Ercp

Abstract

DDW Highlights 745Prevention of post-ERCP pancreatitis ! The concept of hypoperfusion of the microvasculature during the early phase of acute pancreatitis has led to the emphasis on early volume resuscitation, specifically Ringer's lactate solution for acute pancreatitis of any cause to prevent or limit pancreatic injury. Although prevention of PEP has focused on pharmacologic agents (most recently NSAIDs) and PD stents, Buxbaum et al [1] reported the interim results on the use of aggressive hydration to prevent PEP. Patients were prospectively randomized in a 2:1 ratio of aggressive hydration compared with moderate hydration. Aggressive hydration was administered by using lactated Ringer's (LR) solution at 3 mL/kg/h intraprocedurally followed by a bolus of LR 20 mg/kg administered immediately postprocedurally, and continued at 3 mL/kg/h for 8 hours. In the standard hydration group LR was administered at 1.5 mL/kg/ h during the procedure and for 8 hours afterward. Patients were monitored for volume overload, and PEP was defined by using standard criteria. PEP developed in none of the 32 patients in the aggressive fluid arm compared with 4 of 32 (24 %) in the moderate fluid arm. No volume overload occurred. These results suggest that aggressive fluid resuscitation should be considered in all patients who are not at risk of volume overload because this intervention poses little risk otherwise. Cannulation techniques continue to be important because difficult cannulation is associated with an increased risk of PEP. There continues to be a shift from contrast-guided biliary cannulation to wire-guided (WG) cannulation. Two abstracts of note focused on cannulation techniques. When WG cannulation fails, but the guidewire unintentionally and repeatedly enters the main pancreatic duct (PD), 1 option is to leave the guidewire in the pancreas and reattempt biliary cannulation alongside with a second guidewire and catheter. This is termed double wire -guided (DWG) cannulation. Sasahara et al [2] presented results of a randomized trial comparing early DWG cannulation, in which a guidewire remained in the PD after the first unintentional entry compared with repeated conventional WG biliary cannulation in patients undergoing therapeutic endoscopic retrograde cholangiography. Successful biliary cannulation was achieved in 48 % of patients on the first attempt, with a PEP rate of only 4 %. The subsequent 274 patients (137 per group) were defined as difficult cannulation and were randomized. Common bile duct cannulation was successful within 10 minutes or 10 attempts in 75 % of patients in the early DWG group and 70 % of the repeated single WG cannulation group. The final cannulation rate was approximately 97 % in each group with a similar rate of PEP (20 % vs 17 %). No mention was made of the use of prophylactic pancreatic stents or pharmacologic agents. This suggests that the PEP rate in patients with difficult cannulation remains high if PD stent placement and/or NSAIDs are not used, but that DWG cannulation is associated with ...