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Background: Currently, many studies focus on the use of high-dose NSAIDs, showing significant effectiveness in preventing post-ERCP pancreatitis after surgery. However, some studies suggest that low-dose NSAIDs can also have certain effects. Nevertheless, after using propensity score matching to balance potential biases, the results do not seem ideal and fail to demonstrate clear effectiveness. Aim: This study investigates the effectiveness of NSAIDs in preventing post-ERCP pancreatitis through a systematic review and meta-analysis of relevant literature. Methods: We conducted a systematic search of PubMed, Embase, and Web of Science, covering literature up to September 2024. The search utilized keywords such as "ERCP," "NSAIDs," and "propensity score matching." A total of three studies employing propensity score matching were included, encompassing 857 patients—417 receiving NSAIDs before ERCP and 440 in the control group. Statistical analysis was performed using RevMan 5.3, applying a random-effects model for meta-analysis. Results: The meta-analysis revealed no significant difference in treatment outcomes between the NSAID and control groups, with an odds ratio (OR) of 0.82 (95% CI: 0.45–1.49, P = 0.74) and no observed heterogeneity (I²=0%). Sensitivity analysis confirmed the stability of results, indicating minimal impact from the removal of any single study. Discussion: These findings challenge previous assertions that NSAIDs effectively reduce post-ERCP pancreatitis incidence. The lack of consistent evidence raises concerns about the reliability of existing research. Additionally, the lower NSAID doses used in studies may contribute to the observed ineffectiveness. Future large-scale, well-designed clinical trials are essential to establish clear treatment guidelines and enhance patient outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common serious adverse event after endoscopic retrograde cholangiopancreatography (ERCP). Although retrospective models to predict PEP have shown promise, their real-world applicability remains uncertain. Thus, we used prospectively derived cohort data to validate current prediction models. Methods: We conducted a prospective cohort study involving patients who underwent ERCP between August 2020 and December 2023. We validated the original PEP-risk prediction models using prospective cohort data and, if necessary, refined them using logistic regression analysis. Results: Among the 1112 study participants, the original PEP-risk prediction models had limited performance. Although PEP incidence tended to increase across risk groups, the differences were mostly insignificant. Logistic regression highlighted procedural factors—total procedure time [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.01–1.26 per 5 min], unintended pancreatic duct cannulation (OR 2.56, 95% CI 1.11–5.93), and pancreatic opacification (OR 2.57, 95% CI 1.19–5.58)—as independent PEP risk factors. This led to a revised model that assigned 1, 8, and 8 points to these factors. Patients stratified into low- (0–2 points), intermediate- (3–10 points), and high-risk groups (≥ 11 points) exhibited PEP incidences of 2.6% (95% CI 1.5–4.1%), 7.1% (95% CI 4.8–10.3%), and 12.6% (95% CI 8.6–17.8%), respectively. Conclusions: We highlighted limitations of existing PEP-prediction models that necessitate refinement based on procedural variables. Our revised model accounted for the prolonged total procedure time, unintended pancreatic duct cannulation, and pancreatic opacification, offering enhanced accuracy in predicting PEP risk. [ABSTRACT FROM AUTHOR]

Background: We evaluated for predictors of successful cannulation and post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in minor papilla endotherapy (MPE), emphasizing endoscopic minor papilla morphology. Methods: We retrospectively analyzed 232 MPEs in 65 patients, assessing minor papilla morphology based on three features: bulge as "prominent" or "subtle," mucosal appearance as "papilla‐like" resembling the main papilla or "SMT‐like" akin to a gastrointestinal submucosal tumor, and orifice visibility as "clear" or "unclear." Cannulation success was evaluated in 65 enrolled patients, with PEP risk assessed in all 232 MPEs. Results: Minor papilla morphology was categorized as prominent/subtle bulge in 42/23 patients, papilla‐like/SMT‐like mucosal appearance in 42/23, and clear/unclear orifice visibility in 24/41. Cannulation succeeded in 54/65 patients (83%). A papilla‐like appearance and clear orifice visibility was significantly associated with cannulation success. PEP incidence was 5.2% and predominantly mild. A papilla‐like appearance significantly decreased PEP incidence, while precutting technique and orifice dilation significantly increased PEP risk. Conclusion: Evaluating minor papilla morphology may help predict cannulation success and PEP risk in MPE. A papilla‐like mucosal appearance prognosticates cannulation success and reduced PEP risk, with clear orifice visibility serving as a success predictor. These findings provide practical guidance for preprocedural planning by emphasizing the importance of minor papilla morphology evaluation. [ABSTRACT FROM AUTHOR]

Background: Serum amylase (AMY) levels measured 2–6 h after ERCP are a predictor of post‐ERCP pancreatitis (PEP). Trypsin is one of the pancreatic enzymes elevated in the development of PEP. The study assessed whether serum trypsin (TRY) can predict early‐stage PEP. Methods: This prospective study included patients who underwent ERCP from June 2022 to May 2023. TRY, AMY, serum pancreatic AMY (P‐AMY), and serum lipase (LIP) levels were measured immediately after ERCP and 2 h later. The primary outcome was the diagnostic abilities of TRY levels measured immediately (0 h‐TRY) and 2 h after (2 h‐TRY) ERCP to predict PEP (compared with the other serum pancreatic enzymes). Results: Of 130 patients analyzed, 18 developed PEP. The sensitivity and specificity of 0 h‐TRY were 83.3% and 69.6%, respectively, and those of 2 h‐TRY were 88.9% and 72.3%, respectively. The area under the curve (AUC) for 0 h‐TRY was significantly higher than that for 0 h‐AMY (p =.006) and 0 h‐P‐AMY (p =.012), whereas the AUCs for 0 h‐TRY and 0 h‐LIP did not differ significantly (p =.563). The AUC for 2 h‐TRY for predicting PEP was significantly higher than that for 2 h‐AMY (p =.025), whereas there was no significant differences between the AUCs for 2 h‐TRY and 2 h‐P‐AMY(p =.146), or between those for 2 h‐TRY and 2 h‐LIP (p =.792). The median increase ratio (expressed as a ratio relative to baseline) in TRY was highest among all of serum pancreatic enzymes tested immediately after ERCP (5.35, 1.72, 1.94, and 4.44 for TRY, AMY, P‐AMY, and LIP, respectively). Conclusion: Measuring TRY immediately after ERCP is useful for the early prediction of PEP. [ABSTRACT FROM AUTHOR]

Background Following endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP pancreatitis (PEP) is the most common complication. The host's innate immune response to periprocedural pancreatic injury is the hallmark of its pathogenesis. Investigating cytokine signatures associated with PEP and its risk factors can guide understanding of PEP immunopathogenesis. Methods We conducted a single-center, prospective, observational pilot study in adults at high-risk for PEP. Seven serum cytokines relevant to early acute pancreatitis pathogenesis, angiopoietin-2, hepatocyte growth factor (HGF), interleukin-6 (IL-6), IL-8, monocyte chemotactic protein-1, resistin, and soluble tumor necrosis factor-a receptor 1, were measured in sera collected 2 h pre- and post-ERCP. Levels were compared among healthy controls and ERCP participants who either did or did not develop PEP. Heat maps were constructed to perform a multidimensional exploratory analysis that aimed to determine the cytokine signatures associated with PEP and its participant-related risk factors (female sex, young age, and obesity). Results A total of 65 participants were enrolled (36 undergoing ERCP and 29 healthy controls). Eight of the 36 (22.2%) ERCP participants developed PEP. Baseline IL-8 levels measured before ERCP were elevated in participants who developed PEP (7.5 vs. 14.8 pg/mL, P=0.02), and most strongly upregulated in women under 40 years of age. HGF levels post-ERCP were higher in participants with PEP (738.0 vs. 556.6 pg/mL, P=0.04), and most strongly upregulated in obese participants. Conclusions Pre-ERCP IL-8 and post-ERCP HGF are associated with the development of PEP. Findings from this pilot study can inform the design of translational work in the immunopathogenesis of PEP. [ABSTRACT FROM AUTHOR]

Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP) carries a 3–15% risk of post-ERCP pancreatitis (PEP). Rectal indomethacin reduces the risk of PEP, but its cost has increased more than 20-fold over the past decade. Rectal diclofenac is also used to prevent PEP but is not commercially available in the United States. The aim of this study is to compare the incidence of PEP after administration of commercially available rectal indomethacin versus compounded rectal diclofenac and assess financial implications. Methods: ERCP cases at our institution with administration of 100 mg rectal indomethacin or 100 mg compounded rectal diclofenac between May 2018 and January 2022 were retrospectively reviewed. The incidence and severity of PEP was compared between the indomethacin (n = 728) and diclofenac (n = 304) groups. Risk factors (young age, female sex, history of pancreatitis or PEP, sphincterotomy during procedure, pancreatic indication, trainee involvement) and protective factors (prior sphincterotomy, pancreatic duct stenting) for PEP were compared between groups. Results: 60 patients (8.2%) in the rectal indomethacin group and 25 patients (8.2%) in the compounded rectal diclofenac group developed PEP, resulting in moderate or severe PEP in 9 (15.0%) and 2 (8.0%) patients, respectively. The compounded rectal diclofenac group had more trainee involvement (46.1% vs. 32.8%, p = 0.0001) and more prior sphincterotomy cases (15.8% vs. 10.6%, p = 0.0193) compared to the rectal indomethacin group; no statistically significant differences were observed in all other risk and protective factors. Following switch to compounded rectal diclofenac, institutional annual cost savings amounted to $441,460.62 and patient charge decreased 45-fold. Conclusion: This retrospective single-center real-world analysis showed similar efficacy of rectal indomethacin and compounded rectal diclofenac in preventing PEP but demonstrates substantial cost savings after switching to compounded rectal diclofenac. [ABSTRACT FROM AUTHOR]

Background: Precut over a pancreatic duct stent (PPDS) and transpancreatic precut sphincterotomy (TPS) with immediate pancreatic duct stent placement are techniques employed to promote biliary access during endoscopic retrograde cholangiopancreatography (ERCP) in cases of challenging biliary cannulation. However, limited data are available to compare the efficacy of these two pancreatic stent-assisted precut sphincterotomy techniques. Aims: The aim of this study was to compare the efficacy of PPDS versus TPS. Methods: A retrospective analysis was performed on the clinical data of consecutive patients who underwent ERCP between April 1, 2019 and May 31, 2023. According to the selected cannulation approaches, patients were assigned to two groups. In the PPDS group, a pancreatic duct stent was initially placed, followed by needle-knife precut over the stent. In the TPS group, transpancreatic precut sphincterotomy was initially performed, followed by immediate pancreatic stent placement. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) between the two groups were analysed. Results: Among 864 patients who underwent ERCP, 46 patients were equally enrolled in the two groups. Selective bile duct cannulation was successfully achieved in 42 out of 46 (91.3%) cases using the PPDS and in 32 out of 46 (69.6%) cases using TPS technique alone, indicating significantly higher success rate of bile duct cannulation with PPDS compared to TPS (91.3% vs. 69.6%, P = 0.009). The overall success rates for bile duct cannulation were 93.5% and 97.8% in the PPDS and TPS groups, respectively, with no significant difference identified (P = 0.307). PEP occurred in 0 and 4 (8.7%) cases in the PPDS and TPS groups, respectively, with no significant difference between the two groups (8.7% vs. 0%, P = 0.117). There were no cases of bleeding or perforation in either group. Conclusions: Both PPDS and TPS followed by immediate pancreatic duct stent placement are viable options. TPS stands out for its simplicity and cost-effectiveness, while PPDS is more appropriate for patients who are at a high-risk of developing PEP. [ABSTRACT FROM AUTHOR]

Background: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a severe and deadly adverse event following ERCP. The ideal method for predicting PEP risk before ERCP has yet to be identified. We aimed to establish a simple PEP risk score model (SuPER model: Support for PEP Reduction) that can be applied before ERCP. Methods: This multicenter study enrolled 2074 patients who underwent ERCP. Among them, 1037 patients each were randomly assigned to the development and validation cohorts. In the development cohort, the risk score model for predicting PEP was established via logistic regression analysis. In the validation cohort, the performance of the model was assessed. Results: In the development cohort, five PEP risk factors that could be identified before ERCP were extracted and assigned weights according to their respective regression coefficients: –2 points for pancreatic calcification, 1 point for female sex, and 2 points for intraductal papillary mucinous neoplasm, a native papilla of Vater, or the pancreatic duct procedures (treated as ‘planned pancreatic duct procedures’ for calculating the score before ERCP). The PEP occurrence rate was 0% among low-risk patients (≤0 points), 5.5% among moderate-risk patients (1–3 points), and 20.2% among high-risk patients (4–7 points). In the validation cohort, the C statistic of the risk score model was 0.71 (95% CI 0.64–0.78), which was considered acceptable. The PEP risk classification (low, moderate, and high) was a significant predictive factor for PEP that was independent of intraprocedural PEP risk factors (precut sphincterotomy and inadvertent pancreatic duct cannulation) (OR 4.2, 95% CI 2.8–6.3; p

Background and Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable procedure for pancreatobiliary disorders but carries significant risks, including post-ERCP pancreatitis (PEP). The exact cause of PEP is unclear, but mechanical and thermal injuries during the procedure and patient-related factors have been implicated. This study aims to investigate the possible contribution of potential pancreatotoxic drug (PPD) exposure to PEP risk. Methods: This was a retrospective, single-centre, cohort study conducted at Canberra Hospital, a tertiary university hospital. Consecutive ERCP performed with native papillae within a 4-year period from January 2019 to January 2023 were evaluated. Details of ERCP procedures, patient characteristics, and all medications were contemporaneously collected. All patients had follow-up phone calls or review within 24 h post procedure. The diagnosis of PEP was based on the Cotton consensus definition. Results: A total of 32 out of 444 patients (7.2%) developed PEP. There was no significant difference in the incidence of PEP between patients taking PPD compared to patients who were not (7.1% vs. 7.6%, p = 0.845). Three factors were independently associated with PEP in the multivariate analysis: the presence of a periampullary diverticulum (OR = 5.4, 95% CI 1.7–15.3, p = 0.002), the performance of pre-cut sphincterotomy (OR = 2.8, 95% CI 1.2–6.4, p = 0.017), and pancreatic duct cannulation (OR = 3, CI 1.3–7, p = 0.01). Conclusions: The overall incidence of pancreatitis in our selected group of ERCP patients with native papillae was 7.2%. Our study did not find the use of PPD to be a statistically significant risk factor for PEP.

