La prevenzione della pancreatite acuta post-ERCP: stent o farmaci? - Gastrolearning®

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Gastrolearning II modulo/6a lezione
La prevenzione della pancreatite acuta post-ERCP: stent o farmaci?
Prof. M. Mutignani - Università di Milano

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La prevenzione della pancreatite acuta post-ERCP: stent o farmaci? - Gastrolearning®

  1. 1. Massimiliano Mutignani S.C. di Endoscopia Digestiva ed interventistica Azienda Ospedaliera Niguarda Ca Granda Milano La prevenzione della pancreatite acuta post CPRE: stent o farmaci? Gastro-learning
  2. 2. La prevenzione della pancreatite acuta post CPRE: stent o farmaci? Cosa fare per "non farlo arrabbiare"?
  3. 3. Diagnosis and definition of post-ERCP pancreatitis Adapted from Cotton et al, GIE 1991
  4. 4. CT severity index in acute pancreatitis
  5. 5. CT severity index in acute pancreatitis
  6. 6. 57 acute pancreatitis on 1497 ERCP (3.8%) V Bathia et al; J Clin Gastroent 2006
  7. 7. PEP diagnosi • Paziente asintomatico: non necessità di monitorare le amilasi/lipasi nella pratica clinica • Dolore addominale post CPRE: valutazione clinica a 24 ore  dolore persistente: esami di laboratorio (amilasi x 5 volte v.n.; leucocitosi) • Quadro clinico grave: sindrome compartimentale? Perforazione retroperitoneale?  TC, esami di laboratorio urgenti
  8. 8. Post-ERCP pancreatitis Unpredictable and unavoidable? Can be prevented • Patient selection • Technical maneuvers • Pharmacological prophylaxis
  9. 9. Prevention of post-ERCP pancreatitis Patient selection • INDICATIONS!! – Only therapeutic ERCP (EUS, S-MRCP) – High risk patients • Informed consent
  10. 10. Diagnostic ERCP
  11. 11. Training and ERCP an ERCP!
  12. 12. Prevention of post-ERCP pancreatitis Technical maneuvers • Pancreatic duct contrast injection  Avoid multiple injections (Meta-analysis, Masci et al, Endoscopy 2003)  Avoid high pressure injection (“acinarization)  Prefer non-ionic and isotonic contrast Training for the assistant!
  13. 13. Prevention of post-ERCP pancreatitis Technical maneuvers •  risk of AP if repeated attempt at cannulation (> 5) (Freeman et al, NEJM 1996; Vandervoort et al GIE 2002) • Pre-cut and  risk of pancreatitis  Pro (meta-analysis, Masci et al, Endoscopy 2003)  Cons (studies from 11 tertiary referral centers) (Bruins et al, Endoscopy 1996; Harewood AM J Gastro 2002)
  14. 14. Precut
  15. 15. Prevention of post-ERCP pancreatitis Technical maneuvers • Thermal injury during sphx  Bipolar current safer than monopolar (Siegel et al, Am J Gastroenterol 1994)  Pure-cut safer than blended current (Elta et al, GIE 1998; Stefanidis et al, GIE 2003)  HF current generator (“Endocut” mode, ERBE) similar results respect to pure-cut current (Norton et al, GIE 2002, ABSTRACT)
  16. 16. Prevention of post-ERCP pancreatitis Technical maneuvers • Balloon dilation of the biliary sphincter:  risk of AP (Freeman et al, GIE 2001; Baron and Harewood, meta-analysis Am J Gastroenterol 2004) • Stenting without sphx  Proximal biliary stricture (“fulcrum effect”) (Tarnasky et al, GIE 1997)  SOD (38% pancreatitis, severe in 25%) (Goff JS, Am J Gastro 1995)
  17. 17. Prevention of post-ERCP pancreatitis Technical maneuvers • Steerable vs standard catheters: no difference in the rate of pancreatitis (Cortas et al, GIE 1999; Laasch et al, Endoscopy 2003) • Guidewire assisted vs Contrast injection “blind” cannulation ↓ Rate of pancreatitis Lella et al, GIE 2004
  18. 18. Gastrointest Endosc 2004 Guide Wire CM injection Acute pancreatitis (n°) none < 0.01 8 mild - 6 moderate - 1 severe - 1 Cannulation rate (%) 100 100 Cannulation time (min) ? ?
  19. 19. Profilassi farmacologica della pancreatite acuta post CPRE
  20. 20. La prevenzione della pancreatite acuta post CPRE: stent o farmaci? Cosa fare per "non farlo arrabbiare"?
  21. 21. Prevention of post-ERCP pancreatitis Technical maneuvers • Prophylactic pancreatic stenting reduce the risk of pancreatitis in high risk patients 5 prospective randomized controlled trials, 7 case-control studies 1 meta-analysis (Singh et al, GIE 2004) • 3 French pancreatic stent preferred:  distal pigtail, unflanged, 2-3 cm long, 0.018” guidewire  less pancreatitis rate than 4-6 French stent  86% spontaneous migration within 2 weeks Rashdan et al, Clin Gastroenterol Hepatol 2004
  22. 22. Protesi pancreatica (5 fr) post SEB in paziente ad lato rischio di PEP
  23. 23. Protesi pancreatica (5 fr) post papillectomia della papilla minor
  24. 24. Protesi pancreatica (5 fr) post sfinterotomia della papilla minor
  25. 25. Gastrointest Endosc 2007
  26. 26. Gastrointest Endosc 2007
  27. 27. Treatment of post-ERCP pancreatitis • Mild-moderate: usually recover with conservative tx • Severe…  Medical tx ± ICU  Sterile / Infected necrosis: choose the optimal surgical time (multidisciplinary approach)
  28. 28. Prevention of post-ERCP pancreatitis “Bring to home”
  29. 29. Prevention of post-ERCP pancreatitis “Bring to home” • Careful patient selection (avoid unnecessary/inappropriate ERCP) • Expert assistant (he/she inject dye!) • Use pure cut or “endocut current” for Sphx • Avoid balloon dilation of the sphincter in routine practice • Do not place a biliary stent without sphincterotomy • Prophylaxis with NSAID always
  30. 30. Prevention of post-ERCP pancreatitis “Bring to home” • Insertion of a pancreatic stent  in case of risk factors for PEP: Before pre-cut papillotomy Before or after biliary Sphx for SOD Pancreatic Sphx After sphincter manometry or pancreatic instrumentation for SOD Balloon dilation of the intact sphincter Pancreatic brush cytology After difficult cannulation or repeated pancreatic duct injection
  31. 31. Pancreatite acuta post CPRE Settembre 2004 – Agosto 2007 Eseguite circa 3500 CPRE Frequenza della pancreatite acuta post CPRE < 3% - 4 P. A. N. E. * 2 in pazienti con papilla intatta * 2 in pazienti con pregressa sfinterotomia!?!
  32. 32. If you don’t want complications ……… ………in the next life be a pathologist: when they see the “patient”, the complication has already been done by someone else
  33. 33. Grazie per l’attenzione

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