Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) stands as the primary choice for treating pancreatobiliary disorders. Among its complications, post-ERCP pancreatitis (PEP) is the most frequent, with a prevalence ranging from 4-10%, and reaching up to 15% in high-risk patients. To mitigate the hydrostatic pressure contributing to PEP in high-risk patients, the insertion of a pancreatic duct stent is considered a preventive measure. The available options for pancreatic duct stenting include plastic pancreatic stents (PPS) and biodegradable stents (BDS) placement; However, currently, there is no available data on their efficacy, nor the best setting for choosing between the two.

Aims & Methods

Our aim is to compare the effectiveness of PPS vs BDS for the preventing PEP. A single-center, prospective, randomized controlled trial (RCT) in patients with biliary tract disease requiring ERCP was conducted from January/2022 to June/2023. Subjects ≥18 years-old, with a non-manipulated pancreatic papilla and written informed consent were included in the study. Patients not requiring or failed stenting, hemodynamically unstable, pregnant or nursing subjects, at risk of fluid overload, cholangitis, sepsis, acute/flared-up chronic pancreatitis, recent biliary tract manipulation, uncontrolled coagulopathy, kidney or liver failure or comorbidities impacting the cardiac-risk assessment were excluded. During ERCP, PPS (5Fx4cm) or BDS (6Fx4cm or 6Fx6cm) were randomly selected and placed. At three-days and five-weeks post-procedure, the patients required follow-up assessment to rule-out PEP based on physical examination findings, laboratory tests (amylase, lipase, PCR, WBC and total bilirubin), abdominal ultrasound, and history of any post-ERCP hospitalization.

Results

Ninety-seven patients were enrolled (54 BDS and 43 PPS), with a median age of 53 years, 63.9% females. The main indication for ERCP was choledocholithiasis (89.7%). The median time for biliary cannulation was 5 minutes, requiring sphincterotomies in 90/97 patients. Additionally, from the 43/97 PPS cohort, biliary stents simultaneous placement was required in 13/43 (30.2%), compared to 4/54 from BDS cohort (7.4%; p=.0076). It was shown that median post-ERCP total bilirubin was significantly lower in both PPS (1.04 vs 0.96; p=.0338) and BDS cohort (1.04 vs 0.52 mg/dL; p=.0044). The same was observed for median C-reactive protein in PPS (7.03 vs 4.10 mg/dL; p=.0338) and BDS (11.2 vs 5.1 mg/dL; p=.01). Meanwhile, median post-ERCP lipase was significantly higher in both PPS (47 vs 54.8 mg/dL; p=.05) and BDS (48.5 vs 110 mg/dL; p=.0134). PEP was noticed in 8/97 (8.2%), with no significant difference in prevention when PPS and BDS were compared (14% vs 3.7%; p=.133).

Conclusion

A lower but non-significant rate of PEP prevention using BDS vs PPS was noticed. The significant reduction on total bilirubin levels, mainly in the BDS cohort, deserves further studies that must be conceived around this endpoint.

References

1. Cahyadi O, Tehami N, de-Madaria E, Siau K. Post-ERCP Pancreatitis: Prevention, Diagnosis and Management. Medicina (Kaunas). 2022 Sep 12;58(9):1261. doi: 10.3390/medicina58091261 .
2. Borrelli de Andreis F, Mascagni P, Schepis T, Attili F, Tringali A, Costamagna G, Boškoski I. Prevention of post-ERCP pancreatitis: current strategies and novel perspectives. Therap Adv Gastroenterol. 2023 Mar 6;16:17562848231155984. doi: 10.1177/17562848231155984 .
3. Thiruvengadam NR, Kochman ML. Emerging Therapies to Prevent Post-ERCP Pancreatitis. Curr Gastroenterol Rep. 2020 Nov 13;22(12):59. doi: 10.1007/s11894-020-00796-w .
4. Johnson KD, Perisetti A, Tharian B, Thandassery R, Jamidar P, Goyal H, Inamdar S. Endoscopic Retrograde Cholangiopancreatography-Related Complications and Their Management Strategies: A "Scoping" Literature Review. Dig Dis Sci. 2020 Feb;65(2):361-375. doi: 10.1007/s10620-019-05970-3 . Epub 2019 Dec 2.

Disclosure

Carlos Robles-Medranda is a key opinion leader and consultant for Pentax Medical, Steris, Medtronic, Motus, Micro-tech, G-Tech Medical Supply, CREO Medical, EndoSound, and mdconsgroup. All other authors declare no conflicts of interest.

