577 A Prospective Randomized Trial of Aggressive Hydration to Prevent Post-ERCP Pancreatitis

Buxbaum, James; Yan, Arthur W.; Yeh, Kelvin; Vora, Hita; Nguyen, Nancy; Laine, Loren

doi:10.1016/j.gie.2013.04.094

Gastrointestinal Endoscopy

2013

DOI: 10.1016/j.gie.2013.04.094

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577 A Prospective Randomized Trial of Aggressive Hydration to Prevent Post-ERCP Pancreatitis

James Buxbaum

Arthur W. Yan

Kelvin Yeh

et al.

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“…The concept of hypoperfusion of the microvasculature during the early phase of acute pancreatitis has led to the emphasis on early volume resuscitation, specifically Ringer's lactate solution for acute pancreatitis of any cause to prevent or limit pancreatic injury. Although prevention of PEP has focused on pharmacologic agents (most recently NSAIDs) and PD stents, Buxbaum et al [1] reported the interim results on the use of aggressive hydration to prevent PEP. Patients were prospectively randomized in a 2:1 ratio of aggressive hydration compared with moderate hydration.…”

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confidence: 99%

Ercp

Law

Baron

2013

Endoscopy

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DDW Highlights 745Prevention of post-ERCP pancreatitis ! The concept of hypoperfusion of the microvasculature during the early phase of acute pancreatitis has led to the emphasis on early volume resuscitation, specifically Ringer's lactate solution for acute pancreatitis of any cause to prevent or limit pancreatic injury. Although prevention of PEP has focused on pharmacologic agents (most recently NSAIDs) and PD stents, Buxbaum et al [1] reported the interim results on the use of aggressive hydration to prevent PEP. Patients were prospectively randomized in a 2:1 ratio of aggressive hydration compared with moderate hydration. Aggressive hydration was administered by using lactated Ringer's (LR) solution at 3 mL/kg/h intraprocedurally followed by a bolus of LR 20 mg/kg administered immediately postprocedurally, and continued at 3 mL/kg/h for 8 hours. In the standard hydration group LR was administered at 1.5 mL/kg/ h during the procedure and for 8 hours afterward. Patients were monitored for volume overload, and PEP was defined by using standard criteria. PEP developed in none of the 32 patients in the aggressive fluid arm compared with 4 of 32 (24 %) in the moderate fluid arm. No volume overload occurred. These results suggest that aggressive fluid resuscitation should be considered in all patients who are not at risk of volume overload because this intervention poses little risk otherwise. Cannulation techniques continue to be important because difficult cannulation is associated with an increased risk of PEP. There continues to be a shift from contrast-guided biliary cannulation to wire-guided (WG) cannulation. Two abstracts of note focused on cannulation techniques. When WG cannulation fails, but the guidewire unintentionally and repeatedly enters the main pancreatic duct (PD), 1 option is to leave the guidewire in the pancreas and reattempt biliary cannulation alongside with a second guidewire and catheter. This is termed double wire -guided (DWG) cannulation. Sasahara et al [2] presented results of a randomized trial comparing early DWG cannulation, in which a guidewire remained in the PD after the first unintentional entry compared with repeated conventional WG biliary cannulation in patients undergoing therapeutic endoscopic retrograde cholangiography. Successful biliary cannulation was achieved in 48 % of patients on the first attempt, with a PEP rate of only 4 %. The subsequent 274 patients (137 per group) were defined as difficult cannulation and were randomized. Common bile duct cannulation was successful within 10 minutes or 10 attempts in 75 % of patients in the early DWG group and 70 % of the repeated single WG cannulation group. The final cannulation rate was approximately 97 % in each group with a similar rate of PEP (20 % vs 17 %). No mention was made of the use of prophylactic pancreatic stents or pharmacologic agents. This suggests that the PEP rate in patients with difficult cannulation remains high if PD stent placement and/or NSAIDs are not used, but that DWG cannulation is associated with ...

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confidence: 99%

Ercp

Law

Baron

2013

Endoscopy

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Law

Baron

2013

Gastrointestinal Endoscopy

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Aggressive Hydration With Lactated Ringer Solution in Prevention of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis

Zhang

Duan

Wang

et al. 2017

Journal of Clinical Gastroenterology

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Background: Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The results of previous studies evaluating aggressive hydration with lactated Ringer solution for reducing the incidence of post-ERCP pancreatitis (PEP) are inconsistent. Aim: We performed a meta-analysis to determine whether aggressive hydration with lactated Ringer solution reduced PEP. Methods: Randomized controlled trials (RCTs) comparing aggressive hydration with standard hydration with the same lactated Ringer solution for prophylaxis of PEP were searched in PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL databases. ClinicalTrial.gov and International Standard Randomised Controlled Trial Number registry were also searched for unpublished studies. A meta-analysis was conducted in accordance with the Cochrane Handbook for Systemic Reviews of Intervention. Results: A total of 7 RCTs with 1047 participants were included into this meta-analysis. Meta-analysis showed that aggressive hydration reduced the incidence of PEP as compared with standard hydration [odds ratio (OR), 0.47; 95% confidence interval (CI), 0.30-0.72; P=0.0006]. Aggressive hydration also reduced the incidence of post-ERCP hyperamylasemia as compared with standard hydration (OR, 0.38; 95% CI, 0.25-0.59; P<0.00001). No difference of adverse effects was found between aggressive hydration and standard hydration (OR, 0.48; 95% CI, 0.15-1.57; P=0.23). Sensitivity analyses showed that neither alternative effect measures nor statistical models regarding heterogeneity affected the conclusions of this meta-analysis. Sensitivity analyses also showed that omitting 1 study from analysis did not change the conclusion of this meta-analysis. Conclusions: On the basis of this meta-analysis of RCTs, aggressive hydration with lactated Ringer solution is an effective and safe therapy for prophylaxis of PEP.

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577 A Prospective Randomized Trial of Aggressive Hydration to Prevent Post-ERCP Pancreatitis

Cited by 3 publications

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Aggressive Hydration With Lactated Ringer Solution in Prevention of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis

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