To prevent pancreatitis after ERCP, you need to do these 5 steps | Clinical Essentials

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ERCP operation and requirements for the surgeon.
In 1968, since the advent of endoscopic retrograde cholangiopancreatography (ERCP), it has become the "new favorite" in the digestive world, and has played a role in the diagnosis and management of many biliary pancreatic diseases.
Key role.

 However, with the advent of other imaging diagnostic methods such as CT scan, magnetic resonance cholangiopancreatography, and endoscopic ultrasonography, the diagnostic function of ERCP has gradually been replaced.
Nowadays, ERCP is mainly used for treatment (rather than diagnosis).

 ERCP is a challenging operation, and its difficulty is not only reflected in the learning and operation of ERCP, but also in the related adverse reactions that it may produce.

 Pancreatitis after ERCP (PEP) is the most common (3.
5%) serious adverse event, and severe PEP accounts for about 10%.

 Other adverse events related to ERCP included infection (1.
4%), bleeding after sphincterotomy (1.
3%) and perforation (0.
6%).

 Whether postoperative pancreatitis occurs is directly related to the technical proficiency of the surgeon.
Before the operation, the surgeon should receive good ERCP training.

In addition, the patient's individual condition is suitable for ERCP operation is a key factor in reducing PEP, therefore, the endoscopist should clarify the indications of ERCP.

Prevent PEP, follow these five steps 1.
Identify the risk factors of PEP After determining the appropriate indications, the first step to prevent PEP is to identify all risk factors related to the patient and risk factors related to the operation.

2.
Drug prevention The second step to prevent PEP is to use drug prevention (Table 2).

Since 1977, researchers have successively evaluated the effects of at least 35 different drugs in the prevention of PEP, but few have reached satisfactory results.

Finally, Elmunzer et al.
found in 2012 that non-steroidal anti-inflammatory drugs (NSAIDs) administered through the rectum are effective in preventing PEP.

 Since then, researchers from all over the world have opened randomized controlled trials to further verify the effectiveness of NSAIDs administered rectally on PEP.

 In order to optimize the preventive effect, NSAIDs should be administered (transrectally) a short time before the start of the ERCP operation.
Generally speaking, indomethacin 100mg is given clinically 20 minutes before the operation.

 3.
Assess the characteristics of the nipple.
The third step is to carefully evaluate the nipple, including whether the nipple is everted, the type and location of the nipple.

The best intubation method should be selected according to the characteristics of each nipple.
This step is very important for reducing PEP.

 Fourth, thinking before intubation: guide wire guidance technology vs.
contrast agent-assisted method Existing literature believes that guide wire guidance technology is safer than contrast agent-assisted methods.

However, since the concentration, type, and injection volume of the contrast agent are all indicators that are difficult to standardize, it is difficult to eliminate the influence of deviations on the research results.

For example, observing the direction of the catheter by injecting a small amount of contrast agent can greatly promote the doctor's understanding of the anatomical structure of the catheter, and also help the judgment of the guide wire selection.

Therefore, it is very reasonable to inject a small amount of contrast agent.

 5.
Pancreatic duct stent placement The last step is pancreatic duct stent placement, which is another key link to prevent PEP.

 The indications of stent placement are hypertension after injection of the main pancreatic duct, multiple pancreatic guide wires passing through the main pancreatic duct, double guide wire intubation, and endoscopic papillectomy.
In addition, in all high-risk patients Pancreatic duct stent placement should also be used.

 Rescue main pancreatic duct stent implantation can be used to prevent the development of pancreatitis, but the operation should be completed 8-20h after the occurrence of PEP.

 Yimaitong compiled and compiled from: Ivo Boskoski and Guido Costamagna.
How to Prevent Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.
Gastroenterology.
2020, 158 (8) ：2037-2040.