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PubMed2002

ERCP, biliary crystal analysis, and sphincter of Oddi manometry in idiopathic recurrent pancreatitis.

BACKGROUND: This study investigated the role of ERCP, analysis of bile for microcrystals, and sphincter of Oddi manometry in idiopathic recurrent pancreatitis. METHODS: One hundred twenty-six patients met criteria for idiopathic recurrent pancreatitis. Patients with a normal ERCP underwent sphincter of Oddi manometry and analysis of bile. Bile was also collected in patients with papillary stenosis (defined as ductal dilation with delayed drainage of contrast, sphincter basal pressures greater than 40 mm Hg, and positive analysis for cholesterol and/or calcium bilirubinate crystals). RESULTS: ERCP alone identified a cause of idiopathic recurrent pancreatitis in 47 (37%) patients: papillary stenosis in 26 (21%), pancreas divisum in 9 (7%), and choledocholithiasis in 6 (5%). Among patients with a gallbladder, microcrystals were found in 27 (50%) and sphincter dysfunction in 17 (31%). Among patients who have undergone cholecystectomy, sphincter dysfunction was identified in 24 (47%). Minor papilla sphincterotomy was performed in 8 patients (89%) with pancreas divisum. Biliary sphincterotomy was performed in 85 patients and included all patients with choledocholithiasis, choledochocele, microcrystals, papillary stenosis, and sphincter dysfunction except 2 patients with microcrystals who underwent cholecystectomy. Additionally, pancreatic sphincterotomy was performed in 32 (78%) patients with pancreatic sphincter hypertension and in 6 (23%) of 26 patients with papillary stenosis with dilated pancreatic ducts. Thus, among the 126 patients, 93 of the 100 patients with a detected abnormality underwent endoscopic sphincterotomy. Response rates varied from 67% to 100% during follow-up (mean 29.6 months, range 18 to 33 months). CONCLUSION: ERCP techniques including minor papilla cannulation, analysis of bile for microcrystals, and sphincter of Oddi manometry identified a cause of idiopathic recurrent pancreatitis in 79% (endoscopically treatable in 75%) of patients, with or without prior cholecystectomy.

Adolescent↗
PubMed2002

Differential diagnosis of benign versus malignant nonfunctioning islet cell tumors of the pancreas: the roles of EUS and ERCP.

BACKGROUND: Differentiation between benign and malignant nonfunctioning islet cell tumors of the pancreas before surgery is often difficult. The roles of EUS and ERCP were evaluated in the differential diagnosis of these tumors. METHODS: Seven patients with histologically confirmed nonfunctioning islet cell tumors (4 benign, 3 malignant) underwent EUS and ERCP. OBSERVATIONS: EUS demonstrated a homogeneous hypoechoic mass or a hypoechoic mass with a regular central echogenic area in the 4 cases of benign tumor, and a hypoechoic mass with an irregular central echogenic area in all 3 cases of malignant tumor. The irregular central echogenic area corresponded to severe hemorrhage, necrosis, or fibrosis with hyalinosis (hyaline degeneration) on pathologic examination. ERCP demonstrated displacement or complete obstruction (because of ductal invasion) of the main pancreatic duct in 2 patients with malignant tumors and no abnormalities in the other 5 cases. CONCLUSIONS: In patients with nonfunctioning islet cell tumors, a hypoechoic mass with an irregular central echogenic area on EUS or complete obstruction of the main pancreatic duct on ERCP suggests malignancy.

Adenoma, Islet Cell↗
PubMed2003

Bile duct dilation with chronic methadone use in asymptomatic patients: ERCP findings in 6 patients.