Background and Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable procedure for pancreatobiliary disorders but carries significant risks, including post-ERCP pancreatitis (PEP). The exact cause of PEP is unclear, but mechanical and thermal injuries during the procedure and patient-related factors have been implicated. This study aims to investigate the possible contribution of potential pancreatotoxic drug (PPD) exposure to PEP risk. Methods: This was a retrospective, single-centre, cohort study conducted at Canberra Hospital, a tertiary university hospital. Consecutive ERCP performed with native papillae within a 4-year period from January 2019 to January 2023 were evaluated. Details of ERCP procedures, patient characteristics, and all medications were contemporaneously collected. All patients had follow-up phone calls or review within 24 h post procedure. The diagnosis of PEP was based on the Cotton consensus definition. Results: A total of 32 out of 444 patients (7.2%) developed PEP. There was no significant difference in the incidence of PEP between patients taking PPD compared to patients who were not (7.1% vs. 7.6%, p = 0.845). Three factors were independently associated with PEP in the multivariate analysis: the presence of a periampullary diverticulum (OR = 5.4, 95% CI 1.7–15.3, p = 0.002), the performance of pre-cut sphincterotomy (OR = 2.8, 95% CI 1.2–6.4, p = 0.017), and pancreatic duct cannulation (OR = 3, CI 1.3–7, p = 0.01). Conclusions: The overall incidence of pancreatitis in our selected group of ERCP patients with native papillae was 7.2%. Our study did not find the use of PPD to be a statistically significant risk factor for PEP. [ABSTRACT FROM AUTHOR]

Background: Same-session endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) is an attractive policy for patients with distal malignant biliary obstruction (DMBO) requiring fine-needle biopsy (FNB) and biliary drainage. However, scanty and conflicting data exists regarding safety and efficacy when comparing these two procedures performed in same versus separate sessions. Methods: Single-center, retrospective, propensity score-matched study including patients with DMBO who underwent EUS-FNB followed by ERCP during the same or separate sessions. The primary outcome was the safety of the procedure [number of patients experiencing adverse events (AEs), overall AEs, its severity, post-ERCP pancreatitis (PEP)]. Secondary outcomes were successful ERCP, use of advanced cannulation techniques, EUS-FNB adequacy, length of hospital stay, overall procedure time, and time to recurrent biliary obstruction. Results: After propensity matching, 87 patients were allocated to each group. AEs developed in 23 (26.4%) vs. 17 (19.5%) patients in the same and separate sessions group, respectively (p = 0.280). The overall number, the severity of AEs, and the rate of PEP were similar in the two groups. Secondary outcome parameters were also comparable in the 2 groups. Conclusions: Same-session EUS-FNB followed by ERCP with biliary drainage is safe and does not impair technical outcomes of tissue adequacy and biliary cannulation. [ABSTRACT FROM AUTHOR]

Biliary complications are common after liver transplantation (LT). Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred method to treat biliary complications. Nevertheless, ERCP is not without complications and may have a greater complication rate in the LT population. Knowledge of the prevalence, severity, and possible risk factors for post‐ERCP pancreatitis (PEP) in LT recipients is limited. Therefore, this study aims to determine the incidence and severity of PEP and identify potential risk factors in LT recipients. This retrospective cohort included patients ≥18 years who underwent ≥1 ERCP procedures after LT between January 2010 and October 2021. Two hundred thirty‐two patients were included, who underwent 260 LTs and 1125 ERCPs. PEP occurred after 23 ERCP procedures (2%) with subsequent mortality in three (13%). Multivariate logistic regression identified wire cannulation of the pancreatic duct as a significant risk factor for PEP (OR, 3.21). The complication rate of PEP after LT in this study was shown to be low and is lower compared to patients without a history of LT. Nevertheless, the mortality rate of this group of patients was notably higher. [ABSTRACT FROM AUTHOR]

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Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP), a standard procedure used for diagnosing and treating pancreaticobiliary disorders, has the highest rate of complications among endoscopic procedures. We aimed to evaluate the association of post-ERCP pain onset and its severity with the development of acute complications. Methods This cross-sectional study included 172 candidates for ERCP who were referred to Namazi Hospital, Shiraz, from January 21, 2021, to January 21, 2022. Demographic features of the participants, including age and gender, were recorded. ERCP indications, complications during and after ERCP, and narcotic requirements were also noted. Post-ERCP pain severity was evaluated using a 10-point visual analogue scale (VAS), with 0 indicating no pain and 10 indicating the worst pain. Pain severity was evaluated twice: once by the physician and once by the patient. The interval between the procedure and the onset of pain was also recorded. Results Out of the 172 participants of this study with a mean age of 53.77 ± 20.20 years, 98 (57%) were male. The most typical indication of ERCP was common bile duct stone (36%). Complications during and after ERCP occurred in 2.3% and 2.9%, respectively, with retroperitoneal/sphincterotomy perforation (1.2%) being the most common post-ERCP complication. Post-ERCP pain score (both by patient and physician) was significantly higher in patients with complications compared to those without complications (P

Abstract Background Post-ERCP pancreatitis is one of the most common adverse events in ERCP-related procedures. The purpose of this study is to construct an online model to predict the risk of post-ERCP pancreatitis in non-elderly patients with common bile duct stones through screening of relevant clinical parameters. Methods A total of 919 cases were selected from 7154 cases from a major Chinese tertiary hospital. Multivariable logistic regression model was fitted using the variables selected by the LASSO regression from 28 potential predictor variables. The internal and external validation was assessed by evaluating the receiver operating characteristic curve and the area under curve. Restricted cubic spline modelling was used to explore non-linear associations. The interactive Web application developed for risk prediction was built using the R “shiny” package. Results The incidence of post-ERCP pancreatitis was 5.22% (48/919) and significantly higher in non-elderly patients with female, high blood pressure, the history of pancreatitis, difficult intubation, endoscopic sphincterotomy, lower alkaline phosphatase and smaller diameter of common bile duct. The predictive performance in the test and external validation set was 0.915 (95% CI, 0.858–0.972) and 0.838 (95% CI, 0.689–0.986), respectively. The multivariate restricted cubic spline results showed that the incidence of pancreatitis was increased at 33–50 years old, neutrophil percentage > 58.90%, hemoglobin > 131 g/L, platelet 241.40 × 109/L, total bilirubin > 18.39 umol / L, aspartate amino transferase

Background: Endoscopic retrograde cholangiopancreatography (ERCP), a standard procedure used for diagnosing and treating pancreaticobiliary disorders, has the highest rate of complications among endoscopic procedures. We aimed to evaluate the association of post-ERCP pain onset and its severity with the development of acute complications. Methods: This cross-sectional study included 172 candidates for ERCP who were referred to Namazi Hospital, Shiraz, from January 21, 2021, to January 21, 2022. Demographic features of the participants, including age and gender, were recorded. ERCP indications, complications during and after ERCP, and narcotic requirements were also noted. Post-ERCP pain severity was evaluated using a 10-point visual analogue scale (VAS), with 0 indicating no pain and 10 indicating the worst pain. Pain severity was evaluated twice: once by the physician and once by the patient. The interval between the procedure and the onset of pain was also recorded. Results: Out of the 172 participants of this study with a mean age of 53.77 ± 20.20 years, 98 (57%) were male. The most typical indication of ERCP was common bile duct stone (36%). Complications during and after ERCP occurred in 2.3% and 2.9%, respectively, with retroperitoneal/sphincterotomy perforation (1.2%) being the most common post-ERCP complication. Post-ERCP pain score (both by patient and physician) was significantly higher in patients with complications compared to those without complications (P < 0.001). The interval between the ERCP procedure and the onset of pain was significantly shorter in patients with post-ERCP complications (P = 0.003). Also, a significantly higher percentage of patients with complications required narcotics (40% vs 1.2%, P = 0.004). Conclusions: Although the presence of post-ERCP pain may not necessarily be indicative of complications, post-ERCP pain severity and onset, as well as narcotic requirement, appear to be associated with the development of post-ERCP complications. [ABSTRACT FROM AUTHOR]

