Underutilization of prophylactic rectal indomethacin and pancreatic duct stent for prevention of post-ERCP Pancreatitis

Abstract

Background and study aims Incidence of Post-ERCP pancreatitis (PEP) ranges from 1 % to 10 % in unselected patients and as high as 25 % to 30 % in high-risk patients. Rectal indomethacin administered before or immediately after an ERCP and prophylactic pancreatic duct stent placement (PPS) are associated with a reduction in the incidence of PEP. We sought to investigate the utilization rate for prophylactic rectal indomethacin and PPS in average and high-risk patients undergoing ERCP between 2014 and 2019. Patients and methods We performed a retrospective analysis in the IBM Explorys database, a pooled, national de-identified clinical database of over 72 million unique patients from 26 health care networks and 300 hospitals across the United States from 2014 to 2019. Average and high-risk patients undergoing ERCP were identified using Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) diagnosis codes. PEP was defined by the presence of SNOMED CT diagnosis of acute pancreatitis and an inpatient admission within 5 days of an ERCP procedure. Results Out of 31,050 adults who had undergone ERCP from 2014 to 2019, only 10,500 individuals (33.8 %) had a PEP prophylaxis. Rectal indomethacin and PPS accounted for 82.4 % and 12.9 % respectively. Individuals with three risk factors had the highest PEP rates followed by individuals with two risk factors. Conclusions Only one-third of all patients undergoing ERCP received prophylaxis in the form of rectal indothemacin and/or PPS in this large population-based data. Increased implementation of prophylactic use is needed in patients undergoing ERCP as supported by current guidelines.

Comparison of octreotide and proton pump inhibitor in the prevention of acute pancreatitis after endoscopic retrograde cholangiopancreatography for different diseases

“…ERCP in the clinical management of hepatobiliary and pancreatic diseases is significant important, but prevention of postoperative PEP is an important prerequisite to ensure the safety of ERCP [17][18][19]. Complicated causes are involved in the occurrence of PEP after ERCP, which are mainly associated with the following factors [20][21][22][23][24][25]: (1) repeated intubation during ERCP causes papillary injury and edema, resulting in obstruction of biliopancreatic fluid outflow; (2) injury to the opening of the pancreatic duct due to incision of the duodenum causes edema of the surrounding mucosal tissue; (3) contaminated endoscope leads to contamination in the intestinal tract; (4) overdose of contrast agent results in increased pressure in the pancreatic duct and its toxicity causes damage to the pancreatic alveoli. For the above pathogenesis, the prevention of PEP after ERCP is mainly classified into technical prevention and pharmacological prevention, of which technical prevention mainly includes: (1) improving the operator's surgical skills to avoid intraoperative local tissue injury; (2) selective appli-TA B L E 1.…”

American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

“…However, a larger volume of fluid and ongoing aggressive hydration post-ERCP has been shown to be not effective in reducing PEP when rectal indomethacin suppositories are also used (150). Despite the evidence of the benefit of using rectal indomethacin suppositories, in a large study of more than 30,000 patients, only one-third of patients were provided this method of prophylaxis (151). When considering the costs, risks, and potential benefits in light of the published literature, rectal indomethacin and periprocedural hydration should be used in all patients before ERCP (137).…”

Az endoszkópos retrográd cholangiopancreatographia szövődményei

“…Megállapították, hogy a kombináció jobb, mint az egyszeres kezelések, továbbá az agresszív hidrálás a kombinációban hatékonyabb, mint a normálvolumen, végül a Ringer-laktát jobb, mint a fiziológiás sóoldat. Annak ellenére, hogy a megelőzésről rendelkezésre álló adatok meggyőzőek, illetve a nagy endoszkópos társaságok is ajánlják, a mindennapi gyakorlatban az ERCPvizsgálatoknak csak a harmadában használják, mint ahogy azt amerikai szerzők a 2014 és 2019 közötti időszakot felölelő, retrospektív vizsgálatukban kimutatták (31 050 ERCP-betegből 10 500-nál használtak NSAIDot vagy sztentet [33,8%]) [31].…”