BACKGROUND: Bile duct dilation in patients being treated by chronic narcotic substitution with methadone has been described but has not been systematically evaluated with ERCP. Retrograde cholangiographic findings in 6 patients taking methadone who were referred for evaluation of a dilated bile duct are described. METHODS: Six patients with chronic hepatitis (5 because of hepatitis C virus, 1 hepatitis B virus) who were taking methadone were evaluated by ERCP because of biliary dilation. Data were obtained regarding surgery, abdominal pain, weight loss, excessive ingestion of alcohol, liver disease, pancreatitis, and the dose and duration of methadone treatment. OBSERVATIONS: ERCP revealed bile duct dilation without evidence of choledocholithiasis, stricture, or obstructing mass. There was one complication (postprocedure pain thought to be due to methadone withdrawal). CONCLUSIONS: Chronic methadone use can lead to bile duct dilation without evidence of other significant pathology in asymptomatic patients. EUS may be safer than ERCP for evaluation of these patients, given that a need for therapeutic biliary intervention is unlikely.

Bile Duct Diseases↗
PubMed2003

ERCP in the diagnosis and management of complications after surgery for hepatic echinococcosis.

BACKGROUND: Surgery for liver hydatidosis can result in serious morbidity and mortality. The role and efficacy of ERCP in the management of these complications was reviewed. METHODS: Retrospective analysis of 79 patients with liver hydatidosis who underwent ERCP for postoperative complications. RESULTS: All patients with biliary fistulas (n = 50) were managed by endoscopic sphincterotomy, although 9 (18%) also required a biliary endoprosthesis. Surgical reintervention was avoided in 46 (92%) patients with subsequent surgery required in only in 4 (8%). The mean time to fistula closure was 13.3 days. Patients with daughter cysts in the bile ducts (n = 7) were also treated by endoscopic sphincterotomy and evacuation of obstructing cyst material. Seven patients with elevated liver enzymes or biliopancreatic symptoms but normal ERCP findings also underwent endoscopic sphincterotomy with normalization of biochemical tests. CONCLUSIONS: ERCP is valuable for detecting and treating postoperative biliary complications after surgery for hepatic echinococcal disease. In the majority of patients, endoscopic sphincterotomy allows healing of postoperative external biliary fistulas, and should be performed as early as possible. In some cases, a biliary prosthesis may be required. Endoscopic sphincterotomy also enables clearing of the bile ducts of hydatid remnants.

Adolescent↗
PubMed2000

Short-acting general anaesthesia facilitates therapeutic ERCP in frail elderly patients with benign extra-hepatic biliary disease.

AIMS AND OBJECTIVES: To ascertain whether therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for benign biliary disease in frail elderly patients with comorbid conditions can be safely undertaken in a district general hospital, and whether the procedure is facilitated by the use of short-acting general anaesthesia. SETTING: District general hospital in South East England. DESIGN OF STUDY: Clinical study of 25 consecutive patients with benign biliary disease. METHODS: Describes the process of bile duct clearance by therapeutic ERCP under short-acting general anaesthesia in 25 patients with co-morbidity aged > or = 80 years and gives details of the general anaesthesia and monitoring. RESULTS: Twenty-two patients had their bile ducts successfully cleared locally and one patient was stented for a benign biliary stricture. The ampullae of two other patients were lying within diverticula, which hindered cannulation and only pancreatograms were obtained; one of the patients had a successful bile duct clearance at a tertiary centre, the other refused further intervention. Complications (melaena, bronchopneumonia and a Clostridium difficile infection) occurred in two patients (8%). There was no morbidity associated with the anaesthesia, and no mortality occurred within 30 days of the procedure. CONCLUSIONS: Bile duct clearance by therapeutic ERCP can be safely carried out in frail elderly patients in a district general hospital and the process is facilitated by the use of short-acting general anaesthesia. The importance of optimizing the patient's condition before ERCP, and not overfilling the pancreatic duct, is highlighted.

Aged↗
PubMed1993

The role of ERCP and endoscopic sphincterotomy in the era of laparoscopic cholecystectomy.

