Zsolt Dubravcsik

Background/Objectives: Difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) poses significant challenges and increases the risk of adverse events. Pancreatic guidewire (PGW)-assisted techniques offer potential solutions, but real-world comparative data are limited. Methods: This cohort study of prospectively collected data analyzed 234 ERCP cases from the Hungarian ERCP Registry, focusing on three PGW-assisted methods: transpancreatic sphincterotomy (TPS), double-guidewire technique (DGW), and prophylactic pancreatic stent-assisted cannulation (PPS-C). Results: TPS demonstrated the highest primary cannulation success rate (83.1%), significantly outperforming DGW (67.7%) and PPS-C (67.6%) (p < 0.001). With salvage methods, cannulation success was high across all groups. Post-ERCP pancreatitis rates were low (5.0% TPS, 5.6% DGW, 3.9% PPS-C), but prophylactic measures (pancreatic stents, indomethacin) were underutilized. Conclusions: Our findings suggest that TPS is a safe and effective alternative for difficult biliary cannulation in ERCP. Routine considerations of post-ERCP pancreatitis prophylaxis (prophylactic pancreatic stents and non-steroidal suppositories) are recommended in all PGW-assisted cannulations to minimize complications.

Az endoszkópos retrográd cholangiopancreatographia (ERCP) leggyakoribb szövődménye a poszt-ERCP pancreatitis, amelynek számos kockázati tényezője és megelőzésének lehetőségei is ismertté váltak az elmúlt bő három évtizedben. A magas rizikójú betegcsoportban a kis kaliberű, ún. profilaktikus pancreassztentek (PPS) bizonyulnak a leghatékonyabb megelőző eljárásnak, bár használatukhoz megfelelő endoszkópos gyakorlat szükséges. Jelen publikációban a PPS-ekkel kapcsolatos ismeretanyagot foglaltuk össze.

Linked color imaging (LCI) is a new endoscopic technology that may increase colorectal adenoma detection rate (ADR) and polyp detection rate (PDR) by virtual chromoendoscopy. Aim of the present stu...

Objectives: To analyze risk factors of post-ERCP pancreatitis (PEP) in high risk patients in whom prophylactic pancreatic stents (PPSs) were intended to use to prevent endoscopic retrograde cholangiography (ERCP)-related complications. Patients and methods: Three hundred and seventeen high-risk patients for developing PEP were considered for preventive pancreatic stent placement in our endoscopy unit over 5 years. 5 Fr, 3–5 cm long PPSs were used. All data were collected in a predefined database. Development of PEP despite PPS placement was analyzed. Results: PEP occurred in 29 of 288 successfully stented patients (10.07%; 24 mild, four moderate, one severe). PPS was protective against all risks factors except for sphincter of Oddi dysfunction (SOD). PPS related complication rate was 2.78% (n = 8). Unsuccessful stenting occurred in 29 patients (9.15%), PEP developed in 41.38% (n = 12; seven mild, four moderate, one severe). Those patients who had more patient related risk factors were more likely to develop PEP despite preventive measures with PPS. On the contrary, PPS placement was less successful in patients who had more procedure related risk factors. Conclusions: PPS is protective against all risks factors of PEP except for SOD in high-risk patients. More vulnerable patients who have more patient-related risk factors are more likely to develop PEP despite PPS is used, while more complex procedures predispose to unsuccessful PPS placement in patients with more procedure-related risk factors. PPS insertion in high-risk patients is effective and safe preventive method and the procedure related complication rate is reasonably low.

