ERCP in Portugal: A Wide Survey on the Prevention of Post-ERCP Pancreatitis and Papillary Cannulation Techniques

Abstract

Background/Aims: Recently the European Society of Gastrointestinal Endoscopy delivered guidelines on the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and on the papillary cannulation and sphincterotomy techniques at endoscopic retrograde cholangiopancreatography (ERCP). There are no data concerning current practices in Portugal. The aim of this study was to capture practice patterns of Portuguese pancreaticobiliary endoscopists with special interest in the prevention of PEP and cannulation techniques. Methods: A written survey was distributed to all pancreaticobiliary endoscopists attending the first Portuguese meeting dedicated to ERCP in November 2016. The main outcome measures were: technique used for standard biliary cannulation, use of nonsteroidal anti-inflammatory drugs (NSAIDs) in PEP, attempting prophylactic pancreatic stenting after using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation was difficult, and use of precut as the first rescue technique when biliary cannulation was difficult. Results: Completed surveys were collected from 28 of the 32 pancreatobiliary endoscopists attending the meeting (answer rate 87.5%). Biliary cannulation was performed using a guidewire access technique by the majority (77%), usually with a sphincterotome. When cannulation was unsuccessful, precut was the first choice for 70%. NSAIDs were administered routinely for PEP by only 54%; PGW-assisted biliary cannulation was the first choice after failed standard cannulation for a minority of them, and only 27% reported to routinely attempt insertion of a pancreatic stent. High-volume endoscopists (> 150/year) tended to use NSAIDs and to insert a stent in PGW-assisted cannulation less often than low-volume-endoscopists (50 vs. 83.3%, p < 0.01, and 40 vs. 100%, p < 0.01, respectively). Precut was started without prior formal training by more than half of the endoscopists. Conclusions: There is a pronounced discrepancy between evidence-based guidelines and current clinical practice. This discrepancy is more pronounced in PEP prophylaxis, especially among high-volume endoscopists. Some advanced techniques in ERCP are initiated unsupervised, without any previous formal training. Key Message: There is a significant gap between guidelines and routine clinical practice.

Post-ERCP Pancreatitis: Risk factors and role of NSAIDs in primary prophylaxis

“…In a recent survey from Portugal, only 54% patients undergoing ERCP received rectal NSAIDs. 22 Similarly 64.1% of PEP prophylaxis non users cited lack of conviction in its benefit for their decision in a survey from UK. 23 Studies like ours depicting clear benefit of using NSAIDs for preventing PEP will promote its use in clinical practice leading to significant reduction in potentially lethal complication like PEP.…”

Should we incorporate topical epinephrine in the ESGE guideline on prevention of post-ERCP pancreatitis?

“…This has led to slow adoption in the community: In 10 years, the proportion of endoscopists who use rectal NSAIDs for PEP prophylaxis has increased from 15 % to 54 % to 98 % 1 2 3 4 . The latest survey reported use of rectal NSAIDs by 98 % of pancreaticobiliary endoscopists but by only 40 % of them in average-risk patients 4 .…”

Rectal indomethacin and diclofenac are equally efficient in preventing pancreatitis following endoscopic retrograde cholangiopancreatography in average‐risk patients

“…However, the guideline published by the American Society for Gastrointestinal Endoscopy in 2017 only recommended the use of rectal NSAIDs to reduce the incidence and severity of PEP in high‐risk individuals, while also suggesting that rectal indomethacin may reduce the risk and severity of PEP in individuals with average risk 9 . In spite of these guidelines, surveys among endoscopists in Portugal, the United Kingdom, and the United States revealed low adoption rates of rectal NSAIDs to prevent PEP in clinical practice 10–12 …”