The advent of laparoscopic cholecystectomy (LC) has led to some controversy regarding the best method of managing bile duct calculi. This paper reviews the cases of 38 patients who underwent LC and endoscopic retrograde cholangiopancreatography (ERCP), from a series of 600 consecutive laparoscopic cholecystectomies. Twenty-nine patients had ERCP performed pre-operatively because of suspicion of choledocholithiasis. Duct stones were confirmed in eight patients. Recent or current jaundice was the best predictor of bile duct stones. Nine patients had ERCP done postoperatively because of duct stones seen on operative cholangiography. In two patients bile duct cannulation was not possible and a third procedure, open duct exploration, was necessary. Techniques in laparoscopic management of duct stones are improving and the role of ERCP and sphincterotomy should be limited to jaundiced patients or those with proven bile duct stones in whom laparoscopic procedures have been unsuccessful.

Adult↗
PubMed1999

Use of corticosteriods in the prevention of post-ERCP pancreatitis: results of a controlled prospective study.

OBJECTIVE: The aim of this prospective controlled study was to determine whether prophylactic corticosteroids decrease the incidence of post-ERCP pancreatitis. METHODS: A double-blind comparison of hydrocortisone (100 mg by i.v. infusion immediately before endoscopy) with placebo (sodium chloride administered in the same fashion). A total of 535 patients (286 women and 249 men, with an average age of 58.6 yr) who were scheduled to undergo diagnostic or operative ERCP underwent randomization. Six patients were excluded from the final evaluation for various reasons. The remaining 529 patients, 263 in the hydrocortisone group and 266 in the placebo group, were analyzed. Patients were divided into subgroups with regard to high risk factors for acute pancreatitis after ERCP. RESULTS: The overall incidence of acute pancreatitis was 5.3% (28 of 529 patients). Procedure-induced pancreatitis occurred in 15 of 263 (5.7%) patients treated with hydrocortisone and in 13 of 266 (4.9%) patients treated with placebo (p = NS). The results of analysis of risk factors for pancreatitis did not evidence any significant difference between the hydrocortisone group and the placebo group. CONCLUSIONS: Hydrocortisone does not prevent acute pancreatitis after diagnostic or therapeutic ERCP.

Acute Disease↗
PubMed2002

Comparison between magnetic resonance cholangiopancreatography and ERCP for evaluation of the pancreatic duct.

OBJECTIVE: To date, ERCP has been the reference technique in the diagnosis of pancreatic duct pathology. The aim of the present study was to evaluate the accuracy of magnetic resonance cholangiopancreatography (MRCP), a relatively new, noninvasive diagnostic method, in studying the pancreatic duct. METHODS: A prospective 15-month study was done of 78 patients with suspected biliopancreatic pathology and indications for ERCP. In all cases, MRCP was performed <72 h before ERCP. Both techniques were used to assess the size of the pancreatic tract (normal or dilated), the presence or absence of obstruction, the level of obstruction where present, and its etiology. RESULTS: Both techniques found the pancreatic tract to be normal and nondilated in 60 patients. The specificity and sensitivity of MRCP in evaluating the normal pancreatic duct were 98% and 94%, respectively. In nine cases, a stenotic duct of Wirsung was detected (seven at the head of the pancreas and two in the body), with the same correlation being shown by ERCP (sensitivity 100%). The sensitivity and specificity of MRCP relating to diffuse irregular and dilated morphologies of the entire pancreatic duct was 86% and 100%, respectively. Nine patients were diagnosed with pancreatic neoplasms by both techniques, with an accuracy of 100%. Four patients presented chronic pancreatitis, which was correctly diagnosed by MRCP in each case. CONCLUSIONS: MRCP is an effective technique for evaluating both the normal and diseased duct of Wirsung, and for establishing the underlying pathology.

Adult↗
PubMed2003

Safety of ERCP during pregnancy.