We read with great interest the recent article from the Freeman group by Kerdsirichairat et al. [1]. Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), which can be severe or even life threatening in about 10 % of cases [2]. Prophylactic pancreatic stent (PPS) placement is effective in the prevention of post-ERCP pancreatitis (PEP), as demonstrated by several randomized controlled trials and meta-analyses, including the most recent one [3]. It is a generally accepted theory that mechanical or thermal trauma during ERCP can cause papillary edema obstructing the pancreatic duct, which could lead to a rise in intraductal pressure and early intrapancreatic enzyme activation resulting in PEP. PPS placement can prevent PEP by maintaining the outflow of the pancreatic juice. In the early course of severe PEP, marked papillary and duodenal edema is often observed. Rescue ERCP and PPS placement can be effective as a treatment option in these cases. The basic idea and technique of such a rescue ERCP with small-caliber pancreatic stenting was first published by our group in 2009 [4]. We performed rescue ERCP within 8 – 20 hours after the initial ERCP in the early course of clinically severe PEP. Moderate to severe papillary edema was observed, and a small-caliber PPS was successfully placed in every patient, resulting in prompt relief of abdominal pain and symptoms; all patients recovered quickly without any short- or long-term complications. In the recent article, the authors reported the data from five patients who were similar to those in our published series, with convincing results for PPS placement. More interestingly, they successfully treated nine patients who developed PEP despite PPS placement at the initial ERCP. PEP was considered to have been caused by premature PPS dislodgement or stent obstruction. This observation also strengthens the proposed mechanism of rescue ERCP and PPS placement. Two of the nine patients had obstructed PPSs, one caused by blood and the other by purulent material from concurrent cholangitis. The other seven patients with PEP had early stent dislodgement. Premature stent dislodgement before 24 hours may result in PEP. In the recent article, four patients were initially stented with unflanged PPSs. The onset of PEP was 0 – 22 hours after initial ERCP, except for one patient who astonishingly developed PEP after 68 hours. Spontaneous stent dislodgement of unflanged stents occurs in 95 % of all cases within 2 days without any consequences [5]. This latter patient had a history of recurrent acute pancreatitis, and therefore we strongly suspect that this patient had another attack of acute pancreatitis rather than a complication of premature stent dislodgement, although the therapy for this attack was brilliant with the “double barrel” method described. The remaining five patients with initial stenting received PPSs with inner flanges. The two patients with PPS obstruction were among them. As these stents were originally designed to prevent unwanted dislodgement, it would be very interesting to know whether the other three patients had any risk factors (e. g. post-papillotomy bleeding, pancreatic sphincterotomy or dilated pancreatic duct) that could explain the premature stent dislodgement. The concept of rescue or salvage ERCP with PPS placement and the initial results are very promising, so we would also urge a randomized trial on this topic. As a relatively low case number would be expected, international multicenter collaboration would be ideal. Finally, attempted but unsuccessful PPS placement dramatically increases the risk of PEP, to up to 66 %. Therefore, we must emphasize that failure of rescue or salvage ERCP and PPS placement in patients who are already at a risk for further progression of an ongoing PEP might be extremely dangerous in the hands of inexperienced endoscopists [6].

Pancreatic cancer is a disease with a poor prognosis usually diagnosed at a late stage. Therefore, screening, diagnosis, treatment and palliation of pancreatic cancer patients require up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available scientific evidence and international guidelines. The preparatory and consultation board appointed by the Hungarian Pancreatic Study Group translated and complemented/modified the recent international guidelines. 37 clinical statements in 10 major topics were defined (Risk factors and genetics, Screening, Diagnosis, Staging, Surgical care, Pathology, Systemic treatment, Radiation therapy, Palliation and supportive care, Follow-up and recurrence). Evidence was graded according to the National Comprehensive Cancer Network (NCCN) grading system. The draft of the guideline was presented and discussed at the consensus meeting in September 12, 2014. Statements were accepted with either total (more than 95% of votes, n = 15) or strong agreement (more than 70% of votes, n = 22). The present guideline is the first evidence based pancreatic cancer guideline in Hungary that provides a solid ground for teaching purposes, offers quick reference in everyday patient care and guides patient financing options. The authors strongly believe that these guidelines will become a standard reference for pancreatic cancer treatment in Hungary.