Pancreatitis is the most common complication of therapeutic endoscopic retrograde cholangiopancreatography (ERCP), and many pharmacoprophylactic approaches have been suggested, though not without ...controversy. The aim was to investigate the impact of combined therapy with diclofenac plus somatostatin on reducing the frequency and severity of post-ERCP pancreatitis (PEP).
A prospective, double-blind, placebo-controlled trial was conducted in two tertiary referral centers, with 540 eligible patients randomized to receive either combined therapy with diclofenac 100 mg rectally 30 to 60 minutes before ERCP plus somatostatin 0.25 mg/h for 6 hours (group A), or a placebo suppository identical in appearance to the diclofenac along with saline solution (group B). Patients were clinically evaluated and serum amylase levels were determined before ERCP and at 6 and 24 hours post-procedure. Standardized criteria were used to diagnose and grade the severity of PEP. Adverse events were recorded prospectively.
There were no statistical differences between the groups regarding demographic data, ERCP findings, and procedure risk factors for PEP. The overall incidence of acute pancreatitis was 7.2 %. The PEP rate was significantly lower in the patients who received the combination therapy than in controls (4.7 % vs. 10.4 %, P = 0.015). Previous history of acute pancreatitis (P = 0.001), pancreatic opacification of first-class branches and beyond (P = 0.008), and absence of pharmacoprophylaxis (P = 0.023) were identified as independent risk factors for PEP in multivariate analysis.
Although combined prophylactic therapy with diclofenac plus somatostatin was promising in reducing frequency of PEP, further comparative large-scale studies are needed to confirm our findings before definitive conclusions can be drawn.
Deep cannulation of the common bile duct (CBD) is paramount for the success of endoscopic biliary intervention. The aim of the present study was to compare standard ERCP catheter and hydrophilic ...guide wire (HGW) in the selective cannulation of the CBD.
A total of 332 patients were randomly assigned to cannulation with a standard catheter (n = 165) or a HGW (n = 167). If cannulation had not succeeded after 10 minutes with the technique assigned at randomization, a further attempt was made for an additional 10 minutes using the alternative technique. The following were assessed: primary and overall selective cannulation, time to cholangiography, number of pancreatic opacifications and guide-wire pancreatic duct insertions, and complication rates.
The primary success rate of selective CBD cannulation was higher in the HGW (81.4 %) than in the standard catheter group (53.9 %; P < 0.001). The overall cannulation rate after crossover was comparable between the two groups (standard catheter 84 % vs. HGW 83.8 %; P = 0.19). Time required for primary selective CBD cannulation was 3.53 +/- 0.32 minutes in the standard catheter vs. 4.48 +/- 0.32 minutes in the HGW group ( P = 0.04), and the number of insertions of the guide wire into the pancreatic duct was 3.29 +/- 0.47 in the standard catheter vs. 2.7 +/- 0.21 in the HGW group ( P = 0.22). Pancreatic opacifications occurred 3.19 +/- 0.20 times in the standard catheter vs. 1.50 +/- 0.22 times in the HGW group ( P < 0.001). Precut techniques were used in 56 patients (16.9 %) (n = 31 in the standard catheter vs. n = 25 in the HGW group; P = 0.07). The frequency of postinterventional pancreatitis and hemorrhage did not differ between the two groups. A young woman developed post-ERCP hemolytic crisis due to glucose-6-phosphate dehydrogenase deficiency. There was no procedure-related mortality.
The use of HGW, as primary technique or as a secondary technique after failure of cannulation with a standard catheter, achieves a high rate of selective CBD cannulation.
Objectives
There are no data regarding the relationship between Helicobacter pylori infection (Hp‐I) and clinically isolated syndrome (CIS) suggestive of multiple sclerosis. The purpose of this pilot ...study was to investigate the association between active Hp‐I, confirmed by histology, and CIS and to evaluate the impact of Hp eradication on the CIS clinical course.
Material and Methods
We conducted a study on 48 patients with CIS and 20 matched controls. At baseline, apart from histology, serum anti‐Hp‐specific IgG titer, inflammatory mediators, and HLA‐A, HLA‐B, HLA‐DR genetic polymorphisms were estimated. Hp‐positive patients received standard triple eradication regimen, and all patients were followed up for 2 years.
