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PubMed2004

Technical outcomes and complications of ERCP in children.

BACKGROUND: The aim of this study was to compare the success and complications of diagnostic and therapeutic ERCP in children (age <18 years) and adult patients. METHODS: A retrospective case-controlled study was conducted in which all children undergoing ERCP at two centers (1994-2002) were identified from endoscopy databases and were matched with adult patients for all variables (e.g., indication, procedure complexity) except age. Outcomes with regard to technical success and complications were compared between the adult and the pediatric cohorts. Grade of procedure complexity and procedure-related complications were defined by using established criteria. RESULTS: A total of 116 children (mean age 9.3 years, range 1 month to 17 years; median age 8.1 years) and 116 matched adult patients (mean age 56.3 years, range 20-83 years; median age 49.7 years) underwent 163 and 173 ERCP procedures, respectively. According to procedure complexity grade, each group included the same number of patients, grade I, 72 patients; grade II, 12 patients; and grade III, 32 patients. Procedure success rate was 97.5% in children vs. 98% in the adult cohort (p= not significant). The complication rate was not significantly different between children and adult patients (3.4% vs. 2.5%). Most complications were of mild severity and encountered only in patients who underwent grade III procedures, with the exception of a single adult in whom moderate post-sphincterotomy bleeding developed after extraction of a large bile duct stone (grade II complexity). CONCLUSIONS: When ERCP is performed in children by expert endoscopists, the success rate is high and the complication rate is low, both being comparable with those for ERCP in adult patients.

Adolescent↗
PubMed2005

Oral allopurinol does not prevent the frequency or the severity of post-ERCP pancreatitis.

BACKGROUND: Pancreatitis is the most common major complication of ERCP. Efforts have been made to identify pharmacologic agents capable of reducing its incidence and severity. The aim of this trial was to determine whether prophylactic allopurinol, an inhibitor of oxygen-derived free radical production, would reduce the frequency and severity of post-ERCP pancreatitis. Methods A total of 701 patients were randomized to receive either allopurinol or placebo 4 hours and 1 hour before ERCP. A database was prospectively collected by a defined protocol on patients who underwent ERCP. Standardized criteria were used to diagnose and grade the severity of postprocedure pancreatitis. RESULTS: The groups were similar with regard to patient demographics and to patient and procedure risk factors for pancreatitis. The overall incidence of pancreatitis was 12.55%. It occurred in 46 of 355 patients in the allopurinol group (12.96%) and in 42 of 346 patients in the control group (12.14%; p = 0.52). The pancreatitis was graded mild in 7.89%, moderate in 4.51%, and severe in 0.56% of the allopurinol group, and mild in 6.94%, moderate in 4.62%, and severe in 0.58% of the control group. There was no significant difference between the groups in the frequency or the severity of pancreatitis. CONCLUSIONS: Prophylactic oral allopurinol did not reduce the frequency or the severity of post-ERCP pancreatitis.

Administration, Oral↗
PubMedDate not supplied

ERCP in the diagnosis of extrahepatic biliary atresia.

This study assessed the usefulness of ERCP in the diagnosis of biliary atresia. We evaluated 57 infants with prolonged cholestasis with abdominal ultrasound, liver biopsy, and ERCP. Using clinical observations alone, 22 infants were thought to have biliary atresia; whereas 35 children were thought to have neonatal hepatitis. The ERCP was performed with a prototype duodenoscope and was successful in all infants except two with biliary atresia. In 20 infants three types of radiological findings consistent with biliary atresia were seen: type 1, no visualization of biliary tree (35%); type 2, opacification of the distal common duct and gallbladder without visualization of the main hepatic duct (35%); and type 3, opacification of the distal common duct, the gallbladder, and a segment of the main hepatic duct with biliary lakes at the porta hepatis (30%). Twenty-five of 35 infants with suspected neonatal hepatitis were excluded because of a liver biopsy that was diagnostic. In the remaining 10 infants the liver biopsy had some features of extrahepatic biliary atresia and ERCP was performed prior to surgery. A normal extrahepatic biliary tree was obtained in all of them. In conclusion, ERCP permits the visualization of the biliary tree in young infants and is useful in selecting those infants who should be considered for exploratory laparotomy.

