This ASG video tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. This is the most serious and most frequent serious complication, ranging from 3 to 8 percent, as high as 25 percent in some series, if you go way back to the literature. There's all sorts of factors that are related to this, mechanical, hydrostatic, chemical, allergic, enzymatic, thermal injury, and 0.4 percent are severe, as defined there. Risk factors are additive. So you have, and throughout each one of these we'll talk about the different risk factors, you have physician risk factors, and this is operator experience or lack thereof, patient risk factors, which we have listed here, prior posterior pancreatitis, probably the most important, also suspected SOD, female gender, normal bilirubin, absence of chronic pancreatitis and age there. And then there's also procedural risk factors, so difficult cannulation, PD injection, if you're doing a pancreatic duct sphincterotomy, SOD manometry, pre-cut, complicated access certainly contributes, minor pillowwork, and balloon sphincteroplasty and epilectomy. So prevention here, judicious use of ERCP has already been mentioned, wire-guided cannulation, avoid PD cannulation and injection, limit cannulation time, prophylactic stenting, rectal endomethysin and aggressive hydration. Now there's a few older studies I'm gonna show you, because we've been thinking these things for a long time, and we've only recently got a really nice grade document that has kind of confirmed it, but this is some of the older literature that really led us to think this over the past many years. So this was a Cochrane meta-analysis of 12 RCTs over 3,400 patients, and it was looking at wire-guided cannulation versus contrast, and the group with wire-guided cannulation had 3.7% rate of post-EP pancreatitis, and the conventional group had 7.2%. So clearly, better success rate in cannulation as well as lower PEP rates. Then we had a meta-analysis that was looking at the use of pancreatic duct stents, and this was, you know, there's several of these, there's three different meta-analyses that all agreed that stents were favorable. And there's still some issues with that, you know, regarding, you know, what type of stent to use, what size stent, is it a pigtail, is it an internal flange, et cetera, but clearly stents were favorable. Limitations here is that you can sometimes have trouble placing a PD stent, and so how hard you want to try to get that stent in, and we don't have great answers for this. This can require repeat endoscopy, it may increase the cost of the procedure, and there's a lack of expert agreement on the methods, as I said. And then moving on to IV fluids and indomethacin, this was a randomized trial, 48 subjects in each one of these arms, and you have saline plus placebo, saline plus indomethacin, lactated ringers and placebo, and lactated ringers plus indomethacin. And you can see that the, oops, I was going to have a transition there, I'm trying to go backwards, and I'm down to the bottom button, perfect, thank you. So much better. So the difference between saline and placebo versus lactated ringers and indomethacin was significant, and the others weren't quite significant. So that's kind of the background and where we came from on this. Now there's a great guideline from the AHG led by Buxbaum that really goes through this more methodologically. They actually use great methodology. So this is looking at a high level of evidence that's confirming kind of all the things we thought all those years, right? And they went through the various questions, they had five major clinical questions that they looked at. They looked at in unselected patients undergoing ERCP, should rectal insets be given? In high-risk patients, should they be given? In unselected patients undergoing ERCP, is wire-guided cannulation preferred to contrast injection? So the same things that we've kind of suspected. High-risk patients undergoing ERCP, should pancreatic duct stents be placed? And then unselected patients undergoing ERCP, what about aggressive fluid resuscitation? And basically they went through it with very good rigor, and I've kind of pulled out and reworded these a little bit, because great methodology can be kind of strange there, but this is the summary, the take-home messages from the document. ASU recommends that unselected and high-risk patients should be given periprocedural rectal insets to prevent PEP. It's a strong recommendation with moderate quality of evidence. They suggest wire-guided cannulation over contrast-guided cannulation to minimize the risk of PEP in unselected patients undergoing ERCP. It's conditional with moderate quality. It recommends that PD stent placement to reduce the risk of PEP in patients undergoing deep access, as well as ampulectomy, and that's a strong recommendation with moderate quality of evidence. It also recommends that PD stent placement in high-risk groups, including patients with difficult cannulation history of sphincterotomy, and that is a conditional recommendation, and it recommends aggressive periprocedural and post-procedural intravenous hydration.

post-ERCP pancreatitis

risk factors

prevention strategies

wire-guided cannulation

prophylactic stenting