Post-ERCP pancreatitis: still a major issue despite all efforts

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most frequent complication associated with a technique that has otherwise dramatically improved the outcomes of patients with biliopancreatic diseases. Many factors have been associated with PEP, including those related to patients (young age, female sex, obesity), indications (sphincter of Oddi dysfunction, history of PEP), technique (precut sphincterotomy, pancreatic sphincterotomy, papillectomy, difficulty of cannulation, repeated pancreatic duct injections), and experience of the operator [1–3].

The incidence of PEP has remained stable up to the first decade of this century [4] despite a better knowledge of risk factors. Since 2005, however, some modalities have become established (and included in practice guidelines) to reduce the incidence of PEP, including wire-guided cannulation, placement of prophylactic pancreatic stents in high-risk procedures, use of rectal nonsteroidal anti-inflammatory drugs before the procedure [1] or, more recently, the use of aggressive hydration with lactated Ringer’s solution in average- to high-risk patients [5]. On the other hand, the complexity of ERCP procedures has increased, which could have the opposite effect on PEP incidence.

In this issue of Endoscopy, Mutneja et al. [6] analyzed the trends and predictors of occurrence of PEP from 2011 to 2017 using ICD codes from the US Nationwide Inpatient Sample, and identified more than 1.2 million inpatients who underwent an ERCP. In this group of patients, the authors observed an overall 4.5 % incidence of PEP, with a hospital (re)admission rate that increased by 15.3 % over the study period. Moreover, the PEP-related mortality increased from 2.8 % in 2011 to 4.4 % in 2017, a worrying observation that contrasts with what we would subjectively have expected given the progressive implementation of prophylactic measures and the development of clear guidelines during this study period [1, 7].

“ERCP is not an occasional job and its practice requires adequate training, certification (a process that does not exist in most European countries), and sufficient volume of cases to maintain expertise.”

Although these findings are an important “alarm bell,” they must be put into perspective given the biases inherent to studies performed using a nationwide database and interpretation of ICD codes. The study population was limited to inpatient procedures whereas, to the best of my knowledge, many of the large US endoscopy centers perform “routine” ERCP in outpatient units. The population analyzed represents a group of patients who are probably at higher risk of complications and/or require more complex procedures. Moreover, the centers included in the analysis were probably more specialized and/or dealt with the highest volume of ERCPs within an outpatient setting, allowing them to perform most of the procedures without admitting the patient. There was also an increase in complex cases over the study period, suggesting a change in procedures offered by these institutions.

The definition of complexity related to the risk of PEP should focus on the difficulty of cannulation, the number of pancreatic injections, and the use of alternative techniques to reach the desired duct. These data are obviously not available in this study and the authors, in a laudable effort to characterize the complex cases, used surrogate codes with the assumption that patients undergoing multiple techniques might be at higher risk of PEP.

An important observation is that ERCPs performed in teaching hospitals were associated with lower odds of developing PEP. Whether this is in line with the volume of activity cannot be demonstrated from the data. Defining a high-volume center as a place where more than 200 ERCPs/year are performed probably does not correspond any more to the reality in 2021, given the increasing complexity of cases that require not only experienced physicians but also an adequate anesthesiological, paramedical, and technical environment. In addition, if the volume per center is important, the volume per operator is paramount [2, 3] and obviously these data are not available.

The most recent guidelines [1, 7] on PEP prophylaxis appeared toward the end of this study period and we know from previous observations that there is a significant delay between the publication of highly significant scientific studies, updated guidelines, and the application of recommendations in routine practice [8]. It is therefore probable that the current observations were only marginally affected by the most recent recommendations.

High-risk indications have been repeatedly identified, and ERCP performed for sphincter of Oddi dysfunction or involving pancreatic duct manipulations were major risk factors in the multivariate analysis. This further demonstrates that the benefit of these indications not only should be carefully balanced against the risk but also that these treatments should be performed in specialized units taking extreme caution with technique and prophylaxis of PEP.

Whatever the limitations of this study, most of which are adequately acknowledged by the authors, it serves as a good reminder of the need for greater recognition of this potentially life-threatening complication. ERCP is not an occasional job and its practice requires adequate training, certification (a process that does not exist in most European countries), and sufficient volume of cases to maintain expertise. ERCP could benefit from a concentration in teaching hospitals or in very high-volume centers where experienced physicians are working in a specialized environment. Given the risk and the potential severity of PEP, it is currently our task to concentrate these cases and to perform ERCP in an environment where quality controls and outcome measurements are available.

Publication History

Article published online:
29 March 2021

• References

• 1 Dumonceau J-M, Andriulli A, Elmunzer BJ. et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) guideline – updated June 2014. Endoscopy 2014; 46: 799-815
• 2 Freeman ML, Nelson DB, Sherman S. et al. Complications of endoscopic biliary sphincterotomy. New Engl J Med 1996; 335: 909-918
• 3 Lee HJ, Cho CM, Heo J. et al. Impact of hospital volume and the experience of endoscopist on adverse events related to endoscopic retrograde cholangiopancreatography: a prospective observational study. Gut Liver 2020; 14: 257-264
• 4 Andriulli A, Loperfido S, Napolitano G. et al. Incidence rates of post-ERCP complications. Am J Gastroenterol 2007; 102: 1781-1788
• 5 Park CH, Paik WH, Park FT. et al. Aggressive intravenous hydration with lactated Ringer’s solution for prevention of post-ERCP pancreatitis: a prospective randomized multicenter clinical trial. Endoscopy 2018; 50: 378-385
• 6 Mutneja HR, Vohra I, Go A. et al. Temporal trends and mortality of post-ERCP pancreatitis in the United States: a nationwide analysis. Endoscopy 2021; 53: 357-366
• 7 Chandrasekhara V, Khashab MA. ASGE Standards of Practice Committee. et al. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85: 32-47
• 8 Dumonceau JM, Rigaux J, Kahaleh M. et al. Prophylaxis of post-ERCP pancreatitis: a practice survey. Gastrointest Endosc 2010; 71: 934-939