Biliary Atresia↗
PubMed1996

Radiation exposure during ERCP: effect of a protective shield.

OBJECTIVES: To measure the radiation exposure to endoscopists, patients, and assistants during diagnostic and therapeutic ERCP and to assess the effect of a protective lead shield. Radiation dose with and without the protective lead shield was mapped in our standard fluoroscopy room. MATERIALS AND METHODS: Twenty patients undergoing ERCP were selected for this study. Radiation exposure of endoscopists with and without a protective shield was monitored by digital dosimeter. Radiation exposure for diagnostic procedures was correlated with that of therapeutic procedures. RESULTS: Endoscopists were exposed to 2.5 mR without the protective shield, but exposure was reduced to an average of 0.27 mR per procedure with the shield. Endoscopists received an average of 1.5 mR per diagnostic ERCP and 3.17 mR per therapeutic ERCP without the shield. When using the protective shield, however, those numbers were reduced to an average of 0.25 mR per diagnostic procedure and 0.28 mR per therapeutic procedure. Radiation exposure to endoscopic assistants, who were not shielded, averaged 0.56 mR per procedure. CONCLUSION: Amount of radiation exposure to occupational personnel during ERCP was related to duration of fluoroscopy and type of procedure. Radiation exposure to endoscopists can be significantly reduced by the use of a protective shield. Medical assistants received less radiation than did endoscopists because the assistant's position was more distant from x-ray sources.

Adult↗
PubMed1997

ERCP: a review of technical competency and workload in a small unit.

BACKGROUND: ERCP is increasingly performed not only in large referral centers but also in smaller units. We sought to analyze the success rates of selective cannulation and intervention using the cumulative sum method and to document the workload in a small unit. METHODS: Indications, results, and interventions performed by one endoscopist were recorded for all patients undergoing ERCP at Dunedin Hospital. Selective cannulation and successful intervention were used as outcome measures and, using the cumulative sum method, compared to a target value of 90%. RESULTS: Over an 8-year period, 532 ERCPs were performed. Overall 91% and 81% of selective cannulation and interventions respectively, were successful. The cumulative sum method plot shows that satisfactory outcomes for selective cannulation were obtained after some 100 to 120 procedures and after some 120 interventions. ERCP was normal in 171 (32%) patients, stones were found in 169 (32%), and strictures in 81 (15%) patients. CONCLUSIONS: The cumulative sum method is a valuable tool to compare individual performance with a nominated target value and to ensure that an acceptable outcome is achieved and maintained. These results show that small units can develop and maintain expertise in ERCP if procedures are performed regularly.

Adolescent↗
PubMed1999

Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP.

BACKGROUND: The least costly management strategy for patients undergoing laparoscopic cholecystectomy is unclear. METHODS: A decision model incorporating cost ratios, test accuracy, complication, and failure rates was used to determine the costs of 4 peri-laparoscopic cholecystectomy strategies: endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography (IOCG), endoscopic ultrasound (EUS), and expectant management. RESULTS: Expert IOCG is least costly for intermediate-risk patients when the risk of stones is between 17% and 34%. If expert EUS is available, 0% to 10% ("low" risk) merits expectant management; 11% to 55% ("intermediate" risk) merits EUS; and greater than 55% ("high" risk) merits ERCP. Thresholds were most sensitive to changes in the risks of symptoms and complications due to retained stones; and to procedural costs, sensitivity, and success rates. Neither IOCG nor EUS appears likely to reduce overall costs unless their accuracy and success rates are greater than 90% and their procedural cost is less than 60% to 70% that of ERCP. When neither are available, ERCP is preferable when the risk of stones is greater than 22%. Thresholds were relatively insensitive to changes in the risk and severity of ERCP-induced pancreatitis. CONCLUSIONS: The least costly strategy for laparoscopic cholecystectomy patients depends primarily on the risk of stones and stone-related symptoms, but procedural costs and operator expertise are also critical.

