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Surgical Endoscopy

, 23:1887 | Cite as

Rescue ERCP and insertion of a small-caliber pancreatic stent to prevent the evolution of severe post-ERCP pancreatitis: a case-controlled series

  • László Madácsy
  • Gábor Kurucsai
  • Ildikó Joó
  • Szilárd Gódi
  • Roland Fejes
  • András Székely
Article

Abstract

Introduction

Recently prophylactic placement of a trans-sphincteric pancreatic stent has successfully been applied to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Rescue ERCP and emergency application of small-caliber pancreatic stents during the early course of post-ERCP pancreatitis as a possible endoscopic therapy has not been reported yet.

Methods

All patients who underwent ERCP were hospitalized for at least 24 h, with routine laboratory testing of amylase levels. Out of 1,225 ERCPs, evolution of severe post-ERCP pancreatitis was anticipated in six consecutive patients, based on severe pancreatic pain attack, more than tenfold elevation of serum amylase levels at 8 and 24 h, and moderate rise of white blood cell (WBC) and C-reactive protein (CRP) levels. Rescue ERCP and emergency application of small-caliber (4-5F, 4-cm, Geenen stent) pancreatic stents were successfully performed in all patients within 8–20 h after the initial ERCP.

Results

Moderate to severe papillary oedema was observed in all patients during the rescue ERCP. Pancreatic pain was promptly reduced after the rescue pancreatic drainage procedure and completely diminished within 24 h after pancreatic stenting. Serum amylase levels were exponentially reduced and normalized within 72 h in all patients; no pancreatic necrosis or any other late complications were observed. Pancreatic stents could be safely removed a few days later.

Conclusion

Rescue pancreatic stenting with small-caliber prophylactic pancreatic stents seems to be a safe and effective procedure that might be feasible to stop the evolution of severe post-ERCP pancreatitis, but prospective controlled studies are clearly demanded to support this innovative approach.

Keywords

Post-ERCP pancreatitis Pancreatic stent Sphincter of Oddi dysfunction ERCP complications 