Introduction

Effective timing of endoscopic interventions and follow-ups is crucial in the management of severe acute pancreatitis. Implementing a multidisciplinary team (MDT) approach not only enhances this timing but also ensures consistent clinical care, providing rapid responses to complications and timely adjustments in treatment plans. This coordinated approach optimises recovery and improves patient outcomes by integrating timely diagnostics and interventions. The MDT’s strategic involvement is vital for maintaining high standards of care and safety and ensuring consistent and effective treatment of severe acute pancreatitis.

Aims & Methods

This retrospective cohort study assessed the impact of a novel hub-and-spoke severe acute pancreatitis (SAP) multidisciplinary team (MDT) model at a tertiary hepato-pancreato-biliary (HPB) centre. The model, which included Gastroenterologists, Surgeons, Nurses, Dieticians, and Radiologists, focused on optimising clinical outcomes by enhancing the coordination of hospital transfers and precision in the timing of interventional endoscopies. The study compared patient outcomes before the MDT implementation (January 2022 to January 2023) and after (November 2023 to March 2024), to improve intervention scheduling and establish systematic follow-up protocols to ensure comprehensive care. The primary objective was to evaluate how the MDT model influenced the timing of interventions and follow-up procedures in severe acute pancreatitis management.

Results

This study evaluated clinical outcomes for acute pancreatitis across two cohorts, comprising 191 patients before the implementation of a multidisciplinary team (MDT) and 76 patients following the implementation. For the pre-MDT cohort, the aetiology of pancreatitis included gallstone-induced cases (n=50), alcohol-related (n=45), idiopathic (n=2), and unspecified (n=94), with 28.79% of the cohort having a history of gallstones. In the pre-MDT group, the scheduling of interventions lacked consistency. 10 patients required inpatient endoscopic procedures, with a median time from admission to intervention of 13.0 days and a mean time of 12.79 days.
Post MDT implementation, 7 patients required inpatient endoscopic procedures, with waiting times reduced to a median of 6.5 days and a mean of 6.3 days. All these inpatients (n=7/7) received their procedures within the first week. The median duration of hospital stays was reduced from 8 days (pre-MDT) to 5 days (post-MDT). Additionally, the proportion of inpatients discharged within the first week post-intervention increased from 30% (n=3/10) pre-MDT to 71.4% (n=5/7) post-MDT. The average clinic follow-up time decreased from 169 days pre-MDT to 43 days post-MDT. The median timing to outpatient endoscopy was reduced, with 68% of patients receiving it in a six-week window post-discharge.

Conclusion

The integration of a multidisciplinary team (MDT) has markedly improved the management of severe acute pancreatitis, enhancing the precision and efficiency of interventional endoscopies. This optimised coordination has reduced hospital stays and ensured timely interventions, significantly boosting patient outcomes. The MDT approach effectively addresses the complexities of the condition, transforming patient care with tailored and rapid treatment strategies.

Disclosure

No disclosures

Introduction

Colorectal cancer (CRC) patients commonly encounter anemia, with estimates indicating that up to 58% are affected and iron deficiency (ID) anemia being the most prevalent. This study aimed to compare the efficacy and safety of preoperative intravenous iron (IVI) with standard care (no iron or oral iron) in CRC patients with ID anemia.

Aims & Methods

We conducted a systematic search of the Cochrane Library, PubMed, Scopus, and Web of Science databases from inception to September 20, 2023, to identify studies comparing intravenous iron (IVI) versus standard care in colorectal cancer (CRC) patients with iron deficiency anemia. Pooled results were analyzed for changes in hemoglobin (Hb) levels from baseline, need for red blood cell (RBC) transfusions, mean number of RBC units transfused, overall survival (OS), disease-free survival (DFS), and complications.We evaluated randomized clinical trials using the Cochrane Risk of Bias 2 tool and observational studies using the Newcastle Ottawa Scale. Statistical analysis was performed using Revman software Version 5.4.1.