Cholangiography↗
PubMed1999

Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study.

BACKGROUND: Adequate patient sedation is mandatory for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The short-acting anesthetic propofol offers certain potential advantages for endoscopic procedures, but controlled studies proving its superiority over benzodiazepines for ERCP are lacking. METHODS: During a 6-month period 198 consecutive patients undergoing routine ERCP randomly received either midazolam (n = 98) or propofol (n = 99) for sedation. Vital signs (heart rate, blood pressure, oxygen saturation) were continuously monitored and procedure-related parameters, the recovery time and quality (recovery score) as well as the patient's cooperation and tolerance of the procedure (visual analog scales) were prospectively assessed. RESULTS: Patients receiving propofol or midazolam were well matched with respect to demographic and clinical data, ERCP findings, and the performance of associated procedures. Propofol caused a more rapid onset of sedation than midazolam (p < 0.01). Clinically relevant changes in vital signs were observed at comparable frequencies with temporary oxygen desaturation occurring (< 85 %) in 6 patients in the propofol group and 4 patients receiving midazolam (not significant). However, an episode of apnea had to be managed by mask ventilation via an ambu bag (lasting 8 minutes) in one of the patients receiving propofol sedation. Mean recovery times as well as the recovery scores were significantly shorter with propofol (p < 0. 01). Propofol provided significantly better patient cooperation than midazolam ( p < 0.01), but procedure tolerability was rated the same by both groups of patients (not significant). CONCLUSIONS: Intravenous sedation with propofol for ERCP is (1) more effective than sedation with midazolam, (2) safe under adequate patient monitoring, and (3) associated with a faster postprocedure recovery.

Adult↗
PubMed1999

Outpatient therapeutic ERCP with endobiliary stent placement for malignant common bile duct obstruction.

BACKGROUND: Since 1996 patients in stable condition who need therapeutic endoscopic retrograde cholangiopancreatography (ERCP) at our institution have been treated as outpatients whenever possible. We reviewed our institution's experience and compared outpatient versus inpatient therapeutic ERCP for endobiliary stent placement in the care of patients with malignant common bile duct obstruction. METHODS: A retrospective review of all therapeutic ERCPs for the palliation of malignant common bile duct obstruction with endobiliary stents was performed from March 1, 1996, through December 1, 1997. RESULTS: One hundred nine therapeutic ERCPs were performed on 84 patients to place a polyethylene endobiliary stent for malignant common bile duct obstruction. Forty-three procedures were performed on 31 outpatients, 66 on 53 inpatients. There was no significant difference between outpatient and inpatient groups with regard to age, gender, procedure success rate, complication rate, need for endoscopic sphincterotomy, or whether the procedure was for initial stent placement or stent exchange. Inpatients had no procedure-related complications; outpatients had two. There was no procedure-related mortality in either group. CONCLUSION: Therapeutic ERCP for palliation of malignant common bile duct obstruction can be safely and successfully performed on an outpatient basis for selected patients. This should result in better quality of life for these patients with advanced cancer and substantial cost savings.

Aged↗
PubMed2003

Role of ERCP in the management of predicted mild acute biliary pancreatitis.