Objectives: We aimed to clarify the clinical utility of measuring serum pancreatic enzymes after endoscopic retrograde cholangiopancreatography (ERCP) for the purpose of predicting post‐ERCP pancreatitis (PEP) by a meta‐analysis of diagnostic test accuracy studies. Methods: Studies on the prediction accuracy of PEP by serum amylase or lipase measured at 2, 3, and 4 h after ERCP were collected. A literature search was performed in PubMed and the Cochrane Library database for studies published between January 1980 and March 2023. The quality of individual studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies‐2. Data were analyzed using Meta‐DiSc 2.0 software. Results: We searched the databases and identified 20 observational studies (12,313 participants). PEPs were defined according to criteria by Cotton or modified Cotton, revised Atlanta criteria, or the Japanese criteria. Meta‐analysis of eight studies (4389 participants) showed a pooled sensitivity of 71.1% (95% confidence interval [CI] 56.1–82.5) and pooled specificity of 91.2% (95% CI 85.9–94.6) for the serum amylase cut‐off value at 3 times the upper limit of normal (ULN). Another meta‐analysis of five studies (1970 participants) showed a pooled sensitivity of 85.8% (95% CI 61.9–95.7) and pooled specificity of 85.3% (95% CI 81.9–88.1) for the serum lipase cut‐off value at 3 times ULN. Conclusion: Despite a high risk of bias due to various reference standards, this updated meta‐analysis and the utility assessment by a decision tree showed the utility of serum amylase or lipase levels more than 3 times ULN measured 2–4 h after ERCP for predicting PEP. [ABSTRACT FROM AUTHOR]

Background: Post-ERCP pancreatitis is one of the most common adverse events in ERCP-related procedures. The purpose of this study is to construct an online model to predict the risk of post-ERCP pancreatitis in non-elderly patients with common bile duct stones through screening of relevant clinical parameters. Methods: A total of 919 cases were selected from 7154 cases from a major Chinese tertiary hospital. Multivariable logistic regression model was fitted using the variables selected by the LASSO regression from 28 potential predictor variables. The internal and external validation was assessed by evaluating the receiver operating characteristic curve and the area under curve. Restricted cubic spline modelling was used to explore non-linear associations. The interactive Web application developed for risk prediction was built using the R "shiny" package. Results: The incidence of post-ERCP pancreatitis was 5.22% (48/919) and significantly higher in non-elderly patients with female, high blood pressure, the history of pancreatitis, difficult intubation, endoscopic sphincterotomy, lower alkaline phosphatase and smaller diameter of common bile duct. The predictive performance in the test and external validation set was 0.915 (95% CI, 0.858–0.972) and 0.838 (95% CI, 0.689–0.986), respectively. The multivariate restricted cubic spline results showed that the incidence of pancreatitis was increased at 33–50 years old, neutrophil percentage > 58.90%, hemoglobin > 131 g/L, platelet < 203.04 or > 241.40 × 109/L, total bilirubin > 18.39 umol / L, aspartate amino transferase < 36.56 IU / L, alkaline phosphatase < 124.92 IU / L, Albumin < 42.21 g / L and common bile duct diameter between 7.25 and 10.02 mm. In addition, a web server was developed that supports query for immediate PEP risk. Conclusion: The visualized networked version of the above model is able to most accurately predict the risk of PEP in non-elderly patients with choledocholithiasis and allows clinicians to assess the risk of PEP in real time and provide preventive treatment measures as early as possible. [ABSTRACT FROM AUTHOR]

Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care for the management of choledocholithiasis but carries risk of complications which may result in significant morbidity and mortality. While currently available guidelines endorse the use of ERCP for the management of symptomatic common bile duct stones, the need for ERCP in incidentally found asymptomatic choledocholithiasis is more controversial, and practice varies on a geographic and institutional level. This systematic review and meta-analysis is conducted to compare post-ERCP adverse events between asymptomatic and symptomatic choledocholithiasis patients. Methods: We searched PubMed/Embase/Web of Science databases to include all studies comparing post-ERCP outcomes between asymptomatic and symptomatic choledocholithiasis patients. The primary outcome was post-ERCP pancreatitis (PEP), while secondary outcomes included post-ERCP cholangitis, bleeding, and perforation. We calculated pooled risk ratios (RR) and 95% confidence intervals (CIs) using the Mantel–Haenszel method within a random-effect model. Results: Our analysis included six observational studies, totaling 2,178 choledocholithiasis patients (392 asymptomatic and 1786 symptomatic); 53% were female. Asymptomatic patients exhibited a higher risk of PEP compared with symptomatic patients (11.7% versus 4.8%; RR 2.59, 95% CI 1.56–4.31, p ≤ 0.001). No significant difference was observed in post-ERCP cholangitis, bleeding, or perforation rates between the two groups. Conclusions: Asymptomatic patients with choledocholithiasis appear to have a higher risk of PEP than symptomatic patients, while the risk of other post-ERCP adverse events is similar between the two groups. Interventional endoscopists should thoroughly discuss potential adverse events (particularly PEP) with asymptomatic patients before performing ERCP and utilize PEP-prevention measures more liberally in this subgroup of patients. [ABSTRACT FROM AUTHOR]

Hemin, a heme oxygenase 1 activator has shown efficacy in the prevention and treatment of acute pancreatitis in mouse models. We conducted a randomized controlled trial (RCT) to assess the protective effect of Hemin administration to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in patients at risk. In this multicenter, multinational, placebo-controlled, double-blind RCT, we assigned patients at risk for PEP to receive a single intravenous dose of Hemin (4 mg/kg) or placebo immediately after ERCP. Patients were considered to be at risk on the basis of validated patient- and/or procedure-related risk factors. Neither rectal NSAIDs nor pancreatic stent insertion were allowed in randomized patients. The primary outcome was the incidence of PEP. Secondary outcomes included lipase elevation, mortality, safety, and length of stay. A total of 282 of the 294 randomized patients had complete follow-up. Groups were similar in terms of clinical, laboratory, and technical risk factors for PEP. PEP occurred in 16 of 142 patients (11.3%) in the Hemin group and in 20 of 140 patients (14.3%) in the placebo group (p = 0.48). Incidence of severe PEP reached 0.7% and 4.3% in the Hemin and placebo groups, respectively (p = 0.07). Significant lipase elevation after ERCP did not differ between groups. Length of hospital stay, mortality and severe adverse events rates were similar between groups. We failed to detect large improvements in PEP rate among participants at risk for PEP who received IV hemin immediately after the procedure compared to placebo. ClinicalTrials.gov number, NCT01855841). [ABSTRACT FROM AUTHOR]

Abstract Objective Few reports have explored the application of urinary trypsinogen‐2 measurement in the early diagnosis of post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, and none have demonstrated the benefits of noninvasive testing. This study aimed to evaluate the clinical application of the rapid urinary trypsinogen‐2 dipstick test (Nipro, Japan) compared with serum amylase and lipase levels for the early diagnosis of post‐ERCP pancreatitis (PEP). Methods A total of 100 consecutive patients (54 men and 46 women) who were admitted and underwent ERCP at Tokyo Medical University Hospital from August 2021 to December 2021 were recruited. All patients underwent rapid urinary trypsinogen‐2 measurement using the dipstick test before and after ERCP. Measurements were taken 24 h before ERCP for pre‐ERCP and 1–4 h after ERCP for post‐ERCP. Additionally, serum amylase and lipase levels were measured at 8:00 a.m. of the day after ERCP (at least 8 h after ERCP), and their diagnostic abilities for PEP were compared and evaluated. Results PEP occurred in 5/100 patients (5%). The sensitivity, specificity, positive predictive value, and negative predictive value of the dipstick test for diagnosing PEP were 100%, 83.2%, 23.8%, and 100%, respectively. These results were comparable to the diagnostic performance of serum amylase and lipase levels at 8:00 a.m. on the day after ERCP (at least 8 h after ERCP). However, false positives must be considered. Conclusion The dipstick test may be useful in clinical practice as a noninvasive screening test for the early prediction of PEP.

