Abstracts

Su1682Risk Factors for Post-ERCP Pancreatitis in Therapeutic BiliaryERCP Using Wire-guided CannulationYousuke Nakai*, Hiroyuki Isayama, Naoki Sasahira, Hirofumi Kogure,Takashi Sasaki, Natsuyo Yamamoto, Miho Matsukawa, Kei Saito,Gyotane Umefune, Shuhei Kawahata, Dai Akiyama, Tomotaka Saito,Tsuyoshi Hamada, Naminatsu Takahara, Suguru Mizuno, Koji Miyabayashi,Ryota Takahashi, Keisuke Yamamoto, Dai Mohri, Kenji Hirano,Minoru Tada, Kazuhiko KoikeDepartment of Gastroenterology, The University of Tokyo, Tokyo, JapanBackground: Wire-guided cannulation (WGC) reportedly improves biliary cannula-tion and decreases post-ERCP pancreatitis (PEP) by preventing contrast injectionto the pancreatic duct (PD). However, little is known whether unintentionalguidewire (GW) insertion into PD increases PEP or not. The aim of the study is toevaluate risk factors for PEP in therapeutic ERCP using WGC. Patients: Patients withnative papilla undergoing therapeutic biliary ERCP using WGC were enrolled. Incases with difficult cannulation, any cannulation method including contrast injectionwas allowed at discretion of endoscopists. Exclusion criteria were prior history ofERCP, concomitant acute pancreatitis, balloon-assisted ERCP and planned pancreaticintervention. Logistic regression analyses were performed to evaluate risk factors forPEP. Potential risk factors analyzed in the model were as follows: age, gender, BMI,reason for ERCP, pancreatic cancer, ERCP by trainees, periampullary diverticulum,jaundice at ERCP, CBD diameter, procedure time, catheter type, GW type, number/time of cannulation attempt, final cannulation failure, biliary sphincterotomy,papillary balloon dilation, stone extraction, transpapillary brushing and biopsy, in-traductal ultrasonography, nasobiliary drainage, plastic stent, metallic stent, GWinsertion into PD, PD opacification, prophylactic PD stent. Factors with p!0.10 byunivariate analysis and known risk factors for PEP (age, gender, PD opacification,jaundice at ERCP and EPBD) were further analyzed in a multivariate analysis. Results:Among 5234 ERCPs performed at the University of Tokyo Hospital between January2008 and October 2013, a total of 800 ERCPs met the inclusion criteria. Reason forERCP was CBD stone (54.1%), biliary malignancy (36.1%), benign biliary diseases(9.8%). Median procedure time was 40 min. Median cannulation attempts and timeto cannulation were 5 attempts and 5 min. Cannulation was successful by WGC alonein 70.5% and final cannulation rate was 96.1%. PD GW insertion and opacificationoccurred in 55.3% and 21.6%, respectively, and prophylactic PD stent was placed in12.9%. Overall PEP rate was 9.5% (mild 5.6%, moderate 2.9%, severe 1.0%). Multi-variate analysis revealed CBD diameter! 9mm (Odds ratio [OR] 2.03, pZ0.006),GW insertion into PD (OR 2.25, pZ0.014) as risk factors for PEP. In cases with CBDR9 mm, PEP rate did not increase by unintentional PD manipulation, but in caseswith CBD!9 mm, PEP rate was 4.6% without PD manipulation, 8.3% with PDopacification alone, 16.9% with PD GW insertion alone and 22.1% with GW insertionand opacification. Conclusion: PEP rate was 9.8% in therapeutic biliary ERCP usingWGC. A small CBD diameter and GW insertion into PD were risk factors for PEP.There was an incremental increase of PEP by PD opacification in addition to GWinsertion in cases with CBD diameter!9 mm.

Su1683Diclofenac Intramuscular As Prevention of Post - ERCPPancreatitis. Is There a Need Your Universal Application or Just aHigh-Risk Patients ?Cristian F. Florez-Sarmiento*1Hospital Militar Central, Bogota, Colombia; 2Clinica Partenon, Bogota,ColombiaIntroduction: Several studies recommend the use of NSAIDs such as diclofenac andindomethacin end in the prevention of acute post-ERCP ( PPERCP ) pancreatitis .The number of participants included was lacking in some work and others only inselected patients at high risk for PPERCP. Objective: To determine whetheradministration of Diclofenac Intramuscular (IM) at the start of ERCP prevents theoccurrence of post ERCP pancreatitis in unselected patients. Methods: We con-ducted a randomized double - blind prospective study assigning patients undergoingtherapy for one of the two stakeholders ERCP : treatment (Diclofenac 75mg IM atthe start of the test) or placebo (SSN IM ampoule). Known risk factors for devel-oping PPERCP analyzed . The primary endpoint was the occurrence or not of acutepancreatitis. Assessment of PPCPRE and data collection was performed by physicianswho did not perform endoscopies. Results: Between January and September 2013348 ERCPs were performed at our center with a treatment success rate of 91.2 %.183 and 165 patients received placebo treatment. Mild acute pancreatitis 17 wererecorded, representing a rate of 4.8% PPCPRE, 4 cases in the treatment group 2.4%(p Z 0.05 ) and 13 in the placebo group (7.1% p : 0.06). There were no significantdifferences between the other risk factors PPCPRE studied (age, sex, medical history,indication for ERCP and degree of difficulty (ASGE), dilatation of the bile duct ,presence or absence of stones, difficult cannulation, endoscopic experience, etc.Diclofenac administration did not cause any adverse effects. Conclusions: Althoughtwice PPCPRE observed in the placebo group than the treatment, the number ofcollected events is still insufficient to reach statistical significance. It useful tocontinue this study involving standard risk patients PPCPRE to see if this prophy-lactic measure should be applied at the beginning of any ERCP.