OBJECTIVE: The role of endoscopic retrograde cholangiopancreatography (ERCP) in mild acute biliary pancreatitis is controversial. This study examined the results of ERCP in patients with predicted mild disease and analysed biochemical and imaging findings in relation to the occurrence of choledocholithiasis. PATIENTS AND METHODS: There were 172 consecutive patients, admitted between January 1998 and December 2000, with the diagnosis of acute pancreatitis. All patients were investigated using transcutaneous ultrasonography and ERCP if biliary aetiology was suspected. Serum bilirubin and alkaline phosphatase were measured, together with abdominal ultrasonographic findings, as potential predictors for choledocholithiasis. RESULTS: Biliary calculus was the aetiology in 62.8% of patients (108/172). Among these 108 patients, 79.6% (86/108) suffered from mild disease. There were only 80 patients who underwent ERCP, and the incidence of choledocholithiasis was 45% (36/80). Although significant correlation was shown between all three measured parameters (bilirubin, alkaline phosphatase and ultrasonographic abnormalities) and choledocholithiasis, their individual sensitivities, specificities and predictive values were low. Nonetheless, if all three tests were normal, the incidence of ductal stones was significantly lower than that in cases with abnormalities in any one of these parameters (4.8% vs 59.3%). CONCLUSION: Routine ERCP is not recommended for patients with mild, acute biliary pancreatitis when there is no biochemical derangement or ultrasonographic evidence of a dilated biliary system.

Acute Disease↗
PubMed2004

Prophylaxis of ERCP-related pancreatitis: a randomized, controlled trial of somatostatin and gabexate mesylate.

BACKGROUND & AIMS: It still is debated whether post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis can be prevented by administering either somatostatin or gabexate mesylate. The aim of the study is to assess the efficacy of a 6.5-hour infusion of somatostatin or gabexate mesylate in preventing ERCP-related complications. METHODS: In a double-blind multicenter trial, 1127 patients undergoing ERCP were randomly assigned to intravenous administration of somatostatin (750 microg; n = 351), gabexate mesylate (500 mg; n = 381), or placebo (saline; n = 395). The drug infusion started 30 minutes before and continued for 6 hours after endoscopy. Patients were evaluated clinically, and serum amylase levels were determined at 4, 24, and 48 hours after endoscopy. RESULTS: No significant differences in incidences of pancreatitis, hyperamylasemia, or abdominal pain were observed among the placebo (4.8%, 32.6%, and 5.3%, respectively), somatostatin (6.3%, 26.8%, and 5.1%, respectively), and gabexate mesylate groups (5.8%, 31.5%, and 6.3%, respectively). Univariate analysis of patient characteristics and endoscopic maneuvers showed that a Freeman score >1 (P < 0.0001), >/=3 pancreatic injections (P < 0.00001), and precut sphincterotomy (P = 0.01) were significantly associated with post-ERCP pancreatitis. At multiple logistic regression analysis, >/=3 pancreatic injections (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.45-2.63) and a Freeman score >1 (OR, 1.47; 95% CI, 1.11-1.94) retained their predictive power. CONCLUSIONS: Long-term (6.5-hr) administration of either somatostatin or gabexate mesylate is ineffective for the prevention of post-ERCP pancreatitis. Pancreatic injury seems to be related to difficulty in common bile duct access.

Aged↗
PubMed1999

ERCP and stent therapy for progressive jaundice in hepatocellular carcinoma: which patients benefit, which patients don't?

Jaundice in hepatocellular carcinoma (HCC) can be due to biliary obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) can be both diagnostic and therapeutic. Biliary stenting can relieve jaundice and allow further chemotherapy, but at additional expense and potential morbidity. We sought to determine whether CT scan or ultrasound (US) could identify which patients with HCC and jaundice would benefit from endoscopic stenting. We retrospectively analyzed 26 patients with HCC and jaundice who underwent ERCP after CT or US. We compared biliary dilation on CT or US with the dominant biliary stricture seen on ERCP, and with response to biliary stenting. Eleven of 26 patients had dominant biliary stricture on ERCP; 11 underwent stenting. Six of 11 (55%) stented patients had a significant decline in bilirubin; three became eligible for further chemotherapy. All six responders to stenting had biliary dilation on prior CT or US. Procedure-related complications occurred in 1/11 (9%) who underwent stent placement. In conclusion, in selected patients, stenting can safely relieve jaundice and allow subsequent chemotherapy. CT or US accurately predicted lesions that responded to stenting. ERCP and stenting provided no benefit in the absence of biliary dilation on CT or US.

Adult↗
PubMed1999

Review article: antibiotic prophylaxis for endoscopic retrograde cholangiopancreatography (ERCP).