To evaluate outcomes of ERCP as first-line management in patients with malignant biliary obstruction (MBO) of all causes and stages, reflecting a real-life setting. Retrospective observational study of patients with ERCP as the first-line management of MBO at Oslo University Hospital between 2015 and 2021. Primary outcome measure was a ≥ 50% decrease from the pre-procedural bilirubin within 30 days after ERCP. Secondary outcome measures were technical success of ERCP, complications and overall mortality. A total of 596 patients were included, median age 70 years. ASA score was ≥ III in 67% of patients. The most common cancers causing MBO were pancreatic cancer (52%), metastatic lesions (20%) and cholangiocarcinoma (16%). The primary outcome measure was achieved in 62% of patients. With endoscopic access, overall technical success was 80% with 85% for the distal extrahepatic group, 71% for the perihilar, 40% for the intrahepatic and 53% for multiple level MBOs. Reinterventions were performed in 27% of the patients. Complications occurred in 15% of the patients, including post-ERCP pancreatitis in 9%. Most complications were of minor/moderate severity (81%). Overall mortality was 33% within the first 90 days. Patients deceased by the end of the study period (83%) had median survival of 146 days (range 1–2,582 days). ERCP has a high rate of clinical effect and technical success in the management of both distal extrahepatic and perihilar MBO. Our data indicate that ERCP is a valid option in the first-line management of MBO. [ABSTRACT FROM AUTHOR]

Background/Objectives: COVID-19 impacts technical success of endoscopic retrograde cholangiopancreatography (ERCP). In this study, we aimed to assess the influence of COVID-19 on hospitalizations that underwent ERCP. Methods: We identified all adult COVID-19 and non-COVID-19 hospitalizations that underwent ERCP in the United States using the National Inpatient Sample for 2020. Hospitalization characteristics, clinical outcomes, and complications were compared between the two groups. Results: In 2020, 2015 COVID-19 and 203,094 non-COVID-19 hospitalizations underwent ERCP. The COVID-19 cohort had a higher mean age (60.3 vs 55.6 years, p < 0.001) and a higher proportion of Blacks and Hispanics compared to the non-COVID-19 cohort. After adjusting for confounders, the COVID-19 cohort had higher all-cause inpatient mortality (4.77 vs 1.45%, aOR 4.09, 95% CI 2.50–6.69, p < 0.001), mean length of stay (LOS) [10.19 vs 5.94 days, mean difference: 3.88, 95% CI 2.68–5.07, p < 0.001] and mean total hospital charges (THC) [$152,933 vs $96,398, mean difference: 46,367, 95% CI 21,776–70,957, p < 0.001] compared to the non-COVID-19 cohort. Increasing age, higher Charlson Comorbidity Index, and post-ERCP pancreatitis were identified to be independent predictors of inpatient mortality for COVID-19 hospitalizations that underwent ERCP. Furthermore, the COVID-19 cohort had higher odds of developing post-ERCP pancreatitis (PEP) (11.55 vs 7.05%, aOR 1.64, 95% CI 1.19–2.25, p = 0.002) compared to the non-COVID-19 cohort, after adjusting for confounders. However, there was no statistical difference in the rates of bowel perforations and post-ERCP hemorrhage between the two groups. Conclusion: COVID-19 hospitalizations that underwent ERCP had higher inpatient mortality, mean LOS, mean THC, and odds of developing PEP compared to the non-COVID-19 cohort. Clinical Trial Registration: This study is not a part of a clinical trial. [ABSTRACT FROM AUTHOR]

Purpose: Cannulation of the major papilla is the most challenging part of endoscopic retrograde cholangiopancreatography (ERCP) for which physician-controlled wire-guided cannulation (PCWGC) and assistant-controlled wire-guided cannulation (ACWGC) are used as the cannulation techniques. PCWGC can reportedly save up to about 30% of the labor cost by reducing the number of assistants. This study aims to compare the safety and efficacy of PCWGC and ACWGC. Materials and Methods: Of the 2151 patients aged >20 years (4193 cases) who underwent ERCP at Yonsei University Medical Center between January 2015 and December 2016, 989 were included in this study. Results: Among efficacy outcomes, cannulation success rate, rate of precut sphincterotomy (PCWGC vs. ACWGC: 21.3% vs. 25.9%), bile duct cannulation time (PCWGC vs. ACWGC: median 3.0 minutes vs. 3.6 minutes), and total procedure time (PCWGC vs. ACWGC: median 13.6 minutes vs. 13.1 minutes) were not significantly different. Among safety outcomes, lower rates of post- ERCP pancreatitis were observed with PCWGC than with ACWGC (PCWGC vs. ACWGC: 5.8% vs. 8.8%, p=0.128). Among other post-ERCP adverse events (bleeding, perforation, and cholangitis), the difference was not significant between the groups. Radiation exposure (total dose area product, PCWGC vs. ACWGC: median 1979.9 μGym² vs. 2062.0 μGym², p=0.194) and ERCP cost excluding labor cost (PCWGC vs. ACWGC: $1576 vs. $1547, p=0.606) were not significantly different. Conclusion: Requiring less assistants, PCWGC showed comparable efficacy and safety to ACWGC. PCWGC can be considered as an alternative option, especially in facilities lacking manpower and resources. [ABSTRACT FROM AUTHOR]

Background Post-ERCP pancreatitis (PEP) is significantly influenced by the reflux of duodenal fluid. While gastrointestinal decompression represents a fundamental approach in acute pancreatitis management, the effectiveness of immediate duodenal decompression following ERCP to prevent PEP remains uncertain. This study aimed to investigate the impact of immediate duodenal decompression after ERCP on reducing the incidence of hyperamylasemia and PEP. Methods This retrospective study encompassed patients with native papilla who underwent therapeutic ERCP for choledocholithiasis at the Department of Gastroenterology, Chun'an Branch of Zhejiang Provincial People's Hospital (Zhejiang, China) between January 2020 and June 2023. Based on the immediate placement of a duodenal decompression tube post-ERCP, patients were categorized into two groups: the duodenal decompression group and the conventional procedure group. Primary outcomes included the incidence of PEP and hyperamylasemia. Results A total of 195 patients were enrolled (94 in the duodenal decompression group and 101 in the conventional procedure group). Baseline clinical and procedural characteristics exhibited no significant differences between the two groups. PEP occurred in 2 patients (2.1%) in the duodenal decompression group, in contrast to 11 patients (10.9%) in the conventional procedure group (Risk difference [RD] 8.8%; 95% confidence interval [CI] 1.7%–16.5%, P  =   0.014). Hyperamylasemia was observed in 8 patients (8.5%) in the duodenal decompression group, compared to 20 patients (19.8%) in the conventional procedure group (RD 11.3%; 95% CI 1.4%–21.0%; P  =   0.025). Patients with PEP in both groups showed improvement after receiving active treatment. No severe cases of PEP occurred in either group, and no serious adverse events related to duodenal catheter decompression were reported. Conclusion Immediate duodenal decompression following ERCP demonstrates an effective reduction in the incidence of hyperamylasemia and PEP. [ABSTRACT FROM AUTHOR]

Over the past 50 years, endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred minimally invasive method of treating a vast array of pancreatobiliary diseases. An initial sine qua non for ERCP success is selective ductal cannulation. Despite significant progress in the optimisation of ERCP methods and accessories, selective biliary cannulation using conventional techniques remains unsuccessful in approximately 15% of native papilla cases. Furthermore, difficult biliary cannulation has been associated with an increased risk of post-ERCP pancreatitis, among other adverse events. Here, in the first of a two-part series, the authors provide a primer on standard biliary cannulation techniques and discuss the definition, risk factors, and implications of difficult biliary cannulation. The second part of the series will provide an overview of the existing advanced techniques used in cases of difficult biliary cannulation as well as the approach to their selection.