AB258 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014

Cases of Pancreatitis Post ERCP

Intervention/outcome

Diclofenac IM

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Placebo IM

Pancreatitis post ERCP

4 13 Non Pancreatitis 161 169

p: (0,05) Diclofec group, p:(0,06) placebo group

Su1684Is Endoscopic Biliary Stenting a Risk Factor for Post-ERCPPancreatitis? - a Systematic Review and Meta-AnalysisAijaz Sofi*, Abdur R. Khan, Yaseen Alastal, Muhammad Z. Bawany,Ali NawrasGastroenterology, University of Toledo Medical Center, Toledo, OHPlacement of bile stent across the papilla could potentially block pancreatic ductopening which may result in acute pancreatitis. However, biliary stenting as arisk for post-ERCP pancreatitis (PEP) has not been studied widely. Limitednumber of studies that evaluated the risk of PEP from biliary stenting haveshown variable results. The purpose of this meta-analysis is to examinewhether the placement of biliary stent is associated with a higher rate of PEP.Methods: We performed a comprehensive search of several databases between 1980through November 2013 to identify all the studies reporting the association of biliarystenting and PEP. Four studies (2 prospective and 2 retrospective) with a total of16722 patients were included in the meta-analysis. Of these patients, 4578 under-went endoscopic biliary stenting. The Mantel-Haenszel method was used to pooldata of PEP outcomes into random effect model meta-analyses. Odds ratio (OR) wasused to generate an overall effect estimate of the outcome. Publication bias andheterogeneity were assessed by contour funnel plot and the I2 test, respectively.Statistical heterogeneity and publication bias was assessed. Results: The incidence ofPEP varied from 2.0-7.4% between the studies included in the meta-analysis. Therewas mild heterogeneity found which was addressed with random effect meta-ana-lyses. The funnel plot was suggestive of a publication bias (I2 Z 39%). Meta-analysisof the included studies did not show a significant increase in the odds of PEP withbiliary stenting (OR 1.27; 95% confidence interval 0.80-2.02) (Figure-1). Conclusion:With the available evidence, endoscopic placement of a stent in bile duct is notassociated with an increased risk of post-ERCP pancreatitis.

Effect of biliary stent on the risk of pancreatitis

Su1685Nonsteroidal Anti-Inflammatory Drugs (Indomethacin and/orDiclofenac) and Protease Inhibitors (Gabexate Mesilate,Ulinastatin, and Nafamostat Mesilate) As a Prophylaxis AgainstPost-ERCP Pancreatitis, Updated Meta-AnalysisMohamed M. Abdelfatah*, Markus Agito, ALA Nijim, Rabih Nayfe,Nairmeen HallerAGMC, Northeast Ohio medical Universty, Akron, OHBackground: Several pharmacological agents have been studied as prophylaxisagainst post- ERCP pancreatitis (PEP). Despite initial evidence in the literature,Nonsteroidal anti inflammatory drugs (NSAIDs) and protease inhibitors have notbeen widely used to prevent PEP. Aim: To complete a meta-analysis of high qualityrandomized controlled trials that include the latest available literature publishedafter past meta-analytical efforts. Methods: By searching Medline, meeting abstractsand bibliographies, reviewers systematically identified prospective randomizedcontrolled trials examining the effect of rectally administered prophylactic NSAIDsand Protease inhibitors (gabexate mesilate, ulinastatin, and nafamostat mesilate) onthe incidence of PEP. A meta-analysis of these randomized controlled trials wasperformed. Results: nine prospective randomized controlled trials included a total of2300 patients used rectal NSAIDs (indomethacin and/or Diclofenac) as prophylaxisagainst PEP. All studies used similar criteria to define PEP; meta-analysis of thesestudies demonstrates a pooled relative risk for PEP after prophylactic administrationof NSAIDs of 0.449 (95% CI 0.42 to 0.714). Five out of nine randomized controlledtrials used rectal indomethacin only as a prophylaxis against PEP; meta-analysis ofthese studies demonstrates a pooled relative risk for PEP after prophylactic admin-istration of rectal indomethacin of 0.470 (95% CI 0.327 to 0.673). Patients whoreceived NSAIDs in the pre-procedural period were 55% less likely to developpancreatitis and 90% less likely to develop moderate to severe pancreatitis. Theprophylactic efficacy was similar; no adverse events attributable to the use of NSAIDs

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