This review examines the evidence for antibiotic prophylaxis in endoscopic retrograde cholangiopan-creatography (ERCP), and provides detailed advice about suitable antibiotic regimens in appropriate high-risk patients. Ascending cholangitis and infective endocarditis are potential complications of endoscopic ERCP. The pathophysiology of these two complications is quite separate and different sub-groups of patients require prophylaxis with appropriate antibiotic regimens. Ascending cholangitis results from bacterial infection of an obstructed biliary system, usually from enteric Gram-negative microorganisms, resulting in bacteraemia. There is incomplete drainage of the biliary system after ERCP in up to 10% of patients who require stenting. Antibiotics started in these patients will probably reduce the frequency of cholangitis by 80%. If antibiotics are restricted to this group, approximately 90% of all patients having an ERCP will avoid antibiotics, but 80% of cholangitic episodes will be prevented. Infective endocarditis may result from the bacteraemia caused at the time of the ERCP in patients with an abnormal heart valve. Antibiotic prophylaxis, in particular covering alpha-haemolytic streptococci, should be started before the procedure in this defined high-risk group.

Antibiotic Prophylaxis↗
PubMed2001

Octreotide 24-h prophylaxis in patients at high risk for post-ERCP pancreatitis: results of a multicenter, randomized, controlled trial.

BACKGROUND: Pharmacological prophylaxis of post-ERCP pancreatitis is costly and not useful in most non-selected patients, in whom the incidence of pancreatitis is 5% or less. However, it could be useful and probably cost-effective, in patients at high risk for this complication, where the post-procedure pancreatitis rate is 10% and more. AIM: To assess the efficacy of octreotide in reducing the incidence and severity of post-ERCP pancreatitis and procedure-related hospital stay, in subjects with known patient-related risk factors. METHODS: A total of 120 patients were randomly allocated to receive octreotide or not, in a multicentre, randomized, controlled trial. The drug was given subcutaneously, 200 microg t.d.s., starting 24 h before the ERCP procedure, in patients with either sphincter of Oddi dysfunction, or a history of relapsing pancreatitis or post-ERCP pancreatitis, or who were aged under 35 years, or who had a small common bile duct diameter (< 8 mm). RESULTS: A total of 114 patients (58 in the octreotide group and 56 in the control group) completed the trial. Post-procedure pancreatitis occurred in seven octreotide-treated patients (12.0%) and eight controls (14.3%). The two groups showed no significant differences in the incidence or severity of pancreatitis. Twenty-four hours after the procedure, severe hyperamylasemia (more than five times the upper normal limit) without pancreatic-like pain was recorded in three octreotide-treated patients (5.2%) and six controls (10.7%), the difference being not significant. CONCLUSION: Twenty-four-hour prophylaxis with octreotide proved ineffective in preventing post-ERCP pancreatitis and in avoiding 24-h severe hyperamylasemia in high-risk patients.

Adult↗
PubMed2000

Improved sedation in diagnostic and therapeutic ERCP: propofol is an alternative to midazolam.

