Use of PEP prophylaxis techniques may diverge from the evidence

In the United States, endoscopists who participate in advanced endoscopy fellowship programs use rectal NSAIDs more often than pancreatic duct stent placement to prevent post-ERCP pancreatitis (PEP), according to research published online in Gastrointestinal Endoscopy. In addition, methods for PEP prophylaxis in clinical practice are not implemented to the extent that the current evidence warrants.

“Future studies should not only further clarify the optimal PEP prophylaxis strategy, but should also focus on strategies to improve the implementation of evidence-based PEP prophylaxis techniques,” wrote Patrick Avila, MD, MPH, gastroenterologist at the University of California, San Francisco, and colleagues.

A survey of American endoscopists

Approximately 4% of patients who undergo biliopancreatic endoscopy develop PEP, which has a mortality rate of 3%. The American Society for Gastrointestinal Endoscopy (ASGE) recommends prophylactic pancreatic duct stent placement and rectal NSAIDs to reduce the incidence and severity of PEP in patients at high risk. The ASGE further suggests that rectal indomethacin may decrease the risk and severity of PEP in patients at average risk.

The European Society for Gastrointestinal Endoscopy (ESGE) recommends rectal indomethacin for all patients undergoing ERCP (endoscopic retrograde cholangiopancreatography). Several surveys of European endoscopists, however, indicate that relatively few respondents have adopted the recommended prophylactic techniques. The literature does not contain information about practice patterns among American endoscopists, and Dr. Avila and colleagues decided to investigate this question.

The researchers developed a 16-question online survey to assess current practice patterns with regard to PEP prophylaxis. They defined ERCPs that entailed a high risk for PEP as any that involved pancreatic or precut sphincterotomy, traumatic biliary sphincterotomy, balloon dilation of the biliary sphincter, injection of the pancreatic duct, extensive pancreatic duct instrumentation, difficult cannulation, suspected sphincter of Oddi dysfunction, previous PEP, or a female patient. Dr. Avila and colleagues distributed the survey to 233 advanced endoscopists involved in advanced endoscopy fellowship training programs.

Respondents had years of experience

Sixty-two endoscopists (26.7%) completed the survey. Respondents’ mean age was 47 years, and most respondents (74.6%) had been performing ERCP for more than 5 years. Almost all respondents (95%) worked at a tertiary referral center, and all worked with fellows.

All respondents reported having used pancreatic duct stent placement to prevent PEP. Most responders (72%) used pancreatic duct stent placement only in patients at high risk of PEP, and 64% reported using pancreatic duct stent placement in 25% or less of the ERCPs that they had performed. Four respondents (6.8%) used pancreatic duct stent placement for PEP in more than half of ERCPs. Among endoscopists who rarely use pancreatic duct stent placement for PEP, the major reasons cited included concern about increased risk of PEP with failed pancreatic duct insertion, the belief that stents do not provide additional benefit beyond pharmacologic prophylaxis, and difficulties in following up patients to ensure stent passage.

About 98% of respondents reported using rectal NSAIDs for PEP. Thirty-four respondents (59.7%) used this treatment only for patients at high risk, and 23 respondents (40.1%) used it for patients at average risk. Among respondents who used rectal NSAIDs to prevent PEP, 67.8% used the treatment in half or more of ERCPs. The NSAID of choice was indomethacin for all respondents. One respondent reported never using rectal NSAIDs for PEP because of doubts about its efficacy, in addition to cost and availability.

In addition, 49 respondents (83.0%) reported using rapid intravenous fluids to prevent PEP. None reported using octreotide or antibiotics to prevent PEP.