Low-dose heparin for the prevention of post-ERCP pancreatitis: a randomized placebo-controlled trial

Barkay, Olga; Niv, Eva; Santo, Erwin; Bruck, Rafael; Hallak, Aharon; Konikoff, Fred M.

doi:10.1007/s00464-007-9738-2

Cited by 31 publications

(26 citation statements)

References 33 publications

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“…Seven potentially relevant publications were identified through the literature search [8][9][10][11][12][13][14]. Of these, three were excluded as they evaluated the effects of LMWH in the treatment of SAP [8,13,14].…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

“…Of these, three were excluded as they evaluated the effects of LMWH in the treatment of SAP [8,13,14]. Only four trials fulfilled our selection criteria, with three prospective randomized [10][11][12] and one nonrandomized [9]. All the studies were published in full in peer-reviewed journals.…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

“…As shown in Rabenstein et al [11] Ung et al [12] Barkay et al [10] Rabenstein et al [9] Rabenstein et al [11] Ung et al [12] Total events In addition, we carried out the analysis again according to methodological quality by excluding the nonrandomized trial reported by Rabenstein and colleagues in 2002. As shown in Table 2 …”

Section: Subgroup and Sensitivity Analysismentioning

confidence: 99%

“…However, the reports of prophylactic administration of lowdose unfractionated heparin or LMWH on the development of PEP are not conclusive. Some have indicated that pretreatment with heparin reduces the frequency of PEP [9], whereas others have not shown a protective effect of unfractionated heparin [10] or LMWH [11]. For this reason, we intended to perform a systematic review and metaanalysis of all relevant controlled clinical trials, aiming to evaluate whether the prophylactic use of low-dose unfractionated heparin or LMWH can reduce the incidence of PEP.…”

Section: Introductionmentioning

confidence: 99%

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Low-dose heparin in the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis

Cao

Chen

et al. 2012

European Journal of Gastroenterology & Hepatology

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One of the most frequent and serious complications of endoscopic retrograde cholangiopancreatography (ERCP) is acute pancreatitis. The aim of this study was to evaluate the preventive effect of low-dose heparin (unfractionated or low-molecular-weight heparin) on post-ERCP pancreatitis (PEP) and its side-effects by a systematic review and meta-analysis of clinical trials. Searching PubMed and EMBASE, up to August 2011, two independent reviewers systematically identified prospective clinical trials detecting the effect of prophylactic low-dose heparin on the incidence of PEP, severe PEP, and post-ERCP hemorrhage complications. Four clinical trials fulfilled our selection criteria, with three prospective randomized and one nonrandomized. A meta-analysis of these clinical trials was then performed. A total of 1438 patients were included. Meta-analysis of these trials indicated that there was no significant association between the use of heparin and the reduction of PEP [relative risk (RR) 0.67, 95% confidence interval (CI): 0.44-1.03, P=0.07] and severe PEP (RR 0.62, 95% CI: 0.15-2.60, P=0.51). However, low-dose heparin did not increase the incidence of post-ERCP hemorrhage complications (RR 0.84, 95% CI: 0.34-2.03, P=0.69). This meta-analysis did not demonstrate a statistically significant benefit of prophylactic heparin use for the prevention of post-ERCP pancreatitis. More multicenter trials involving a larger number of patients are needed to show a possible prevention effect of PEP from heparin and its related compounds.

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Section: Characteristics Of Included Studiesmentioning

confidence: 99%

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

Section: Subgroup and Sensitivity Analysismentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Low-dose heparin in the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis

Cao

Chen

et al. 2012

European Journal of Gastroenterology & Hepatology

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“…Among these, placement of prophylactic pancreatic stents and nonsteroidal anti-inflammatory agents are the two interventions with the most robust evidence supporting efficacy in PEP prevention. Other interventions have either shown no evidence of efficacy, demonstrated conflicting results, or have not been rigorously evaluated in multiple large randomized trials (Table 4) [30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47]. …”

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confidence: 99%

Post-ERCP Pancreatitis: Mechanisms, Risk Factors, and Prevention

Zouhairi¹

2013

Pancreat Disorders Ther

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Background and EpidemiologyAcute pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP) [1,2]. The incidence of acute pancreatitis after ERCP in large prospective studies published over the last two decades ranges from 1.6 to 15.1% [3][4][5][6][7][8][9][10][11][12][13]. Most cases of post-ERCP pancreatitis (PEP) tend to be mild to moderate in severity. Only 0.4% of patients undergoing ERCP develop severe acute pancreatitis, and mortality resulting from PEP is estimated to only be 0.11%. However, the risk of PEP may be as high as 30-40% in patients with certain risk factors. Furthermore, pancreatitis is the single most common reason for ERCP-related lawsuits, accounting for up to 50% of all ERCP-related litigation [14]. Definition and GradingStudies estimating the incidence of PEP are confounded by the lack of consistency in the definition of PEP utilized by investigators. In a large cohort of patients undergoing ERCP, Testoni el al demonstrated that the incidence of PEP ranged from 5.1% to 11.7% depending on the pain duration and amylase level required to diagnose PEP [15].In an attempt to standardize the definition of PEP, Cotton et al published consensus criteria in 1991 that were based on review of over 15,000 cases. These consensus criteria require four components to diagnose PEP: elevation in serum amylase concentration greater than three times upper normal level, pancreatic-type abdominal pain, duration of pain greater than 24 hours after ERCP, and pain severe enough to require hospitalization. The consensus definition also graded PEP as mild, moderate, and severe based on hospital length of stay, and procedure complications (Table 1).While the criteria proposed by Cotton et al have been widely employed in the published literature, alternative criteria have also been utilized by researchers in the field. The Atlanta criteria, one of the more commonly used alternative consensus classifications, were published in 1992 and recently revised, and defined severe acute pancreatitis based on the presence of local or systemic complications and organ failure [16] (Table 2). MechanismsAlthough the exact mechanism of PEP is not known, several hypotheses have been proposed. Leading explanations identify mechanical trauma to the papillary orifice, hydrostatic injury, and enzymatic injury from activated proteolytic enzymes introduced from the duodenum as potential precipitants for PEP.The mechanical trauma theory proposes that injury to the papillary orifice may cause sphincter of Oddi spasm or edema of the pancreatic orifice, thereby leading to obstruction of pancreatic juice outflow, and promoting pancreatic injury and inflammation. Papillary injury can occur during ERCP by prolonged or repeated attempts at cannulating the pancreatic duct , multiple contrast injections into the pancreatic duct [17], or thermal injury from electrocautery current during sphincterotomy [18].The theory of hydrostatic injury is based on the possibility that overinjection of the pancreat...

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Acute Pancreatitis

Cohen¹,

Nguyen²,

Pachter³

2013

Common Problems in Acute Care Surgery

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Low-dose heparin for the prevention of post-ERCP pancreatitis: a randomized placebo-controlled trial

Abstract: The study did not demonstrate a significant effect of low-dose unfractionated heparin in the prevention of post-ERCP pancreatitis. A multicenter trial with a larger number of patients is needed to demonstrate a benefit from this drug.

Cited by 31 publications

References 33 publications

Low-dose heparin in the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis

Low-dose heparin in the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis

Post-ERCP Pancreatitis: Mechanisms, Risk Factors, and Prevention

Acute Pancreatitis

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