OBJECTIVES: There are few data in the literature regarding the indications, therapy, and safety of endoscopic management of pancreatico-biliary disorders during pregnancy. We report the largest single center experience with ERCP in pregnancy. METHODS: We reviewed 15 patients that underwent ERCP during pregnancy. In all patients, the pelvis was lead-shielded and the fetus was monitored by an obstetrician. Fluoroscopy was minimized and hard copy radiographs taken only when essential. RESULTS: The mean patient age was 28.9 yr (15-36 yr). The mean duration of gestation was 25 wk (12-33 wk); one patient was in the first, five in the second, and nine in the third trimester. The indications were gallstone pancreatitis (n = 6), choledocholithiasis on ultrasound (n = 5), elevated liver enzymes and a dilated bile duct on ultrasound (n = 2), abdominal pain and gallstones (n = 1), and chronic pancreatitis (n = 1). ERCP findings were bile duct stones (n = 6), patulous papilla (n = 1), bile duct debris (n = 1), normal bile duct and gallstones or gallbladder sludge (n = 3), dilated bile duct and gallstones (n = 1), normal bile duct and no gallstones (n = 2), and chronic pancreatitis (n = 1). Six patients underwent sphincterotomies and one a biliary stent insertion. One sphincterotomy was complicated by mild pancreatitis. All infants delivered to date have had Apgar-scores >8, and continuing pregnancies are uneventful. Mean fluorosocopy time was 3.2 min (SD +/- 1.8). An estimated fetal radiation exposure was 310 mrad (SD +/- 164) which is substantially below the accepted teratogenic dose. CONCLUSIONS: ERCP in pregnancy seems to be safe for both mother and fetus; however, it should be restricted to therapeutic indications with additional intraprocedure safety measures.

Adult↗
PubMed2003

Comparison of two dosing regimens of gabexate in the prophylaxis of post-ERCP pancreatitis.

OBJECTIVES: A continuous 13-h infusion of gabexate starting 30-90 min before endoscopic cholangiopancreatography (ERCP) can reduce postprocedural pancreatitis, the onset of which is generally observed within the first 6 h after ERCP. This study was designed to verify whether a 6.5-h infusion of gabexate was as effective as a 13-h infusion, at the same concentration, for reducing the incidence of post-ERCP pancreatitis (primary endpoint) and pancreatic hyperenzymemia and pain (secondary endpoints). METHODS: A total of 434 patients (201 male and 233 female; mean age 63.9 yr, range 18-96 yr) scheduled for ERCP were prospectively recruited in 25 Italian centers. Patients were randomized double-blind to two treatment groups. All subjects enrolled were first treated with a 500-mg continuous intravenous infusion of gabexate, starting 30 min before the endoscopic maneuvers and continuing up to 6.5 h after it. Over the next 6.5 h, 214 patients (group I) continued the infusion of gabexate (for a total of 1 g over 13 h) and 220 patients (group II) were given placebo (saline solution). RESULTS: The overall incidence of acute pancreatitis was 1.8% (eight patients), which included 1.4% in group I (three of 214 patients) and 2.2% in group II (five of 220 patients). Serum amylase and lipase values over time, peak levels of the two enzymes, pancreatic pain, and need for analgesics did not significantly differ in the two groups. CONCLUSIONS: These results suggest that a 6.5-h infusion of gabexate (for a total of 500 mg) is not less effective than a 13 h infusion, with evident savings.

Acute Disease↗
PubMed2005

Sedation with propofol for routine ERCP in high-risk octogenarians: a randomized, controlled study.

OBJECTIVES: Adequate patient sedation is mandatory for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). In this respect it is known that the short-acting anesthetic propofol offers certain potential advantages for sedation during ERCP, but there are no controlled studies concerning the feasibility and safety of propofol sedation in elderly, high-risk patients. METHODS: One hundred and fifty consecutive patients aged >or=80 yr with high comorbidity (ASA score >or=III: 91 %), randomly received midazolam plus meperidine (n = 75) or propofol alone (n = 75) for sedation during ERCP. Vital signs were continuously monitored and procedure-related parameters, recovery time, and quality as well as patients' cooperation and tolerance of the procedure were assessed. RESULTS: Clinically relevant changes in vital signs were observed at comparable frequencies with a temporary oxygen desaturation (<90%) occurring in eight patients in the propofol-group and seven patients receiving midazolam/meperidine (n.s.). Hypotension was documented in two patients in the propofol group and one patient receiving midazolam/meperidine. Propofol provided a significantly better patient cooperation than midazolam/meperidine (p < 0.01), but the procedure tolerability was rated nearly the same by both groups. Mean recovery time was significantly shorter in the propofol group (22 +/- 7 min vs 31 +/- 8 min for midazolam/meperidine (p < 0.01)) while the recovery score was significantly higher under propofol (8.3 +/- 1.2 vs 6.1 +/- 1.1(p < 0.01)). During recovery a significant lower number of desaturation events (<90%) were observed in the propofol group (12%) than in the midazolam/meperidine group (26%, p < 0.01). CONCLUSION: Under careful monitoring the use of propofol for sedation during ERCP is superior to midazolam/meperidine even in high-risk octogenarians.