Results
The prevalence of Hp‐I was significantly higher in patients with CIS (43/48, 89.6%) than in control (10/20, 50%) (P < 0.001, OR: 8.6, 95% CI: 2.4–30.8). When compared with controls, patients with CIS also showed significantly higher serum anti‐Hp IgG titer and HLA‐A26, HLA‐A30, and HLA‐B57 frequencies. Hp‐positive patients also showed higher serum concentrations of inflammatory cytokines and homocysteine. At 2‐year clinical endpoint, in the subgroup of CIS patients with successful Hp eradication, the number of patients who presented with a second episode was significantly lower accompanied by significant improvement in mean Expanded Disability Status Scale score.
Conclusions
Hp‐I seems more frequent in a Greek CIS cohort and its eradication might delay CIS progression, suggesting a possible link between Hp‐I and CIS.
Linked ContentThis article is linked to Ahn et al papers. To view these articles visit https://doi.org/10.1111/apt.13866 and https://doi.org/10.1111/apt.13911.
The aim of this observational prospective study was to evaluate the safety of outpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in a very elderly cohort.
A total of 600 ...patients were included in the study between June 2006 and June 2009. All underwent first therapeutic ERCP and were scheduled to be discharged on the same day following a postprocedure observation period of 6 hours. Of the 600 patients, 123 patients (group A) were re-admitted due to postprocedure complications that presented during the observation period, and 477 patients (group B) were discharged on the same day. Concomitant diseases, details of ERCP procedures, complications, and outcomes were all evaluated. The accuracy of the 6-hour postprocedure observation period, clinical criteria in predicting those patients aged 80 years and older in whom all therapeutic ERCP can be performed on an outpatient basis, and costs saved were all assessed.
There was a statistical difference in incidence of concomitant diseases between groups A and B (group A 84.5 % vs. group B 74.6 %; P = 0.020). However, there was no difference between the groups with regard to indication for ERCP and type of intervention. There was no difference in postprocedure complication rate between very elderly patients and younger patients (< 80 years), except for prolonged sedation or hypotension, which occurred more frequently in older (≥ 80 years) than in younger (< 80 years) patients (7.6 % vs. 3.2 %; P = 0.037). In group B, complications necessitating re-admission after the 6-hour observation period occurred in 10 patients (2.09 %) (patients ≥ 80 years 0.8 % and patients < 80 years 2.5 %). The costs saved by performing the procedure on an outpatient basis was calculated as 150 € per patient.
Outpatient therapeutic ERCP with postprocedure observation of 6 hours is a safe and cost-effective procedure in a significant proportion of very elderly patients.
Abstract Background When common bile duct (CBD) stones cannot be removed after conventional endoscopic techniques or mechanical lithotripsy, biliary stenting serves for further planned endoscopic ...attempt of stone removal or operation. The aim of our study was to investigate the effect of ursodeoxycholic acid (UDCA) or placebo plus endoprostheses on stones’ fragmentation or size. Methods Forty-one patients with difficult to extract CBD stones were prospectively studied. They were randomised to receive either a 10 Fr straight plastic stent and oral 750 mg UDCA (group A, 21 patients) or placebo (group B, 20 patients) daily for 6 months. Results A total clearance of CBD was achieved in 16 patients (76.9%) of group A and 15 patients (75%) of group B. The stones remained unchanged in size in five patients (23.8%) of group A and five patients (25%) of group B. In seven patients (33%) of group A and five patients (25%) of group B a repeated ERCP demonstrated fragmentation of CBD stones that were easily extracted. A reduction in stones’ size was observed in 8 patients (38%) of group A (1.61 ± 0.32 cm before treatment vs. 1.21 ± 0.24 cm after treatment, p = 0.002) and 10 patients (50%) of group B (1.61 ± 0.35 cm before vs. 1.24 ± 0.22 cm after treatment, p = 0.001). There was no statistically significant difference on stone size reduction ( p = 0.602) and fragmentation ( p = 0.558) between the two groups. Conclusion The results of this study suggest that UDCA does not seem to contribute to the reduction in stones’ size or stones’ fragmentation during the endoprosthetic procedure.
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