References

  1. 1.
    Freeman ML, DiSario JA, Nelson DB, Fennerty MB, Lee JG, Bjorkman DJ, Overby CS, Aas J, Ryan ME, Bochna GS, Shaw MJ, Snady HW, Erickson RV, Moore JP, Roel JP (2001) Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc 54(4):425–434PubMedCrossRefGoogle Scholar
  2. 2.
    Masci E, Mariani A, Curioni S, Testoni PA (2003) Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis. Endoscopy 35(10):830–834PubMedCrossRefGoogle Scholar
  3. 3.
    Cheng CL, Sherman S, Watkins JL, Barnett J, Freeman M, Geenen J, Ryan M, Parker H, Frakes JT, Fogel EL, Silverman WB, Dua KS, Aliperti G, Yakshe P, Uzer M, Jones W, Goff J, Lazzell-Pannell L, Rashdan A, Temkit M, Lehman GA (2006) Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol 101(1):139–147PubMedCrossRefGoogle Scholar
  4. 4.
    Andriulli A, Caruso N, Quitadamo M, Forlano R, Leandro G, Spirito F, De Maio G (2003) Antisecretory vs. antiproteasic drugs in the prevention of post-ERCP pancreatitis: the evidence-based medicine derived from a meta-analysis study. JOP 4(1):41–48PubMedGoogle Scholar
  5. 5.
    Smithline A, Silverman W, Rogers D, Nisi R, Wiersema M, Jamidar P, Hawes R, Lehman G (1993) Effect of prophylactic main pancreatic duct stenting on the incidence of biliary endoscopic sphincterotomy-induced pancreatitis in high-risk patients. Gastrointest Endosc 39(5):652–657PubMedCrossRefGoogle Scholar
  6. 6.
    Tarnasky PR, Palesch YY, Cunningham JT, Mauldin PD, Cotton PB, Hawes RH (1998) Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction. Gastroenterology 115(6):1518–1524PubMedCrossRefGoogle Scholar
  7. 7.
    Fazel A, Quadri A, Catalano MF, Meyerson SM, Geenen JE (2003) Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study. Gastrointest Endosc 57(3):291–294PubMedCrossRefGoogle Scholar
  8. 8.
    Brackbill S, Young S, Schoenfeld P, Elta G (2006) A survey of physician practices on prophylactic pancreatic stents. Gastrointest Endosc 64(1):45–52PubMedCrossRefGoogle Scholar
  9. 9.
    Elta GH (2008) Temporary prophylactic pancreatic stents: which patients need them? Gastrointest Endosc 67(2):262–264PubMedCrossRefGoogle Scholar
  10. 10.
    Verma D, Gostout CJ, Petersen BT, Levy MJ, Baron TH, Adler DG (2007) Establishing a true assessment of endoscopic competence in ERCP during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy. Gastrointest Endosc 65(3):394–400PubMedCrossRefGoogle Scholar
  11. 11.
    Freeman ML (2003) Understanding risk factors and avoiding complications with endoscopic retrograde cholangiopancreatography. Curr Gastroenterol Rep 5(2):145–153; ReviewPubMedCrossRefGoogle Scholar
  12. 12.
    Singh P, Das A, Isenberg G, Wong RC, Sivak MV Jr, Agrawal D, Chak A (2004) Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials. Gastrointest Endosc 60(4):544–550PubMedCrossRefGoogle Scholar
  13. 13.
    Saad AM, Fogel EL, McHenry L, Watkins JL, Sherman S, Lazzell-Pannell L, Lehman GA (2008) Pancreatic duct stent placement prevents post-ERCP pancreatitis in patients with suspected sphincter of Oddi dysfunction but normal manometry results. Gastrointest Endosc 67:255–261PubMedCrossRefGoogle Scholar
  14. 14.
    Elta GH (2008) Temporary prophylactic pancreatic stents: which patients need them? Gastrointest Endosc 67(2):262–264PubMedCrossRefGoogle Scholar
  15. 15.
    Andriulli A, Forlano R, Napolitano G, Conoscitore P, Caruso N, Pilotto A, Di Sebastiano PL, Leandro G (2007) Pancreatic duct stents in the prophylaxis of pancreatic damage after endoscopic retrograde cholangiopancreatography: a systematic analysis of benefits and associated risks. Digestion 75(2–3):156–163PubMedCrossRefGoogle Scholar
  16. 16.
    Das A, Singh P, Sivak MV Jr, Chak A (2007) Pancreatic-stent placement for prevention of post-ERCP pancreatitis: a cost-effectiveness analysis. Gastrointest Endosc 65(7):960–968. Epub 2007 Feb 28PubMedCrossRefGoogle Scholar
  17. 17.
    Testoni PA, Bagnolo F (2001) Pain at 24 hours associated with amylase levels greater than 5 times the upper normal limit as the most reliable indicator of post-ERCP pancreatitis. Gastrointest Endosc 53(1):33–39PubMedCrossRefGoogle Scholar
  18. 18.
    Testoni PA, Bagnolo F, Caporuscio S, Lella F (1999) Serum amylase measured four hours after endoscopic sphincterotomy is a reliable predictor of postprocedure pancreatitis. Am J Gastroenterol 94(5):1235–1241PubMedCrossRefGoogle Scholar
  19. 19.
    Safrany L, Cotton PB (1981) A preliminary report: urgent duodenoscopic sphincterotomy for acute gallstone pancreatitis. Surgery 89(4):424–428PubMedGoogle Scholar
  20. 20.
    Freeman ML, Overby C, Qi D (2004) Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success. Gastrointest Endosc 59(1):8–14PubMedCrossRefGoogle Scholar
  21. 21.
    Lawrence C, Cotton PB, Romagnuolo J, Payne KM, Rawls E, Hawes RH (2007) Small prophylactic pancreatic duct stents: an assessment of spontaneous passage and stent-induced ductal abnormalities. Endoscopy 39(12):1082–1085. Epub 2007 Sep 21PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • László Madácsy
    • 1
  • Gábor Kurucsai
    • 1
  • Ildikó Joó
    • 1
  • Szilárd Gódi
    • 1
  • Roland Fejes
    • 1
  • András Székely
    • 1
  1. 1.First Department of Internal Medicine and OMCH Endoscopy UnitFejér Megyei Szent György HospitalSzékesfehérvárHungary

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