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Background and study aims: Pancreatitis is the most common complication of therapeutic endoscopic retrograde cholangiopancreatography (ERCP), and many pharmacoprophylactic approaches have been suggested, though not without controversy. The aim was to investigate the impact of combined therapy with diclofenac plus somatostatin on reducing the frequency and severity of post-ERCP pancreatitis (PEP). Patients and methods: A prospective, double-blind, placebo-controlled trial was conducted in two tertiary referral centers, with 540 eligible patients randomized to receive either combined therapy with diclofenac 100 mg rectally 30 to 60 minutes before ERCP plus somatostatin 0.25 mg/h for 6 hours (group A), or a placebo suppository identical in appearance to the diclofenac along with saline solution (group B). Patients were clinically evaluated and serum amylase levels were determined before ERCP and at 6 and 24 hours post-procedure. Standardized criteria were used to diagnose and grade the severity of PEP. Adverse events were recorded prospectively. Results: There were no statistical differences between the groups regarding demographic data, ERCP findings, and procedure risk factors for PEP. The overall incidence of acute pancreatitis was 7.2 %. The PEP rate was significantly lower in the patients who received the combination therapy than in controls (4.7 % vs. 10.4 %, P = 0.015). Previous history of acute pancreatitis ( P = 0.001), pancreatic opacification of first-class branches and beyond ( P = 0.008), and absence of pharmacoprophylaxis ( P = 0.023) were identified as independent risk factors for PEP in multivariate analysis. Conclusion: Although combined prophylactic therapy with diclofenac plus somatostatin was promising in reducing frequency of PEP, further comparative large-scale studies are needed to confirm our findings before definitive conclusions can be drawn.

BACKGROUND AND STUDY AIM The aim of this observational prospective study was to evaluate the safety of outpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in a very elderly cohort. PATIENTS AND METHODS A total of 600 patients were included in the study between June 2006 and June 2009. All underwent first therapeutic ERCP and were scheduled to be discharged on the same day following a postprocedure observation period of 6 hours. Of the 600 patients, 123 patients (group A) were re-admitted due to postprocedure complications that presented during the observation period, and 477 patients (group B) were discharged on the same day. Concomitant diseases, details of ERCP procedures, complications, and outcomes were all evaluated. The accuracy of the 6-hour postprocedure observation period, clinical criteria in predicting those patients aged 80 years and older in whom all therapeutic ERCP can be performed on an outpatient basis, and costs saved were all assessed. RESULTS There was a statistical difference in incidence of concomitant diseases between groups A and B (group A 84.5 % vs. group B 74.6 %; P = 0.020). However, there was no difference between the groups with regard to indication for ERCP and type of intervention. There was no difference in postprocedure complication rate between very elderly patients and younger patients (< 80 years), except for prolonged sedation or hypotension, which occurred more frequently in older (≥ 80 years) than in younger (< 80 years) patients (7.6 % vs. 3.2 %; P = 0.037). In group B, complications necessitating re-admission after the 6-hour observation period occurred in 10 patients (2.09 %) (patients ≥ 80 years 0.8 % and patients < 80 years 2.5 %). The costs saved by performing the procedure on an outpatient basis was calculated as 150 € per patient. CONCLUSION Outpatient therapeutic ERCP with postprocedure observation of 6 hours is a safe and cost-effective procedure in a significant proportion of very elderly patients.

BACKGROUND AND STUDY AIMS Deep cannulation of the common bile duct (CBD) is paramount for the success of endoscopic biliary intervention. The aim of the present study was to compare standard ERCP catheter and hydrophilic guide wire (HGW) in the selective cannulation of the CBD. PATIENTS AND METHODS A total of 332 patients were randomly assigned to cannulation with a standard catheter (n = 165) or a HGW (n = 167). If cannulation had not succeeded after 10 minutes with the technique assigned at randomization, a further attempt was made for an additional 10 minutes using the alternative technique. The following were assessed: primary and overall selective cannulation, time to cholangiography, number of pancreatic opacifications and guide-wire pancreatic duct insertions, and complication rates. RESULTS The primary success rate of selective CBD cannulation was higher in the HGW (81.4 %) than in the standard catheter group (53.9 %; P < 0.001). The overall cannulation rate after crossover was comparable between the two groups (standard catheter 84 % vs. HGW 83.8 %; P = 0.19). Time required for primary selective CBD cannulation was 3.53 +/- 0.32 minutes in the standard catheter vs. 4.48 +/- 0.32 minutes in the HGW group ( P = 0.04), and the number of insertions of the guide wire into the pancreatic duct was 3.29 +/- 0.47 in the standard catheter vs. 2.7 +/- 0.21 in the HGW group ( P = 0.22). Pancreatic opacifications occurred 3.19 +/- 0.20 times in the standard catheter vs. 1.50 +/- 0.22 times in the HGW group ( P < 0.001). Precut techniques were used in 56 patients (16.9 %) (n = 31 in the standard catheter vs. n = 25 in the HGW group; P = 0.07). The frequency of postinterventional pancreatitis and hemorrhage did not differ between the two groups. A young woman developed post-ERCP hemolytic crisis due to glucose-6-phosphate dehydrogenase deficiency. There was no procedure-related mortality. CONCLUSIONS The use of HGW, as primary technique or as a secondary technique after failure of cannulation with a standard catheter, achieves a high rate of selective CBD cannulation.

BACKGROUND: We prospectively investigated the efficacy and safety of double injection of dextrose 50 % plus epinephrine (D (50)+E) solution in endoscopic hemostasis of postendoscopic sphincterotomy (ES) hemorrhage. PATIENTS AND METHODS: The study included 1331 consecutive patients who underwent 1331 ES procedures between March 2002 and June 2006. Bleeding patterns (trickle, oozing, pulsatile, none) were recorded. Patients with oozing or trickle bleeding who did not respond to spray irrigation of D (50)+E solution and all the patients with pulsatile bleeding, received double injection of D (50)+E solution at 2 - 3 cm proximal and into the bleeding point with a sclerotherapy needle. Risk factors for post-ES hemorrhage were also assessed. RESULTS: ES-induced hemorrhage occurred in 63 patients (4.73 %). Visible bleeding patterns immediately following ES were: 44 trickle (69.84 %), 13 oozing (20.63 %) and six pulsatile (9.52 %). Hemostasis was achieved by spray irrigation of solution in 41 of 44 patients (93.18 %) with trickle, and in three of 13 patients (23.07 %) with ooze bleeding. Double injection was required in all patients with pulsatile bleeding, in 10 patients (76.92 %) with oozing, and in three patients (6.82 %) with trickle bleeding. Overall, successful hemostasis was achieved with double injection in 18 of 19 patients (94.74 %). The "zipper" cut was revealed to be a sole significant risk factor to the occurrence of bleeding ( P < 0.001). Five non-bleeding patients (0.37 %) presented with delayed hemorrhage. The difference in the incidence of other complications between the groups treated or not treated by endoscopic hemostasis was not statistically significant. CONCLUSION: Double injection of the readily available and inexpensive D (50)+E solution is a safe and effective treatment and is recommended for post-ES hemorrhage.