Aims Post-ERCP pancreatitis (PEP) is still the most common major complication of ERCP
despite technical advancements and meticulous patient selection. The efficacy of the
existing techniques is conflicting. We aimed to compare the efficacy of peripapillary
epinephrine injection and rectal indomethacin in the prevention of PEP. [1]
[2]
Methods Between January 2023 and August 2023, a total of 378 patients were enrolled. We calculated
that 189 patients in each group (rectal indomethacin – Group A and peripapillary epinephrine
injection – Group B) would suffice based on a previous study by our group (α:0.05,
80% power). Patients with a non-naive papillae, ampulla of Vater cancer, biliary pancreatitis,
altered anatomy, pregnancy, and pancreatic diseases such as chronic pancreatitis were
excluded. Patients were assigned in a 1:1 simple randomized fashion. The primary outcome
was the rate of PEP. Secondary outcomes were the rate of hyperamylasemia and rates
of other adverse events
Results Demographic characteristics, indications, and procedure-related risk factors were
similar between the groups. The overall success rate of selective cannulation was
99.2% in Group A and 99.3% in Group B (p=0.997). PEP occurred in 9 of the 189 (4.8%)
patients in Group A and 2 of the 189 (0.5%) patients in Group B. All cases were mild
and managed conservatively. The rate of post-procedure 4th-hour hyperamylasemia was
significantly higher in Group A (19% vs 5%, p<0.001). Postsphincterotomy-related bleeding
developed in 5 patients in Group A (2.64%) but none of the patients had bleeding in
Group B. Stapfer type-II perforation occurred in two patients in each group. No major
cardiac adverse events-related to epinephrine injection were detected in Group B.
Conclusions Compared to rectal indomethacin, peripapillary epinephrine injection significantly
reduced the incidence of PEP, post-procedure hyperamylasemia, and sphincterotomy-related
bleeding