Results

We analyzed data from 11 studies, encompassing 2,024 patients, and found that IVI significantly increased Hb levels at various crucial time points: preoperative (MD=1.17, CI 95% [0.95, 1.40], P<0.01), postoperative day one (MD=1.32, CI 95% [0.89, 1.76], P<0.01), hospital discharge (MD=0.76, CI 95% [0.28, 1.24], P=0.002), and 30 days postoperative (MD=1.57, CI 95% [1.27, 1.87], P<0.01). The overall need for RBCT significantly decreased with IVI (RR=0.39, CI 95% [0.27, 0.56], P<0.01), particularly in the postoperative period (RR=0.69, CI 95% [0.52, 0.92], P=0.01). No significant differences were found between preoperative and intraoperative periods. IVI notably reduced transfused red blood cell units, total complications, and wound dehiscence. However, there were no significant differences in total death, hospital stay, OS and DFS.

Conclusion

Preoperative IVI significantly increased Hb levels at critical time points and markedly reduced the overall need for RBCT, complications, and wound dehiscence. To further validate these findings, more well-designed randomized controlled trials are warranted.

Introduction

Managing decompensated cirrhosis is a significant challenge due to high morbidity and mortality rates. The recently proposed Baveno VII criteria provide a standardized definition to assess recompensation. In this study, we validated the Baveno VII definition of recompensation and aimed to evaluate recompensation factors in patients with decompensated viral cirrhosis.

Aims & Methods

This is a retrospective descriptive study over a 10-year period between 2012 and 2022, enrolling 99 patients from the hepato-gastroenterology department of Mohamed Taher Maamouri Hospital in Nabeul who had been treated for decompensated viral cirrhosis B or C and achieved sustained virological response with a follow-up of at least 12 months.

Results

A total of 99 patients with decompensated viral cirrhosis (B or C), who had received treatment and achieved sustained virological response, were included in the study. The mean age was 62 ± 11 years, and 56 patients were female. The most common mode of decompensation was ascites, observed in 81.8% of the patients. The mean MELD score was 15 ± 4, and the majority (59.7%) were classified as Child-Pugh class B. Overall, 45.5% of the decompensated patients achieved recompensation during the study period. The recompensation rate was higher in patients with hepatitis B-related cirrhosis (51.1%) compared to those with hepatitis C-related cirrhosis (40.4%).
According to the results of logistic regression, four independent factors associated with recompensation were found: albumin ( OR = 2.033, IC95% [1,461-2,827], p<0.001 ), diabetes ( OR =0.003, IC95%[0.000-0.045], p<0.001 ), Child Pugh score ( OR=0.162, IC95% [0.057-0.459], p=0.001 ), INR ( OR =0.017, IC95%[0.000-0.939].

Conclusion

This study identified key factors associated with recompensation in patients with viral decompensated cirrhosis, including serum albumin levels, INR values, history of diabetes, and severity of liver disease. The knowledge of recompensated indicators may help support the development of different prevention strategies to reduce the incidence of acute decompensation.

Introduction

In the early phase of acute pancreatitis (AP), fluid resuscitation plays a crucial role. Changes in fluid distribution, increased capillary permeability, minimized intravascular volume, and loss of vascular resistance may lead to cardio-vascular and renal failure. On the other hand, overhydration is associated with cardiac decompensation and respiratory failure. Previously, intensive fluid therapy with large volumes of crystalloids was recommended without addressing individual needs for fluid therapy.
We used measurements of physiological parameters focusing on cardiac function and changes in body composition, to study the association between fluid therapy and physiological response, in the patient with AP.

Aims & Methods

This study aimed to assess fluid distribution in relation to fluid therapy, inflammation, and cardiac- and renal function in the early phase of AP.
This was a single-centre, prospective observational cohort study. On baseline, day 1, 2, 10 and 90 following were assessed: preload dependency (passive leg raise manoeuvre and defined as a >10% increase in stroke volume), hemodynamic parameters (stroke volume, cardiac output measured by non-invasive monitoring (Non-invasive LiDCOrapidTM; LiDCO, London, UK)), bioimpedance variables (weight, extracellular water (ECW), total body water(TBW) by seca mBCA 525, Germany). White blood count (WBC), C-reactive protein (CRP), and creatinine were measured and Modified Marshall score was calculated on each time point. Data are presented as medians with interquartil range (IQR). [jK1] Pearson correlation coefficient was used to assess the relationship between changes in weight and haemodynamic and bioimpedance parameters.

