ASGE Postgraduate Course at ACG: Innovative Practices for the Endoscopist of Today, Tomorrow and Beyond | October 2023-1

1_Elmunzer Post ERCP Pancreatitis

Pdf Summary

The document is a presentation by B. Joseph Elmunzer at the ASGE Postgraduate Course at ACG on October 20, 2023, focusing on the latest strategies for preventing Post-ERCP Pancreatitis (PEP), a significant complication following Endoscopic Retrograde Cholangiopancreatography (ERCP).<br /><br />Key strategies for PEP prevention include:<br />1. **Appropriate Patient Selection and Risk Stratification**: Identifying patients at high risk for PEP can help tailor preventative measures.<br />2. **Technical Proficiency during Procedure**: Techniques such as guidewire-assisted cannulation and avoiding aggressive pancreatic duct contrast injections can reduce risk. Early use of alternative techniques is backed by meta-analyses showing significant risk reduction (Tse et al. 2012, Cennamo et al. 2010).<br />3. **Prophylactic Pancreatic Stent Placement**: This technique helps maintain pancreatic duct drainage and has shown a profound reduction in severe/necrotizing pancreatitis based on 12 RCTs and non-randomized studies (Choudhary et al. 2011, Mazaki et al. 2014). However, potential disadvantages include complications, changes to the pancreatic duct, and inconvenience factors.<br />4. **Pharmacological Prevention**: Rectal NSAIDs, specifically indomethacin, have been proven effective and safe. A recommendation (Grade A) suggests routine administration of 100mg of diclofenac or indomethacin immediately before or after ERCP.<br />5. **Lactated Ringer’s Solution**: Aggressive fluid therapy with Lactated Ringer’s solution is preferable over normal saline, reducing the incidence and severity of PEP (Wu et al. 2011, Hoque et al. 2014, Buxbaum et al. 2014, Choi et al. 2017).<br /><br />The presentation includes findings from various studies, such as the SVI Trial—a study comparing rectal indomethacin alone versus its combination with a pancreatic stent in high-risk patients, which completed enrollment in January 2023.<br /><br />In summary, preventing PEP involves a combination of patient selection, refined procedural techniques, strategic use of pancreatic stents, pharmacological interventions, and aggressive fluid management. Indomethacin remains a pivotal component, and ongoing research like the SVI Trial continues to refine these prevention strategies.

Keywords

Post-ERCP Pancreatitis

PEP prevention

patient selection

risk stratification

technical proficiency

prophylactic pancreatic stent

pharmacological prevention

rectal NSAIDs

Lactated Ringer’s solution

SVI Trial