Early ERCP and biliary sphincterotomy with or without small ...Presentation Transcript
Early ERCP and biliary sphincterotomy with or without small caliber pancreatic stent in patients with gallstone pancreatitis(nonrandomized, prospective, dual center trial) Z.Dubravcsik1, A.Szepes1, R.Fejes2, G.Balogh2, Z.Virányi1, P.Hausinger1, A.Székely2, L.Madácsy2 1Gastroenterology and Endoscopy, Bács-Kiskun Megyei Önkormányzat Hospital, Kecskemét, 2First Department of Internal Medicine and Gastroenterology, Fejér Megyei Szent György Hospital, Székesfehérvár, HUNGARY
Introduction – acute pancreatitis Incidence: 5-73 /100,000 Mortality: 5-15 % Severe (SAP): 20 % Biliary origin: 38 % ERCP, EST within 72 hours (SABP) Yamada (ed): Textbook of Gastroenterology, 5th ed., Blackwell Publisging, 2009. McDonald, Burroughs, Feagan (ed): Evidence Based Gastroenterology and Hepatology, 2nd ed., Blackwell Publishing,2004. Tonsi et al: Acute pancreatitis at the beginning of the 21th century, World J Gastroenterol, 2009; 15(24):2945-59.
Recent Meta-Analysis of Early ES in Acute BiliaryPancreatitis CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009;7:S3–S9
Pathophysiology –acute biliary pancreatitis Acinar cell injury Defective intracellular transport Duct obstruction Trypsin Trypsinogen Kumar, Abbas, Fausto (eds): Robbins and Cotran Pathologic Basis of Disease, 7th ed., Elsevier Saunder, 2005.
Hypothesis – Why early ERCP and EST is ineffective in recent RCT with ABP patientswithout cholangitis? In certain subgroups of patients ERCP and repeated PD cannulation with contrast filling may cause further pancreatic injury (similarly to patients with post-ERCP pancreatitis) EST and gallstone extraction from the CBD itself does not completely relieve the pancreatic duct obstruction, which may be due to:
Papillary edema and inflammation caused by spontaneous gallstone migration or EST itself
Prolonged spasm of the pancreatic sphincter due to paradoxical response of the SO evoked by high plasma levels of CCK
Introduction – Feasibility trial of PD stent application in ABP Post-ERCP pancreatitis Freeman et al: Pancreaticstentsforprevention of post-ERCP pancreatitis, ClinGastroenterolHepatol 2007; 5: 1354-65. Madácsy et al: Prophylactic pancreas stenting followedbyneedle-knife fistulotomy in patientswith SOD and difficult cannulation: newmethodtopreventpost-ERCP pancreatitis,DigEndosc, 2009; 21: 8-13. Madácsy et al: Rescue ERCP and insertion of a small-caliberpancreaticstenttopreventtheevolution of severepost-ERCP pancreatitis: a case-controlled series,SurgEndosc, 2009; 23 (8):1887-93.
Acute biliary pancreatitis
Godi et al: Emergencypancreaticdrainagewithpostponed biliary sphincterotomy in patientswithacute biliary pancreatitis: sparinglittletimemaysave a lot, Endoscopy 2008; 40 (Suppl 1): A 412. Fejesatal: Feasibility and safety of emergency ERCP and small-caliberpancreatic stenting as a bridgingprocedure in patientswithacute biliary pancreatitis butdifficult sphincterotomy,SurgEndosc, 2010; 24:1878-1885.
Methods – prospective nonrandomized study Dual large volume endoscopic center (Kecskemét + Székesfehérvár County Hospital, >800 ERCP/year) Non-alcoholic pts (n=116) Biliary pancreatitis with cholangitis Gallbladder stones ± dilated CBD Elevated obstructive LFTs and WBC (>1.5N) EST (n=59) vs. EST+PD stent (n=57) Hospitalization, treatment (medical therapy, jejunal feeding), follow up (CT)
Hospitalization Admission History, physical examination Blood tests, abdominal USS ERCP (<72 hours from onset of pain) Contrast enhanced CT scan On day 3-5 Follow up (at emission or day 10) Blood tests, USS
Indications for small caliber PD stent implantation Severe papillary edema due to impacted gallstone Repeated PD contrast filling (>5x) Repeated PD cannulation (>5x) Difficult biliary cannulation (>5x unsuccessful cannulation attempts during > 10 min) Use of needle knife precut papillotomy
Small caliber PD stents used Geenen® stent (5 Fr) Inner and duodenal flaps and sideholes Length: 3-5 cm 0,025 F hydrophilic guidewire (until the border of pancreas head and body) Minimizing further PD contrast filling Stent extraction after 10 days with gastroscope 5 F, 3-5 cm www.cookmedical.com
ABP, impacted gallstone:urgent ERCP, EST, PD stenting
Conclusion Early ERCP and EST with small caliber PD stenting is better to conventional EST alone: May offer sufficient drainage to reverse the process of ABP Results significantly less complications Results better outcome It could be a new endoscopic therapeutic strategy, but randomized controlled trials are necessitated to support this innovative approach