Early Ductal Decompression Versus Conservative Management for Gallstone Pancreatitis With Ampullary Obstruction

Departments of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, USA.
Annals of Surgery (Impact Factor: 8.33). 02/2006; 243(1):33-40. DOI: 10.1097/01.sla.0000194086.22580.92
Source: PubMed


To compare the efficacy of endoscopic retrograde cholangiopancreatography +/- endoscopic sphincterotomy (ERCP +/- ES) versus traditional conservative management in early gallstone pancreatitis with persistent ampullary obstruction (GSP + AO).
The effectiveness of early ERCP +/- ES in this setting is controversial.
Sixty-one consecutive patients with GSP + AO within 48 hours from the onset of symptoms were randomized to receive either conservative treatment and selective ERCP +/- ES after 48 hours (control group, 31 patients) or initial conservative treatment and systematic ERCP +/- ES within 48 hours if obstruction persisted 24 hours or longer (study group, 30 patients). Patient outcome was compared in relation to treatment groups and to duration of obstruction.
In the control group, 22 patients disobstructed spontaneously within 48 hours; 3 of the remaining 9 patients underwent ERCP +/- ES and none had impacted stones. In the study group, 16 patients disobstructed spontaneously and 14 underwent ERCP within 48 hours from the onset of symptoms; impacted stones were found and extracted by ES in 79% (11 of 14) of these.
There were no deaths in either group. Patients in the study group showed a shorter period of obstruction (P = 0.016) and a lower rate of immediate complications (P = 0.026) than controls. Patients with obstruction lasting < or =48 hours regardless of the treatment group had fewer immediate complications than those whose obstruction persisted longer (P < 0.001).
This study shows that in patients with GSP + AO limiting the duration of obstruction to not longer than 48 hours by ERCP + ES decreased morbidity.

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Available from: Denice Tsao-Wei, Mar 10, 2014
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    • "More recent meta-analyses or guidelines might reach different conclusions as new data have come available over time. However, this argument is contradicted by the observation that the latest meta-analyses (2006-2009; Table 1) are not concurrent in which of the most recent (randomized) clinical trials were included in their analysis: Acosta 22 (2006), Oria 26 (2007), and van Santvoort 47 (2009), which result in conflicting outcomes (like the older meta-analyses). The second likely explanation is what has just been alluded to that is selection of which studies to include in the meta-analysis. "
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    ABSTRACT: Objectives: Several randomized controlled trials studied the role of endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic sphincterotomy (ES) in acute biliary pancreatitis (ABP). No study assessed whether these trials resulted in international consensus in published meta-analyses and treatment guidelines. Methods: A systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, of meta-analyses and guidelines on ERCP in ABP was performed in PubMed until August 2011.The methodological quality of the meta-analysis and guidelines was assessed by a validated quality assessment tool. Results: Eight meta-analyses and 12 guidelines fulfilled the inclusion criteria. There is consensus that ERCP is indicated in case of ABP with coexistent cholangitis and/or persistent cholestasis. By exception of the first meta-analysis, all included studies disapproved early ERCP in predicted mild ABP. Consensus is lacking regarding the role of early ERCP in predicted severe ABP, as 3 meta-analyses and 1 guideline do not advice this strategy. Routine early ERCP in predicted severe ABP is recommended in 7 of the 11 guidelines. Conclusions: There is consensus in guidelines and meta-analyses that ERCP/ES is indicated in patients with ABP and coexisting cholangitis and/or persistent cholestasis. Consensus is lacking on the role of routine early ERCP/ES in patients with predicted severe ABP.
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    • "Gazdasági számítás alapján a két stratégia költséghatékonysága – nem meg­ lepő módon – az epeúti kő gyakoriságától függ. Ha a kő valószínűsége kisebb, mint 50%, akkor költségha­ tékonyabb, ha előbb EUH történik, majd ennek az kodás, mintha később a panaszok kezdete után 48 órá­ nál is később történik meg a beavatkozás [11]. Mivel cholangitis esetén egyértelmű a korai ERCP kedvező hatása, ezért a további vizsgálatok és metaana­ lízisek cholangitis nélküli biliaris pancreatitisben vizs­ gálták a korai ERCP hatásosságát. "
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    ABSTRACT: Although the effectivity of an urgent endoscopic retrograde cholangio-pancreatography was documented, some aspects relating to this method are still debated. Timing of this procedure has not been established yet. Indications for urgent endoscopic retrograde cholangio-pancreatography with stone extraction from the common bile duct in patients with biliary pancreatitis remains controversial. Biliary decompression and drainage is the cornerstone of acute cholangitis treatment. The timing of endoscopic retrograde cholangio-pancreatography should be based on the grade of the severity of the disease. Using endoscopic retrograde cholangio-pancreatography, the accurate diagnosis and treatment of bile leaks in a timely manner is imperative to limit associated morbidity and mortality. Difficulty in cannulating the common bile duct is one of the main risk factors for pancreatitis occurring after the procedure. Alternative techniques to facilitate difficult cannulation are discussed. Organized training and introduction of objective measures of the investigator's competence are emphasized to improve the performance of the procedure in Hungary.
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    • "Complication of ERCP-EBS denotes post-sphincterotomy bleeding. of the disease) as compared to patients with early conservative management. Another recent study of acute biliary pancreatitis showed that there was significantly more immediate complication in patients with biliary obstruction lasting more than 48 h from the onset of pancreatitis, suggesting a therapeutic window lasting not more than this time interval (Acosta et al., 2006). In totality three studies have shown that early endoscopic intervention can significantly decrease the occurrence of pancreas-specific complications of acute biliary "
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    ABSTRACT: Risk factors of post-ERCP pancreatitis are well characterized in various clinical settings. These factors may worsen the outcome of acute biliary pancreatitis treated by endoscopic sphincterotomy. Our aim was to investigate the effect of patient-and intervention-related factors on the outcome of acute biliary pancreatitis treated by endoscopic sphincterotomy. The data of 69 retrospectively analyzed using multiple logistic regression method to explore factors significantly associated with the outcome of pancreatitis. We found that multi-system organ failure was associated with predicted severe pancreatitis (odds ratio [OR] 24.24; 95% confidence interval [CI]: 1.35 – 434.76; p = 0.030), condition of previous cholecystectomy (OR 23.94; 95% CI: 1.58 – 361.03; p = 0.022) and the performance of access precut sphincterotomy (OR 21.34; 95% CI: 1.32 – 344.92; p = 0.031). Predictors of development of necrosis were post-sphincterotomy bleeding (OR 52.01; 95% CI: 1.67 – 1617.54; p = 0.024), the predicted severe pancreatitis at admission (OR 20.30; 95% CI: 2.92 – 141.19; p = 0.002) and female gender (OR 6.70; 95% CI: 1.00 – 44.73; p = 0.049). The single variable post-cholecystectomy state proved to be a predictor of mortality (OR 13.40; 95% CI: 1.5-; p = 0.026). We concluded that the outcome of acute biliary pancreatitis treated by ERCP and biliary sphincterotomy of acute biliary pancreatitis is influenced by certain patient-and intervention-related factors.
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