Endoscopic retrograde cholangiopancreatography (ERCP) plays a significant role in the treatment of a vast array of pancreatobiliary diseases. However, despite significant progress in the optimisation of ERCP methods and accessories, the technical and clinical success of ERCP can vary significantly due to a variety of patient and operator factors. Over the past several decades, a number of advanced techniques have been developed to improve cannulation success rates, including the use of double-guidewire, pancreatic duct accessory-assisted, precut, and rendezvous techniques. Here, the authors provide an update and overview of the existing advanced techniques used in cases of difficult biliary cannulation, as well as the approach to their selection.

Abstract Background Periampullary diverticulum (PAD) may make the performance of endoscopic retrograde cholangiopancreatography (ERCP) in patients with choledocholithiasis more difficult and may increase complication rates. The present study evaluated the effects of PAD on first-time ERCP in patients with choledocholithiasis. Methods Outcomes were compared in patients with and without PAD and in those with four types of PAD: papilla located completely inside the diverticulum (type I), papilla located in the inner (type II a) and outer (type II b) margins of the diverticulum; and papilla located outside the diverticulum (type III). Parameters compared included cannulation time and rates of difficult cannulation, post-ERCP pancreatitis (PEP) and perforation. Results The median cannulation times in patients with types I, II a, II b, III PAD and in those without PAD were 2.0 min, 5.0 min, 0.67 min, 3.5 min, and 3.5 min, respectively, with difficult cannulation rates in these groups of 7.4%, 31.4%, 8.3%, 18.9%, and 23.2%, respectively. The rates of PEP in patients with and without PAD were 5.3% and 5.1%, respectively. Four patients with and one without PAD experienced perforation. Conclusions The division of PAD into four types may be more appropriate than the traditional division into three types. Cannulation of type I and II b PAD was easier than cannulation of patients without PAD, whereas cannulation of type II a PAD was more challenging. PAD may not increase the rates of PEP.

Endoscopic retrograde cholangio-pancreatography (ERCP) is one of the primary procedural techniques used for diagnosing biliary and pancreatic diseases. Post-ERCP pancreatitis (PEP) is the most common complication of ERCP, which resulted in prolonged hospitalization and potential risk of patients' lives, especially in severe cases. Understanding the risk factors associated with PEP is of paramount importance for its prevention. Currently, recognized risk factors for PEP encompass both patient-related factors and ERCP procedure-related factors. By considering these risk factors, implementing appropriate preoperative, intraoperative, and postoperative interventions could effectively reduce the incidence of PEP. In this article, we concisely summarized the common risk factors and preventive methods for PEP, offering valuable insights for healthcare professionals in clinical practice.

There is an unmet clinical need for effective, targeted interventions to prevent post-ERCP pancreatitis (PEP). We previously demonstrated that the serine-threonine phosphatase, calcineurin (Cn) is a critical mediator of PEP and that the FDA-approved calcineurin inhibitors, tacrolimus (Tac) or cyclosporine A, prevented PEP. Our recent observations in preclinical PEP models demonstrating that Cn deletion in both pancreatic and hematopoietic compartments is required for maximal pancreas protection, highlighted the need to target both systemic and pancreas-specific Cn signaling. We hypothesized that rectal administration of Tac would effectively mitigate PEP by ensuring systemic and pancreatic bioavailability of Tac. We have tested the efficacy of rectal Tac in a preclinical PEP model and in cerulein-induced experimental pancreatitis. C57BL/6 mice underwent ductal cannulation with saline infusion to simulate pressure-induced PEP or were given seven, hourly, cerulein injections to induce pancreatitis. To test the efficacy of rectal Tac in pancreatitis prevention, a rectal Tac suppository (1 mg/kg) was administered 10 min prior to cannulation or first cerulein injection. Histological and biochemical indicators of pancreatitis were evaluated post-treatment. Pharmacokinetic parameters of Tac in the blood after rectal delivery compared to intravenous and intragastric administration was evaluated. Rectal Tac was effective in reducing pancreatic injury and inflammation in both PEP and cerulein models. Pharmacokinetic studies revealed that the rectal administration of Tac helped achieve optimal blood levels of Tac over an extended time compared to intravenous or intragastric delivery. Our results underscore the effectiveness and clinical utility of rectal Tac for PEP prophylaxis. [ABSTRACT FROM AUTHOR]

In the present era, post-ERCP pancreatitis (PEP) stands out as one of the most commonly occurring complications associated with endoscopic choledochal lithiasis extraction. The ability to predict the occurrence of such an event, particularly by utilizing absolute values and ratio dynamics of the emergency blood tests, constitutes the primary step in effectively managing a patient with a complex pathology. The study involved 134 patients who performed ERCP to extract choledochal lithiasis (n = 48 with PEP and n = 86 without PEP). The results revealed increased risks of post-ERCP pancreatitis in women and lower risks in those who benefited from manipulation of the main bile duct with the Dormia probe and dilatation balloon (OR: 2.893 CI 95%: 1.371–6.105, p = 0.005 and respectively OR: 0.346 CI 95%: 0.156–0.765, p = 0.009), without biliary stent placement. Moreover, the results brought novel elements to the literature, showing that higher values of CRPR (OR: 4.337 CI 95%: 1.945–9.668; p < 0.001), TBIR (4.004 CI 95%: 1.664–9.634; p = 0.002) and NLR post-ERCP (3.281 CI 95%: 1.490–7.221; p = 0.003) are predictive for PEP. Nevertheless, lower total bilirubin levels upon admission are predictive of PEP with an OR of 5.262 (95% confidence interval: 2.111–13.113, p < 0.001). [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy and safety of left lateral decubitus versus prone position during endoscopic retrograde cholangio-pancreaticography (ERCP). Methods: This prospective single-centre cohort study was carried out at Pak Emirates Military Hospital from January to June 2021. Patients requiring ERCP were subsequently allotted LL or PP group randomly (unequal randomization) except patients with recent abdominal surgery, in-dwelling catheters, raised intra-abdominal pressure, cervical spine abnormalities and limb contractures. Qualitative data was analysed using frequencies and chi square statistics whereas, quantitative data was analysed using mean±SD and student T or Mann Whitney U-test. Results: A total of 114 patients were enrolled according to the inclusion criteria with 62(54%) males and majority of the patients (42%) belonging to the age group 31-45 years. The most common ERCP indication was choledocholithiasis (36%). Technical success was achieved in 109(96%) patients with no statistically significant difference between the two groups. The total time of procedure, time for deep cannulation, time for acquiring therapeutic goal and ERCP complexity level were all similar between the two groups. The rate of inadvertent PD cannulation and PEP were relatively higher for the PP group but were statistically non-significant through univariate and logistic regression analyses and the only outcome measure that showed significance was multiple cannulations in the PP group. Conclusion: The study concludes that LL is non-inferior to PP and both positions have comparable outcomes with non-significant differences in terms of technical success rate, complications (specifically PEP), total procedure time, time required for deep cannulation and attainment of goal, ERCP complexity level and inadvertent PD cannulation. [ABSTRACT FROM AUTHOR]