BACKGROUND AND STUDY AIMS: Adequate sedation of the patient is required for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The anesthetic propofol, with its shorter half-life, affording better control, offers an alternative to the benzodiazepine midazolam. The aim of this randomized, controlled, unblinded study was to compare prospectively the quality of sedation under propofol and midazolam in patients undergoing ERCP. PATIENTS AND METHODS: A total of 80 patients were randomized to sedation with propofol alone (n = 40) or midazolam alone (n = 40). Blood pressure, pulse, and oxygen saturation were measured. Midazolam was given by the endoscopist and titrated to the patients' response during ERCP, to a maximum dose of 15 mg per patient. In the propofol group an anesthetist was present to administer the propofol and to observe the patient. Standardized testing procedures (Steward score, Trieger test) were used to determine the length of postendoscopy recovery time. Efficacy of sedation was assessed by investigators and patients, using scoring systems. RESULTS: Complete ERCP and adequate sedation was possible in 80% of patients (32 out of 40) with midazolam, and in 97.5% of patients (39 out of 40) with propofol (P<0.01). The average propofol induction dose was 1.24 mg/kg body weight, with maintenance requiring a mean dose of 9 mg/kg body weight per hour, or the equivalent of 354 mg in total. The average dose of midazolam administered was 0.12 mg/kg body weight; the total dose averaged 8 mg. Recovery time in the propofol patients was significantly shorter (P<0.01). The investigators (P<0.01) and the patients (P<0.05) both judged the quality of sedation to be better in the propofol group. There were no differences in blood pressure, pulse, or oxygen saturation between the two groups. One patient in the propofol group (79 years old) suffered a protracted apneic phase accompanied by hypotension that was managed by manual ventilation and drug therapy, and led to no complications. CONCLUSIONS: Propofol proves to be an excellent sedative for ERCP and shows a shorter recovery time than midazolam. Because of the narrow therapeutic window, we recommend close patient monitoring.

Anesthesia Recovery Period↗
PubMed2002

Endoscopic examination with the duodenoscope at ERCP: frequency of lesions and accuracy of detection.

BACKGROUND: Little is known about the yield and accuracy of endoscopic examination with the duodenoscope after ERCP, and there appears to be no uniform standard of practice for endoscopic examination in this setting. METHODS: Over a 1-year period, all patients undergoing ERCP also underwent endoscopic examination of the duodenum, stomach, and esophagus with the duodenoscope upon completion of ERCP. Patients were then placed in the left lateral decubitus position and upper endoscopy was performed with a standard forward-viewing endoscope. The same investigator performed both endoscopic examinations. Patients were queried about prior ulcer disease, upper GI symptoms, and use of antisecretory medication as well as nonsteroidal anti-inflammatory drugs. RESULTS: During the 12-month study, 368 patients (mean age 53 years) underwent 474 procedures. The most frequent indication for ERCP was suspected choledocholithiasis (24%). Endoscopic examination was normal in 42% of patients, and the most frequent endoscopic finding was hiatal hernia (132 patients, 36%). The lesions most frequently missed with the duodenoscope were trauma at the upper esophageal sphincter (12 patients) and small benign gastric polyps (3 patients). Examination with the duodenoscope was superior to the forward-viewing endoscope for identification of Schatzki's ring. No carcinoma, gastric varices, or severe esophagitis were missed with the duodenoscope. CONCLUSIONS: Given the frequency of endoscopic lesions, a yield of positive findings similar to that obtained with the forward-viewing endoscope, and the ease of performing endoscopy with the duodenoscope, endoscopic examination of the esophagus, stomach, and duodenum with the duodenoscope should become standard practice after ERCP.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2002

Complications of endoscopic sphincterotomy: can heparin prevent acute pancreatitis after ERCP?

BACKGROUND: An exploratory analysis of a prospective study of risk factors for acute pancreatitis after ERCP combined with endoscopic sphincterotomy showed that the frequency of acute pancreatitis was lower in patients who received heparin compared with patients not treated with heparin. The study was continued to further analyze the effect of heparin on the frequency of acute pancreatitis. METHODS: Potential risk factors for acute pancreatitis and outcomes were evaluated prospectively for all ERCP procedures with endoscopic sphincterotomy performed between September 1994 and December 1998. The results were analyzed by univariate and multivariate methods to determine risk factors for complications. Heparin was administered to 32.9% of the patients (heparin group [HEP group], n = 268) for various clinical reasons (low-molecular-weight heparin, n = 208, unfractionated heparin n = 60). A group of 547 patients who did not receive heparin served as control patients (CON group). RESULTS: Eight hundred fifteen patients underwent ERCP with endoscopic sphincterotomy; acute pancreatitis occurred in 6.4% (n = 52). The frequency of acute pancreatitis was significantly lower in the HEP group versus the CON group in the final multivariate model, which included significant risk factors for acute pancreatitis (HEP group: 3.4%, 9/268 vs. CON group: 7.9%, 43/547; p = 0.005). HEP did not increase the risk of hemorrhage (HEP group: 1.1%, 3/268, 2 severe, none fatal vs. CON group: 2.0%, 11/547, 3 severe, 2 fatal). HEP (p = 0.005; OR 0.3: 95% CI [0.16, 0.73]) and the number of risk factors present (p = 0.0001; OR 2.5: 95% CI [1.80, 3.50]) influenced the frequency of acute pancreatitis independently. CONCLUSIONS: Heparin was significantly associated with an extremely low frequency of post-ERCP pancreatitis without increasing the risk of hemorrhage after endoscopic sphincterotomy. Because this effect could not be attributed to other known or suspected confounders, our conclusion was that heparin administration before ERCP reduces the risk of pancreatitis.

