THE GREAT DEBATE # 3
Pro: ERCP is indicated in ABP
Manuel Pérez-Miranda
Hospital Universitario Río Hortega
Valladolid, Spain
Quality in Endoscopy: ERCP, Munich 2011
Early ERCP in ABP
Quality in Endoscopy: ERCP, Munich 2011
Early ERCP in ABP
Quality in Endoscopy: ERCP, Munich 2011
Elective ERCP in ABP
1. High surgical risks
2. Necrotizing pancreatitis
3. Pregnancy
4. Postcholecystectomy
Quality in Endoscopy: ERCP, Munich 2011
Elective ERCP in ABP
Endoscopic
Cholecystectomy
Sphincterotomy
(ES)
n
16
32
AGE mean (range)
70.5 (21-83)
82.4 (68-97)
Mean ASA Score
1.7
3.2
Sánchez-Antolín, Digestive Disease Week 1999
Quality in Endoscopy: ERCP, Munich 2011
Pancreatic Stent in necrotizing AP
Kozarek, GI Endosc 2002
Quality in Endoscopy: ERCP, Munich 2011
RCTs on early ERCP for ABP
Significant
Reduction
morbidity
mortality
1988
NEOPTOLEMOS, UK
yes
no
predicted severe
1993
FAN, HONG-KONG
yes
no
biliary sepsis
1997
FÖLSCH, GERMANY
no
no
Bb > 5 mg/dL excl.
1995
NOWAK, POLAND
yes
yes
best < 24 hrs
2007
ORIA, ARGENTINA
no
no
CBDS w/o cholang
Quality in Endoscopy: ERCP, Munich 2011
Quality in Endoscopy: ERCP, Munich 2011
Quality in Endoscopy: ERCP, Munich 2011
Quality in Endoscopy: ERCP, Munich 2011
p > 0.05
p > 0.05
SOFA: Sequential Organ Failure Assessment score.
Quality in Endoscopy: ERCP, Munich 2011
Quality in Endoscopy: ERCP, Munich 2011
Katowice: Design
Years
1984-1993
280
patients
with ABP
DUODENOSCOPY
within 24 hours
Impacted stone
Normal
RANDOMIZATION
178
75
103
75
ES
103
102
Conventional
management
Quality in Endoscopy: ERCP, Munich 2011
Results of treatment
Significance of ES timing
40%
0.000
30%
p for trend
0.001
n = 307
32
20%
Complication
16
10%
0%
2
7
1
(n=76)
2-3
(n=160)
13
Death
>3
(n=71)
Days between pain onset andQuality
ESin Endoscopy: ERCP, Munich 2011
Results of treatment
AP predicted severity (Ranson)
Sphincterotomy
Mild
100%
100%
n=137
75%
9
1
50%
100%
Severe
5
0%
p=0.0000
p=0.0000
100%
n=41
75%
25%
20
25%
0%
50%
n=75
75%
p=0.005
50%
25%
Conventional management
34
75%
p=0.006
7
0%
50%
n=27
41
33
25%
0%
Recovery
Complications
Death
Quality in Endoscopy: ERCP, Munich 2011
Results of treatment
Common bile duct stones
No CBD stones
Sphincterotomy
100%
100%
n=50
75%
14
2
50%
CBD stones
11
0%
p=0.979
100%
p=0.837
100%
n=128
75%
25%
25
25%
0%
50%
n=61
75%
p=0.039
50%
25%
Conventional management
15
p=0.001
2
0%
n=41
75%
50%
25%
27
15
0%
Recovery
Complications
Death
Quality in Endoscopy: ERCP, Munich 2011
PANCREATIC SPHINCTER IN ABP
Hernandez & Lerch, Lancet 1993
Quality in Endoscopy: ERCP, Munich 2011
Early ERCP in ABP
Patient Population
D
B
C
E
N
O
T
S
T
N
E E
T
IS ON
S
R ST
E
P BD
C
Y N
R
A TIO
I
L
IC
BI RUC
T
A
T
E
S
R T ON
C
OB
N UC T I
S
A
TI
D UC
I
P
G
R
N
T
A
S
L
B
O
O
H
C
Quality in Endoscopy: ERCP, Munich 2011