Background: Periampullary diverticulum (PAD) may make the performance of endoscopic retrograde cholangiopancreatography (ERCP) in patients with choledocholithiasis more difficult and may increase complication rates. The present study evaluated the effects of PAD on first-time ERCP in patients with choledocholithiasis. Methods: Outcomes were compared in patients with and without PAD and in those with four types of PAD: papilla located completely inside the diverticulum (type I), papilla located in the inner (type II a) and outer (type II b) margins of the diverticulum; and papilla located outside the diverticulum (type III). Parameters compared included cannulation time and rates of difficult cannulation, post-ERCP pancreatitis (PEP) and perforation. Results: The median cannulation times in patients with types I, II a, II b, III PAD and in those without PAD were 2.0 min, 5.0 min, 0.67 min, 3.5 min, and 3.5 min, respectively, with difficult cannulation rates in these groups of 7.4%, 31.4%, 8.3%, 18.9%, and 23.2%, respectively. The rates of PEP in patients with and without PAD were 5.3% and 5.1%, respectively. Four patients with and one without PAD experienced perforation. Conclusions: The division of PAD into four types may be more appropriate than the traditional division into three types. Cannulation of type I and II b PAD was easier than cannulation of patients without PAD, whereas cannulation of type II a PAD was more challenging. PAD may not increase the rates of PEP. [ABSTRACT FROM AUTHOR]

Background The occurrence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) after using covered self-expandable metallic stents (CSEMS) and multiple plastic stents (MPS) in the therapy of benign biliary strictures (BBS) remains ambiguous, this analysis aimed to evaluate the outcomes.Methods A systematic search of electronic databases (PubMed, Web of Science and Cochrane Library) was conducted for randomised controlled trials (RCTs), and the included studies were published between 2008 and 2021. The primary outcome was PEP, while the secondary outcomes were stricture resolution, recurrence, overall adverse events, costs, and ERCP sessions. Pooled effect sizes were calculated with the random-effects model or fixed-effects model depending on the heterogeneity.Results Six RCTs contained 444 patients (221 with CSEMS, 223 with MPS) finally included in the meta-analysis. The present analysis shows that compared to MPS, PEP is more likely to occur in CSEMS (OR [odds ratio] = 3.34, 95% confidence intervals [CI]:1.44–7.77, p = .005). CSEMS needs fewer ERCP sessions (Mean Deviation [MD]: −1.56; 95%CI:−2.66, −0.46], p = .006). The difference in stricture resolution and recurrence was not significant between the two stent types (OR = 0.87, 95%CI: 0.49–1.56, p = .64; and OR = 2.3, 95%CI: 0.68–7.76, p = .18). The incidence of overall adverse events was comparable between CSEMS and the MPS group (OR = 1.49, 95% CI: 0.97–2.29, p = .07).Conclusions Compared with MPS, CSEMS caused a significantly higher incidence of PEP but fewer ERCP procedures, while the rate of stricture resolution, recurrence, and overall adverse events were comparable. Prevention methods of PEP should be further evaluated in BBS when undergoing CSEMS placement.Systematic Review Registration PROSPERO CRD42022314864. Key messagesCSEMS and MPS placement remain a mainstay for patients with BBS, and severe complications after stent placement have not been compared.The incidence of PEP was higher after deployment of CSEMS compared to MPS.Prevention methods of PEP should be evaluated in BBS when undergoing CSEMS placement.

Pancreatitis is the most common complication following endoscopic retrograde cholangio-pancreatography (ERCP). With the progress of research in many drugs and technologies, promising efficacy has been achieved in preventing post-ERCP pancreatitis (PEP). Recently, combined prevention has received more attention in order to further reduce the incidence of PEP. However, there is no review about the combined prevention of PEP. This review summarizes the medication and ERCP techniques that are used to prevent PEP and emphasizes that appropriate combination prevention approaches should be based on risk stratification.

Background: Despite numerous advances that have aimed to increase the safety of endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP pancreatitis (PEP) still remains a major issue. We aimed to assess the rate of PEP as well as the relation to the cannulation techniques in our unit, a high-volume center in north-eastern Romania. Methods: ERCPs performed in our unit from March to August 2022 were retrospectively included. Data concerning demographic information, presence of difficult cannulation, the technique used for cannulation, as well as immediate complications, were gathered from the electronic database. Results: 233 ERCPs were included. PEP was diagnosed in 23 (9.9%) of cases. Precut sphincterotomy (PS), transpancreatic sphincterotomy (TPBS), and a combination of TPBS and PS were performed in 6.4%, 10.3%, and 1.7% of cases, respectively, while an Erlangen precut papillotomy was performed in one case. Both in patients with PS and TPBS the rate of PEP was 20%. When the two techniques were associated, the rate of PEP was 25%. TPBS and PS represented risk factors for PEP (OR 1.211 for a CI of 0.946–1.551, p = 0.041, and OR 1.124 for a CI of 0.928–1.361, p = 0.088, respectively). No PEP-associated deaths were found. Conclusions: Both PS and TPBS presented a similar risk of PEP. [ABSTRACT FROM AUTHOR]

There is an urgent need for safe and targeted interventions to mitigate post-ERCP pancreatitis (PEP). Calcineurin inhibitors (CnIs) offer therapeutic promise as calcineurin signaling within acinar cells is a key initiating event in PEP. In previous proof-of-concept studies using experimental models, we showed that concurrent intra-pancreatic ductal administration of the CnIs, tacrolimus (Tac) or cyclosporine A (CsA) with the ERCP radiocontrast agent (RC) prevented PEP. To translate this finding clinically, we investigated potential toxic effects of intraductal delivery of a single-dose RC-CnI formulation on endocrine pancreas function and systemic toxicities in a preclinical PEP model. C57BL/6J mice underwent ductal cannulation and received a single, intra-pancreatic ductal infusion of RC or RC with Tac or CsA (treatment groups) or underwent ductal cannulation without infusion ('sham' group). To assess endocrine function, intraperitoneal glucose tolerance test (IPGTT) was performed at two days before infusion and on day 2 and 14 post-surgery. To evaluate off-target tissue toxicities, renal and hepatic function-related parameters including blood urea nitrogen, plasma creatinine, potassium, aspartate aminotransferase, alanine aminotransferase, and total bilirubin were measured at the same time-points as IPGTT. Histological and biochemical indicators of pancreas injury and inflammation were also evaluated. No abnormalities in glucose metabolism, hepatic or renal function were observed on day 2 or 14 in mice administered with intraductal RC or RC with Tac or CsA. Intraductal delivery of RC-CnI formulation was safe and well-tolerated with no significant acute or subacute endocrine or systemic toxicities, underscoring its clinical utility to prevent PEP. [ABSTRACT FROM AUTHOR]

Background : Although rectal nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be effective for the prevention of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis (PEP) in high-risk patients, the benefit in average-risk patients is unclear. We aimed at assessing the benefit of prophylactic rectal NSAIDs in unselected consecutive patients to prevent PEP. Methods: All patients undergoing index ERCP procedures from January 2018 until March 2020 were included. All patients received prophylactic rectal diclofenac. A prophylactic pancreatic duct (PD) stent was placed if there was repeated PD cannulation, at the discretion of the endoscopist. The frequency of PEP was compared with historical controls. Results: Of 769 patients who underwent ERCP, 34 (4.4%) developed PEP (mild in 29 [85.3%], moderate in four [11.8%] and severe in one [2.9%]). Female gender, precut sphincterotomy, inadvertent PD cannulation and procedural time of > 30 minutes predicted PEP in univariate analysis. Inadvertent PD cannulation (OR 4.6, 95% CI: 1.8–11.7; p < 0.001) and procedural time of > 30 minutes (OR 8.5, 95% CI: 3.7–10.1; p < 0.001) were independent risk factors on multivariate analysis. When compared with historical controls, the odds of PEP with prophylactic use of rectal NSAIDs and selective PD stenting was 0.54 (CI: 0.31–0.93, p = 0.027). The number needed to treat (NNT) was 22 to prevent one PEP with prophylactic rectal NSAIDs. Conclusion: Routine use of prophylactic rectal NSAIDs effectively prevents the occurrence of PEP in unselected consecutive patients in a real-world scenario. [ABSTRACT FROM AUTHOR]

