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

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. La prevenzione della
pancreatite acuta post CPRE:
stent o farmaci?
Cosa fare per "non farlo arrabbiare"?

4. Diagnosis and definition
of post-ERCP pancreatitis
Adapted from Cotton et al,
GIE 1991

13. CT severity index in
acute pancreatitis

14. CT severity index in acute pancreatitis

15. 57 acute pancreatitis on 1497 ERCP (3.8%)
V Bathia et al; J Clin Gastroent 2006

16. 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

17. Post-ERCP pancreatitis
Unpredictable and unavoidable?
Can be prevented
• Patient selection
• Technical maneuvers
• Pharmacological prophylaxis

18. Prevention of post-ERCP pancreatitis
Patient selection
• INDICATIONS!!
– Only therapeutic ERCP (EUS, S-MRCP)
– High risk patients
• Informed consent

19. Diagnostic ERCP

24. Training and ERCP
an ERCP!

27. 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!

30. 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)

31. Precut

33. 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)

34. 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)

36. 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

37. 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) ? ?

42. Profilassi farmacologica della
pancreatite acuta post CPRE

48. La prevenzione della
pancreatite acuta post CPRE:
stent o farmaci?
Cosa fare per "non farlo arrabbiare"?

49. 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

54. Protesi pancreatica (5 fr) post SEB in paziente ad lato rischio di PEP

55. Protesi pancreatica (5 fr) post papillectomia della
papilla minor

56. Protesi pancreatica (5 fr) post sfinterotomia della papilla
minor

57. Gastrointest Endosc 2007

58. Gastrointest Endosc 2007

61. 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)

64. Prevention of post-ERCP pancreatitis
“Bring to home”

65. 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

66. 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

67. 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!?!

68. 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

69. Grazie per l’attenzione