Massimiliano Mutignani

S.C. di Endoscopia Digestiva ed interventisticaAzienda Ospedaliera Niguarda Ca GrandaMilano

La prevenzione della pancreatite acuta post CPRE:

stent o farmaci?

Gastro-learning

La prevenzione della pancreatite acuta post CPRE:

stent o farmaci?

Cosa fare per "non farlo arrabbiare"?

Diagnosis and definition

of post-ERCP pancreatitis

Adapted from Cotton et al, GIE 1991

CT severity index in acute pancreatitis

CT severity index in acute pancreatitis

57 acute pancreatitis on 1497 ERCP (3.8%)

V Bathia et al; J Clin Gastroent 2006

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

Post-ERCP pancreatitisUnpredictable and unavoidable?

Can be prevented

• Patient selection

• Technical maneuvers

• Pharmacological prophylaxis

Prevention of post-ERCP pancreatitis

Patient selection

• INDICATIONS!!

– Only therapeutic ERCP (EUS, S-MRCP)

– High risk patients

• Informed consent

Diagnostic ERCP

Training and ERCP

an ERCP!

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!

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)

Precut

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)

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)

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 ofpancreatitis

Lella et al, GIE 2004

Gastrointest Endosc 2004

Guide Wire CM injection

Acute pancreatitis (n°) none < 0.01 8

mild - 6moderate - 1severe - 1

Cannulation rate (%) 100 100

Cannulation time (min) ? ?

Profilassi farmacologica dellapancreatite acuta post CPRE

La prevenzione della pancreatite acuta post CPRE:

stent o farmaci?

Cosa fare per "non farlo arrabbiare"?

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 studies1 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

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

Protesi pancreatica (5 fr) post papillectomia della papilla minor

Protesi pancreatica (5 fr) post sfinterotomia della papilla minor

Gastrointest Endosc 2007

Gastrointest Endosc 2007

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)

Prevention of post-ERCP pancreatitis“Bring to home”

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

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

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!?!

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

Grazie per l’attenzione