Aged↗
PubMed1996

MR cholangiopancreatography after unsuccessful or incomplete ERCP.

PURPOSE: To assess the value of magnetic resonance (MR) cholangiopancreatography in patients in whom endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessful or did not completely delineate ductal abnormalities. MATERIALS AND METHODS: MR cholangiopancreatography was performed in 37 consecutive patients because ERCP was unsuccessful (n = 20), postsurgical biliary-enteric anatomy was present (n = 10), or evidence of complete pancreatic duct obstruction was found ar ERCP (n = 7). RESULTS: MR cholangiopancreatography was successful in all patients. Eleven patients had normal MR findings and required no further intervention. Eight patients has abnormalities that were detected with MR but were followed up clinically. Eleven patients subsequently underwent laparotomy, three underwent therapeutic percutaneous transhepatic cholangiography (PTC), two underwent diagnostic (PTC), and one underwent ultrasound-guided biopsy. CONCLUSIONS: MR cholangiopancreatography plays an important role in the care of patients in whom ERCP is unsuccessful or incomplete and when technical difficulties can be anticipated.

Bile Duct Diseases↗
PubMed2000

Preoperative ERCP approach to common bile duct stones: results of a selective policy.

BACKGROUND: In a previous study, we made a plea for more selective indications for preoperative ERCP in patients with gallstones based on the results obtained from a liberal policy. Following 3.5 years of implementing this selective policy, a report on the results are presented here. This study was performed in a referral academic hospital. METHODS: Between June 1994 and December 1997, 328 patients underwent cholecystectomy because of symptomatic cholelithiasis. Absolute indications for preoperative ERCP were: acute cholangitis (4 patients); obstructive jaundice (22 patients); gallstone pancreatitis (within the first 24 h in 14 patients), and wide common bile duct (CBD, >8 mm) with suspicion of stones in the biliary tree (2 patients). RESULTS: In 42 patients (12.8%) a preoperative ERCP was performed for these indications. Stones were found in the CBD in 30 patients and edema in the papilla in 2 patients (total 76.2%). The stones could be extracted by endoscopic sphincterotomy in 24 of the 30 patients (80%). Complications were seen in 7 patients (16.7%). All these complications (bleeding of the papilla in 4 and mild pancreatitis in 3 patients) could be treated conservatively. During a mean follow-up of 2.5 years, CBD stones could be demonstrated postoperatively in 3 patients (0.3%). No mortality was observed in this series. CONCLUSIONS: The results of this selective policy included the expected outcome of a significant reduction in the number of ERCPs performed from 29 to 12.8% (p < 0.001, chi(2) test) and a better yield of stones, from 29 to 76.2% of the patients. The mortality of the procedure decreased from 2 to 0% whereas morbidity remained the same. This selective policy seems adequate for the preoperative assessment of CBD stones.

Adolescent↗
PubMed2006

MRCP compared to diagnostic ERCP for diagnosis when biliary obstruction is suspected: a systematic review.

