March 29, 2018
How I Combine strategies to reduce post ERCP pancreatitis rates to a minimum
By Dr Martin L Freeman, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota
There are a number of strategies – now up to 5 all beginning with the letter P (well, almost!)
- Patient selection – understand risk factors and avoid marginally indicated ERCP, especially in high risk patients
- Procedure related variables are important, but new data suggest that guidewire passage into the pancreas may be as or more important than contrast injection – thus caution with the pure guidewire cannulation technique, and see measures below; when a guidewire is passed into a normal pancreatic duct, especially in a high risk patient, it is advisable to place a pancreatic stent, especially during the ‘Dual Wire” cannulation approach, or prior to precut sphincterotomy.
- Pancreatic stents – despite all the new approaches, placement of a pancreatic stent remains a cornerstone of prevention in high risk cases; learning how to reliably place a small caliber pancreatic stent, even in difficult anatomy, can be a lifesaver, and generally involves use of small caliber (0.018 to 0.025″) guidewires and newer stent designs; 3 or 4 French stents can be either long (8-12 cm), unflanged, or short (2-3cm), generally with an inner flange if patient very high risk; softer materials are available for pancreatic stents from at least two manufacturers now.
- Pharmacologic prevention. Administration of rectal NSAIDs, particularly indomethacin, has been shown to reduce risk of PEP by about 40-60%; however its role in supplanting the above measures is unclear. A substantial number of patients have contraindications to NSAIDs – allergy, renal insufficiency, coagulopathy, etc, such that overreliance on NSAIDS will not be an effective strategy.
- Phluids (Fluids!). A number of studies have recently shown that pre and post procedure administration of aggressive hydration with lactated Ringer’s solution reduces risk and/or severity of post ERCP pancreatitis; when allowed by absence of cardiac or renal issues, this strategy is useful in combination with above approaches.
Combining all of the above should lead to post ERCP pancreatitis rates of well under 5%, even in centers performing high risk cases.