Objective: To determine that early needle-knife sphincterotomy does not increase post-ERCP pancreatitis in patients with difficult biliary cannulation as compared to standard cannulation. Method: This prospective single-centre cohort study was carried out at Pak Emirates Military Hospital from January 2021 to June 2021. Patients requiring ERCP were enrolled in the study (according to inclusion and exclusion criteria) and were subsequently allotted different groups according to the technique used for deep biliary cannulation. Qualitative data was analysed using frequencies and chi square statistics whereas, quantitative data was analysed using mean±SD and one way ANOVA test. Result: The cohort included 114 patients with 52.6% male patients and predominance of relatively younger age group (31-45 years). The most common indication for ERCP was choledocholithiasis (36%) with an overall technical success rate of 96%. Deep cannulation was achieved either through standard cannulation (56%), double guidewire and/or pancreatic stent assisted (10.5%), use of early Needle-Knife Sphincterotomy (19%), NKS as a last resort (3.5%) or Transpancreatic Stenting and/or combined sphincterotomy (6%). Pancreatitis as a complication occurred in 4(3.5%) patients, bleeding in 2(1.8%), on-table desaturation in 2(1.8%) and perforation in 1(0.9%) patient. The occurrence of pancreatitis was only related significantly to inadvertent PD cannulation through univariate and logistic regression analysis whereas, multiple cannulations (>5), gender, age, classification of papilla and the use of early NKS had no impact on pancreatitis or the occurrence of other complications. Conclusion: NKS is an effective and safe modality for deep biliary cannulation and achieving technical success where cannulation is deemed difficult and does not increase the risk of PEP if done by experienced endoscopists in high volume centres. [ABSTRACT FROM AUTHOR]

Objective: The precut sphincterotomy technique is widely used for difficult biliary cannulation during the endoscopic retrograde chola ngiop ancre atogr aphy procedure. Even though an accepted risk factor for post-endoscopic retrograde cholangiopancreatography is a risk factor for pancreatitis, there are numerous studies showing whether this risk is technique-related or due to prolonged procedure time and recurrent cannulation attempts. The study's primary aim was to evaluate the incidence of post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis in early precut procedures compared to the standard technique in patients with difficult biliary cannulation. The secondary aim was to compare complications and cannulation success. Methods: In this prospective, single-center, randomized clinical trial, patients referred for therapeutic biliary endoscopic retrograde chola ngiop ancre atogr aphy and difficult biliary cannulation were divided into 2 groups. The first group was the early precut group (group A) and the second group was the late precut group (group B). Post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis was defined as upper abdominal pain associated with at least a 3-fold rise in serum pancreatic enzymes above the normal level more than 24 hours after the procedure. Results: Three hundred patients were enrolled in the study. Nine of 150 patients (6%) in group A and 21 of 150 patients (14%) in group B developed postendoscopic retrograde chola ngiop ancre atogr aphy pancreatitis (odds ratio 2.33). Successful biliary cannulation without precutting was performed in 25 patients in group B, whereas delayed precutting was required in the remaining 125 patients. Compared to the delayed precut group (19/125, 15.2%), the incidence of postendoscopic retrograde chola ngiop ancre atogr aphy pancreatitis was significantly lower in the early precut group (9/150, 6%) (odds ratio 3.3). The "late precut" subgroup had a post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis rate with an odds ratio of 2.5 compared to the group with cannulation without precut. These data suggest that the post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis risk among patients who received a late precut was higher than among patients who had an early precut or could be cannulated after repetitive efforts. Conclusion: Early precutting is an effective technique for patients with challenging biliary tract cannulation and can significantly reduce post-endoscopic retrograde chola ngiop ancre atogr aphy pancreatitis incidence. Recurrent biliary cannulation attempts constitute a real risk factor for this complication. [ABSTRACT FROM AUTHOR]

Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure in the diagnosis and treatment of biliopancreatic diseases. The most common adverse event of ERCP is post-ERCP pancreatitis (PEP), which can sometimes be severe. Our previous study suggested that injecting ice water at the end of ERCP suppressed PEP, and we decided to investigate this effect in a multicenter randomized controlled trial. Methods This study is being conducted at eight hospitals in Japan starting in April 2022. Patients undergoing ERCP will be randomized to ice water group and control group. In the ice water group, 250 ml of ice water is injected toward the papilla at the end of ERCP. The next morning, a physical examination and blood tests are performed to evaluate for the development of pancreatitis. The goal is to have 440 cases in each group. Discussion The main cause of PEP is thought to be papilla edema. Cooling the papilla, as everyone naturally does at the time of a burn, is expected to prevent its inflammation and edema. Various methods to suppress PEP have been reported, but so far none of them are reliable. The method we have devised is very simple, easy, and safe. We hope that our study will change the world's ERCP common practice. Trial registration:UMIN000047528. Registered 20 April 2022, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000053209

Abstract Background Nafamostat mesilate decreases the incidence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, no studies have administered nafamostat mesilate after ERCP. So we investigated if the infusion of nafamostat mesilate after ERCP can affect the post-ERCP pancreatitis (PEP) in high-risk patients. Methods In a tertiary hospital, 350 high-risk patients of PEP were reviewed retrospectively. Among them, 201 patients received nafamostat mesilate after ERCP. Patient-related and procedure-related risk factors for PEP were collected. We performed a propensity score matching to adjust for the significant different baseline characteristics. The incidence and severity of PEP were evaluated according to the infusion of nafamostat mesilate. The risk factors of PEP were also analyzed by multivariate logistic regression. Results The baseline characteristics were not different after the matching. The PEP rate (17.4% vs. 10.3%, P = 0.141) was insignificant. Among the PEP patients, mild PEP was significantly higher in the nafamostat mesilate group (85.7% vs. 45.5%, P = 0.021). Only one patient in the nafamostat mesilate group developed severe PEP. Although young age (odds ratio [OR] 3.60, 95% CI 1.09–11.85, P = 0.035) was a risk factor, nafamostat mesilate (odds ratio [OR] 0.30, 95% CI 0.09–0.98, P = 0.047) was a protective factor for moderate to severe PEP. Conclusions The administration of nafamostat mesilate after ERCP in high-risk patients was not effective in preventing PEP, but may attenuate the severity of PEP.

The objective: development of a method for determining the individual risk of post-ERCP pancreatitis (PEP) before endoscopic intervention.Subjects and Methods. A prospective observational study of the results of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) was performed in 1,210 patients. The primary end point was the development of PEP. Multiple regression logistic analysis was used to determine the risk of developing PEP.Results. A model of independent variables was determined, which significantly (p = 0.0001) affected the risk of developing PEP. Based on the results of the logistic analysis, regression coefficients were calculated for all significant patient-dependent factors (gender, age, preoperative level of amylasemia and bilirubinemia, and nature of the underlying disease). The risk of PEP decreased in men (by 47.5%), with an increase in the age of patients (for 1 year by 2.3%) and bilirubin (with an increase of 1 μmol/l by 0.3%) but increased with an increase in amylase activity blood serum (by 0.7% for each 1 U/l). A formula has been developed to assess the individual risk of PEP at the stage of preparing a patient for therapeutic ERCP.Conclusion. Analysis of patient-dependent factors makes it possible to reliably determine the risk of developing PEP. It was determined that a female gender, young age (under 40 years old), sphincter of Oddi dysfunction increased the risk of PEP, while a male sex, stenting of the main pancreatic duct, and jaundice reduced this risk. The use of the proposed formula will help predict a significant (p = 0.0001) degree of risk of PEP before performing primary therapeutic ERCP in a particular patient.