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is an alternative to diagnostic endoscopic retrograde cholangiopancreatography (ERCP) for investigating biliary obstruction. The use of MRCP, a non-invasive procedure, may prevent the use of unnecessary invasive procedures. The aim of the study was to compare the findings of MRCP with those of ERCP by the computation of accuracy statistics. METHODS: Thirteen electronic bibliographic databases, covering biomedical, science, health economics and grey literature were searched. A systematic review of studies comparing MRCP to diagnostic ERCP in patients with suspected biliary obstruction was conducted. Sensitivity, specificity, likelihood ratios, acceptability and adverse events were reported. RESULTS: 25 studies were identified reporting several conditions including choledocholithiasis (18 studies), malignancy (four studies), obstruction (three studies), stricture (two studies) and dilatation (five studies). Three of the 18 studies reporting choledocholithiasis were excluded from the analysis due to lack of data, or differences in study design. The sensitivity for the 15 studies of choledocholithiasis ranged from 0.50 to 1.00 while specificity ranged from 0.83 to 1.00. The positive likelihood ratio ranged: from 5.44-47.72 and the negative likelihood ratio for the 15 studies ranged from 0.00-0.51. Significant heterogeneity was found across the 15 studies so the sensitivities and specificities were summarised by a Receiver Operating Characteristic (ROC) curve. For malignancy, sensitivity ranged from 0.81 to 0.94 and specificity from 0.92 to 1.00. Positive likelihood ratios ranged from 10.12 to 43 and negative likelihood ratios ranged from 0.15 to 0.21, although these estimates were less reliable. CONCLUSION: MRCP is a comparable diagnostic investigation in comparison to ERCP for diagnosing biliary obstruction.

Journal Article↗
PubMed1997

Endoscopic retrograde cholangiopancreatography (ERCP) in biliary tract disease of infants less than one year old.

We performed a total of 75 examinations with endoscopic retrograde chlangiopancreatography (ERCP) in 73 infants aged from 8 days to 300 days (mean 71 days) between 1977 and 1995. ERCP examination was performed with a prototype duodenoscope and was successful in 47 of 52 examinations in biliary atresia, 9 of 11 in neonatal hepatitis, all 4 in paucity of intra-hepatic bile duct, 4 of 5 in congenital biliary dilatation, 1 of 2 in duodenal stricture, and 1 case of in postoperative jaundice of hepatoblastoma. In 46 infants with biliary atresia, excluding one in whom the findings could not be evaluated due to poor x-ray image quality, we distinguished the following four patterns of ERCP findings: Pattern 1, only the pancreatic duct could be demonstrated and no bile duct was visualized (76%); Pattern 2, only a part of the distal common bile duct with the pancreatic duct was visualized (2%); Pattern 3, the entire length of the common bile duct with the pancreatic duct was visualized without the gallbladder and the common hepatic duct (4%); and Pattern 4, the common bile duct and the gallbladder with the pancreatic duct were visualized without the common hepatic duct (18%). In all of these 46 patients, laparotomy, an operative cholangiogram, and histological evaluation of the biliary duct were performed. In 9 neonates with neonatal hepatitis, the biliary tract was opacified and biliary atresia was excluded. Laparotomy was thus avoided in these neonates. There was no complication caused by either ERCP or by anesthesia.

Anesthesia↗
PubMed1979

Ampicillin concentrations in pancreatic fluid bile obtained at endoscopic retrograde cholangiopancreatography (ERCP).

To investigate the distribution of ampicillin to the pancreas, ampicillin concentrations in pancreatic fluid obtained at endoscopic retrograde cholangiopancreatography (ERCP) were determined. Alternatively, ampicillin concentrations in bile obtained via ERCP were determined. Ten subjects with non-acute biliary-tract or pancreatic disease received a single dose of ampicillin (250 or 500 mg) parentally before ERCP. Timed simultaneous specimens of blood and pancreatic fluid or bile were obtained. Serum concentrations of ampicillin were measured in all subjects. In six of seven subjects no ampicillin was detectable in pancreatic fluid; in the seventh less than 1 microgram/ml was found. Pancreatic duct anatomy did not appear to correlate with pancreatic fluid concentrations. Failure to detect ampicillin in pancreatic fluid may account for results of clinical studies in which no clinical benefit from ampicillin has been found. Low or undetectable concentrations of ampicillin were found in bile; these concentrations in bile obtained at ERCP are similar to those found previously in bile recovered at biliary-tract surgery.