Acute Disease↗
PubMed2003

Does prophylactic administration of corticosteroid reduce the risk and severity of post-ERCP pancreatitis: a randomized, prospective, multicenter study.

BACKGROUND: Pancreatitis is the most common major complication of diagnostic and therapeutic ERCP. There have been continuing efforts to identify a pharmacologic agent capable of reducing the frequency and severity of this complication. On the basis of several case reports, experimental data, and knowledge of their mechanism of action, corticosteroids might be effective in this regard. The aim of this randomized, double-blind, controlled trial was to determine whether prophylactic, orally administered corticosteroid reduces the frequency and/or severity of post-ERCP pancreatitis. METHODS: A total of 1115 patients were randomized to receive either prednisone (40 mg) or a placebo orally 15 hours and 3 hours before ERCP. A 160 variable database was prospectively collected according to a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group. Standardized criteria were used to diagnose and grade the severity of postprocedure pancreatitis. RESULTS: The overall frequency of pancreatitis was 15.07%. It occurred in 92 of 555 patients in the corticosteroid group (16.6%), and in 76 of 560 patients in the control group (13.6%; p = 0.19). The pancreatitis was mild in 10.04%, moderate in 4.04%, and severe in 0.99%. There was no difference between the groups with regard to the severity of pancreatitis. Moreover, the groups were similar with regard to age, gender, body mass index, frequency of prior pancreatitis, type of procedure performed (diagnostic or therapeutic), difficulty of cannulation, frequency of pre-cut sphincterotomy, pancreatic sphincterotomy, sphincter of Oddi dysfunction, sphincter of Oddi manometry, pancreatic acinarization, chronic pancreatitis, number of pancreatic duct injections, and bile duct diameter. CONCLUSION: Prophylactic orally administered corticosteroid did not reduce the frequency or severity of post-ERCP pancreatitis.

Administration, Oral↗
PubMed2003

ERCP in patients 90 years of age and older.

BACKGROUND: Biliary diseases represent particular diagnostic and therapeutic problems in elderly patients. METHODS: Patients 90 years of age or older who underwent ERCP from January 1993 to September 2001 were studied retrospectively. RESULTS: A total of 126 patients underwent 147 ERCP procedures (range 1-5 per patient). Twelve additional ERCPs were performed in 9 of the patients during follow-up because of recurrent symptoms. A total of 159 procedures were, therefore, available for analysis. The most frequent indications were suspicion of bile duct stones (46.8%) and obstructive jaundice (35.7%). Midazolam (95.6%) was used for conscious sedation and hyoscine (74.8%) for duodenal ileus. Patient tolerance of the procedure was good in 92.4% of sessions. Diagnoses included bile duct stones (54%), bile duct dilatation without any apparent obstruction (11.9%), and malignant stenosis (9.5%). Therapeutic procedures were indicated in 95.6% of diagnosed patients and completed in 96.3% of cases. Complications occurred in association with 2.5% of the ERCP procedures; the procedure-related mortality rate was 0.7%. CONCLUSIONS: ERCP in elderly patients is practicable. The complication rate is low, and therapeutic efficacy is good.

Adjuvants, Anesthesia↗