To determine the effect of early dislodgement of PPS in patients with moderate or severe PEP.METHOD: A total of 27,176 ERCP procedures from January 1994 to September 2007 for PPS placement in high-risk patients were analyzed. Patient and procedure data were analyzed to assess risk factors for PEP, and to evaluate the severity of pancreatitis, length of hospitalization and subsequent complications. Timing of stent dislodgment was assessed radiographically.RESULTS: PPS were placed in 7661 patients. Of these, 580 patients (7.5%) developed PEP, which was graded as mild in 460 (6.0%), moderate in 87 (1.1%) and severe in 33 (0.4%). Risk factors for developing PEP were not different in patients who developed moderate PEP compared with those with severe PEP. PPS dislodged before 72 h in seven of 59 (11.9%) patients with moderate PEP and five of 27 (18.5%) patients with severe PEP (P=0.505). The mean (± SD) length of hospitalization in patients with moderate PEP with stent dislodgement before and after 72 h were 7.43±1.46 days and 8.37±1.16 days, respectively (P=0.20). The mean length of hospitalization in patients with severe PEP whose stent dislodged before and after 72 h were 21.6±6.11 and 22.23±3.13 days, respectively (P=0.96).CONCLUSION: Early PPS dislodgement was associated with moderate and severe PEP in less than 20% of cases and was not associated with a more severe course. Factors other than ductal obstruction contribute to PEP in high-risk patients undergoing ERCP and PPS placement.

Post-ERCP pancreatitis (PEP) remains the most common complication following ERCP. Although once considered unpredictable, understanding patient and procedure-related risk factors, and measures such as pancreatic stent placement and pharmacoprophylaxis have been shown to substantially decrease the risk of PEP. In this issue of the Journal, the role of pharmacoprophylaxis is explored in a study comparing rectal indomethacin plus sublingual nitrates vs. rectal indomethacin alone. While showing improved efficacy, dual pharmacoprophylaxis does not appear adequate to obviate the importance of technique-related variables and pancreatic stents. Rather, a comprehensive approach is likely to be the most efficacious strategy to reduce PEP.