Adult↗
PubMed2004

Diagnostic role of secretin-enhanced MRCP in patients with unsuccessful ERCP.

AIM: To evaluate the value of MR cholangiopancreatography (MRCP) in patients in whom endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessfully performed by experts in a tertiary center. METHODS: From January 2000 to June 2003, 22 patients fulfilled the inclusion criteria. The indications for ERCP were obstructive jaundice (n = 9), abnormal liver enzymes (n = 8), suspected chronic pancreatitis (n = 2), recurrent acute pancreatitis (n = 2), or suspected pancreatic cancer (n = 1). The reasons for the ERCP failure were the postsurgical anatomy (n = 7), duodenal stenosis (n = 3), duodenal diverticulum (n = 2), and technical failure (n = 10). MRCP images were evaluated before and 5 and 10 min after i.v. administration of 0.5 IU/kg secretin. RESULTS: The MRCP images were diagnosed in all 21 patients. Five patients gave normal MR findings and required no further intervention. MRCP revealed abnormalities (primary sclerosing cholangitis, chronic pancreatitis, cholangitis, cholecystolithiasis or common bile duct dilation) in 10 patients, who were followed up clinically. Four patients subsequently underwent laparotomy (hepaticojejunostomy in consequence of common bile duct stenosis caused by unresectable pancreatic cancer; hepaticotomy+Kehr drainage because of insufficient biliary-enteric anastomosis; choledochojejunostomy, gastrojejunostomy and cysto-Wirsungo gastrostomy because of chronic pancreatitis, or choledochojejunostomy because of common bile duct stenosis caused by chronic pancreatitis). Three patients participated in therapeutic percutaneous transhepatic drainage. The indications were choledocholithiasis with choledochojejunostomy, insufficient biliary-enteric anastomosis, or cholangiocarcinoma. CONCLUSION: MRCP can assist the diagnosis and management of patients in whom ERCP is not possible.

Adult↗
PubMed2003

Antisecretory vs. antiproteasic drugs in the prevention of post-ERCP pancreatitis: the evidence-based medicine derived from a meta-analysis study.

Uncertainties still exist about the clinical benefit of pharmacological prevention of post-ERCP pancreatitis by either antisecretory drugs such as somatostatin and its long-acting analogue octreotide, or protease inhibitors such as gabexate mesilate. Recent, large-scale prospective studies have reported a fourfold reduction in acute pancreatitis as compared to a placebo with the prophylactic administration of either gabexate mesilate or somatostatin, whereas octreotide was found to be ineffective. An initial meta-analysis of all available controlled trials on this topic has confirmed these findings. The indiscriminate use of these drugs in all patients is unlikely to be cost-effective, but the selective use of prophylaxis for high-risk patients might be advocated. Moreover, inasmuch as 85% of complications developed within 4 to 6 hours of completing the ERCP, it would be reasonable to infuse drugs only for this limited length of time. A recent prospective trial, carried out on high-risk patients, has surprisingly documented a higher incidence, although a non-significant one, of pancreatitis in patients who received short-term prophylaxis with somatostatin or gabexate mesilate than those given a placebo: 11.5% and 8.1% vs. 6.5%, respectively. In order to explore this discrepancy, the original meta-analysis was updated by including data of this negative trial: heterogeneity among the trials was apparent. A careful scrutiny of the most recent studies has revealed differences in patient population, protocols of drug administration, technique and operator-related risk factors for complications among the trials, which could explain, by themselves, the contrasting results reported by the interventional studies. In conclusion, current literature does not support the prophylactic use of either somatostatin or gabexate mesilate for the prevention of ERCP-related pancreatic damage, even in patients deemed to be at high risk for complications. At present, post-ERCP complications (and pancreatitis) can be prevented efficaciously by appropriate selection of patients, mastering of the technique and operator competence.

Cholangiopancreatography, Endoscopic Retrograde↗