Real-world evidence comparing early and late pancreatic stent placement to prevent post-ERCP pancreatitis

Abstract

Background and study aims Pancreatic stenting effectively lowers the occurrence of post-ERCP pancreatitis (PEP) and reduces its severity. However, limited research has been conducted to determine the optimal timing for pancreatic stent placement. Our objective was to evaluate whether early pancreatic stent placement (EPSP) is more effective than late pancreatic stent placement (LPSP) in preventing PEP among patients with naive papilla.

Patients and methods We conducted a retrospective cohort study that analyzed 590 patients with difficult biliary cannulation using the pancreatic guidewire technique, who were divided into EPSP and LPSP groups. In the EPSP group, a pancreatic stent was placed immediately before/after endoscopic retrograde cholangiography (ERC) or endoscopic sphincterotomy (EST). Conversely, in the LPSP group, a pancreatic stent was placed after partial/all completion of major endoscopic procedures.

Results From November 2017 to May 2023, 385 patients were in the EPSP group and 205 in the LPSP group. EPSP was associated with a decreased PEP occurrence compared with LPSP (2.9% vs. 7.3%; P = 0.012). Similarly, hyperamylasemia was lower in the EPSP group (19.7% vs. 27.8%; P = 0.026). Furthermore, sensitivity analysis using multivariable analysis and propensity score–matched (PSM) analysis also validated these findings.

Conclusions Early pancreatic stent placement reduced the incidence of PEP and hyperamylasemia compared with late pancreatic stent placement. Our findings favor pancreatic stenting immediately before/after ERC or EST.

Keywords

Pancreatobiliary (ERCP/PTCD) - ERC topics - Statistics

• References

• 1 Laquiere A, Privat J, Jacques J. et al. Early double-guidewire versus repeated single-guidewire technique to facilitate selective bile duct cannulation: a randomized controlled trial. Endoscopy 2022; 54: 120-127
• 2 Thiruvengadam NR, Forde KA, Ma GK. et al. Rectal indomethacin reduces pancreatitis in high- and low-risk patients undergoing endoscopic retrograde cholangiopancreatography. Gastroenterology 2016; 151: 288-297
• 3 Sasahira N, Kawakami H, Isayama H. et al. Early use of double-guidewire technique to facilitate selective bile duct cannulation: the multicenter randomized controlled EDUCATION trial. Endoscopy 2015; 47: 421-429
• 4 Luo H, Zhao L, Leung J. et al. Routine pre-procedural rectal indomethacin versus selective post-procedural rectal indomethacin to prevent pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography: a multicentre, single-blinded, randomised controlled trial. Lancet 2016; 387: 2293-2301
• 5 Elmunzer BJ, Scheiman JM, Lehman GA. et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med 2012; 366: 1414-1422
• 6 Buxbaum JL, Freeman M, Amateau SK. et al. American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: methodology and review of evidence. Gastrointest Endosc 2023; 97: 163-183
• 7 Ashat M, Kandula S, Cote GA. et al. Utilization pattern of prophylactic measures for prevention of post-ERCP pancreatitis: a National Survey Study. Gastrointest Endosc 2023; 97: 1059-1066
• 8 Akshintala VS, Kanthasamy K, Bhullar FA. et al. Incidence, severity, and mortality of post-ERCP pancreatitis: an updated systematic review and meta-analysis of 145 randomized controlled trials. Gastrointest Endosc 2023; 98: 1-6
• 9 Elmunzer BJ, Foster LD, Serrano J. et al. Indomethacin with or without prophylactic pancreatic stent placement to prevent pancreatitis after ERCP: a randomised non-inferiority trial. Lancet 2024; 403: 450-458
• 10 Dietrich CF, Bekkali NL, Burmeister S. et al. Controversies in ERCP: Technical aspects. Endosc Ultrasound 2022; 11: 27-37
• 11 Bai B, Wang S, Du Y. et al. Indomethacin does not reduce post-ERCP pancreatitis in high-risk patients receiving pancreatic stenting. Dig Dis Sci 2024;
• 12 Wang S, Bai B, Liu S. et al. Transpancreatic sphincterotomy after double guidewire technique was noninferior to primary transpancreatic sphincterotomy in difficult biliary cannulation. Dig Dis Sci 2024; 69: 2215-2222
• 13 Cotton PB. Analysis of 59 ERCP lawsuits; mainly about indications. Gastrointest Endosc 2006; 63: 378-382
• 14 Freeman ML. Preventing Post-ERCP pancreatitis: Update 2016. Curr Treat Options Gastroenterol 2016; 14: 340-347
• 15 Elmunzer BJ. Reducing the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis. Dig Endosc 2017; 29: 749-757
• 16 Wang P, Li ZS, Liu F. et al. Risk factors for ERCP-related complications: a prospective multicenter study. Am J Gastroenterol 2009; 104: 31-40
• 17 Choudhary A, Bechtold ML, Arif M. et al. Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review. Gastrointest Endosc 2011; 73: 275-282
• 18 Yi JH, Li ZS, Hu L H. Pancreatic duct stents. J Dig Dis 2022; 23: 675-686
• 19 Buxbaum J L, Freeman M, Amateau SK. et al. American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: summary and recommendations. Gastrointest Endosc 2023; 97: 153-162
• 20 Dumonceau JM, Kapral C, Aabakken L. et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 127-149
• 21 Hakuta R, Hamada T, Nakai Y. et al. Early pancreatic stent placement in wire-guided biliary cannulation: A multicenter retrospective study. J Gastroenterol Hepatol 2019; 34: 1116-1122
• 22 Jowell PS, Baillie J, Branch MS. et al. Quantitative assessment of procedural competence. A prospective study of training in endoscopic retrograde cholangiopancreatography. Ann Intern Med 1996; 125: 983-989
• 23 Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13: e1-e15
• 24 Yokoe M, Hata J, Takada T. et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2018; 25: 41-54
• 25 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 26 Haraldsson E, Lundell L, Swahn F. et al. Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study. United Eur Gastroenterol J 2017; 5: 504-510
• 27 Kochar B, Akshintala VS, Afghani E. et al. Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials. Gastrointest Endosc 2015; 81: 143-149
• 28 Dubravcsik Z, Hritz I, Keczer B. et al. Network meta-analysis of prophylactic pancreatic stents and non-steroidal anti-inflammatory drugs in the prevention of moderate-to-severe post-ERCP pancreatitis. Pancreatology 2021; 21: 704-713
• 29 Shi QQ, Ning XY, Zhan LL. et al. Placement of prophylactic pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: a meta-analysis. World J Gastroenterol 2014; 20: 7040-7048
• 30 Facciorusso A, Ramai D, Gkolfakis P. et al. Comparative efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis. Gastrointest Endosc 2022; 95: 60-71
• 31 Artifon E L, Chu A, Freeman M. et al. A comparison of the consensus and clinical definitions of pancreatitis with a proposal to redefine post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreas 2010; 39: 530-535
• 32 Chandrasekhara V, Khashab MA, Muthusamy VR. et al. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85: 32-47
• 33 Talukdar R. Complications of ERCP. Best Pract Res Clin Gastroenterol 2016; 30: 793-805
• 34 Lee JG, Lee CE. Infection after ERCP, and antibiotic prophylaxis: a sequential quality-improvement approach over 11 years. Gastrointest Endosc 2008; 67: 476-477
• 35 Thiruvengadam NR, Kochman ML. Emerging therapies to prevent post-ERCP pancreatitis. Curr Gastroenterol Rep 2020; 22: 59