Results

Eighty-eight patients with first-time AP were included. Median age was 58 years, 46 were females. Gallstones were the predominant etiology (55%). At baseline, 35 patients (40%) were preload dependent. However, the median increase in weight during the first 10 days of admission was 2.65 kg (IQR: 0.9;4.73). Across time points, patients in the fourth upper quartile of weight increase had significantly higher volume of ECW than patients in the 1-3. quartile (p=0.02). No differences were observed for stroke volume, nor cardiac output. CRP was significantly higher in patients in the fourth upper quartile of weight increase than in patients in quartile 1-3. No difference was found for WBC and creatinine.
We found a significant correlation between increasing bodyweight and extracellular water volume, R=0.383, (p<0.0001), but not between increasing bodyweight and stroke volume R=-0.016 (p=0.783) or cardiac output, R=0.015 (p=0.796). Also, a significant correlation was found between creatinine and increasing weight, R=0.229 (p<0.0001). Modified Marshall score was significantly correlated to increasing body weight, R=0.159 (p=0.006).

Conclusion

The assessment of hydration status in AP requires an in-depth knowledge of body fluid homeostasis. Our data provide physiological rationale for emerging evidence regarding more restricitive fluid resuscitation. Personalized- and goal directed therapy may be a promising novel way in the transition from necessary fluid resuscitation to harmful fluid volume accumulation in the early phase of AP.

References

The Interplay between Inflammation, Coagulation and Endothelial Injury in the Early Phase of Acute Pancreatitis: Clinical Implications.
Dumnicka P, Maduzia D, Ceranowicz P, Olszanecki R, Drożdż R, Kuśnierz-Cabala B.
Int J Mol Sci. 2017 Feb 8;18(2):354. doi: 10.3390/ijms18020354.
Tenner S, Baillie J, DeWitt J, Vege SS;
American college of Gastroenterology guideline: management of acute pancreatitits
Am J Gastroenterol 2013; 108: 1400-16.27.
Working group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidencebased guidelines for the management of acute pancreatitis
Pancreatology 2013; 13:Suppl 2:e1-e15
Disturbances of the microcirculation in acute pancreatitis.
Cuthbertson CM, Christophi C.
Br J Surg. 2006 May;93(5):518-30. doi: 10.1002/bjs.5316.
Fluid Resuscitation in Acute Pancreatitis - Going over the WATERFALL.
Gardner TB
N Engl J Med. 2022 Sep 15;387(11):1038-1039. doi: 10.1056/NEJMe2209132.

Introduction

With the advent of EUS guided biliary interventions, there is a lot of hype created that ERCP will cease to be performed. The most important and limiting factor for ERCP is successful bile duct cannulation. We have studied a large series of our cases and tried to study the impact of properly performed precut on success of bile duct cannulation.

Aims & Methods

Aim: To analyze the efficacy of freehand precut for selective cannulation in difficult ERCP and its role in improving technical success rate, obviating need for EUS guided / other rendezvous techniques.
Methods: Retrospective analysis of 3000 patients undergoing ERCP from 2017 till date for varied etiologies. No. of patients required precut accessotomy were noted and technical success rate was measured.

Results

No. of patients analyzed- 3000. Selective biliary cannulation- 2452 (81.74%). Difficult cannulations requiring freehand precut accessotomy- 548 (18.26%). Technical success after precut achieving biliary access- 539 (98.36%). Failure of biliary cannulation even after precut- 09 (1.64%). Most common etiology in precut casesstone disease 360 (65.70%) followed by malignant lesions 118 (21.53%), benign strictures 28 (5.11%), post cholecystectomy biliary leak 28 (5.11%), post traumatic biliary leak 10 (1.82%), post hydatid surgery biliary leak 02 (0.36%), post central hepatectomy biliary leak 02 (0.36%). Most common cause for failure in precut cases was extensive edema and deformed anatomy. Of all failed cases 3 were large stones who were subjected to surgery and 6 were malignant lesions who were subjected to EUS guided biliary drainage.

Conclusion

Free hand precut technique, done correctly, is a savior in difficult cannulation cases and it increases the success rate of selective biliary cannulation significantly avoiding the need for other costlier techniques such as EUS guided / Rendezvous techniques.

References

Mariani A, Di Leo M, Giardullo N, Giussani A, Marini M, Buffoli F, Cipolletta L, Radaelli F, Ravelli P, Lombardi G, D'Onofrio V, Macchiarelli R,
Iiritano E, Le Grazie M, Pantaleo G, Testoni PA. Early precut sphincterotomy for difficult biliary access to reduce post-ERCP pancreatitis: a randomized trial. Endoscopy. 2016 Jun;48(6):530-5. doi: 10.1055/s-0042-102250. Epub 2016 Mar 18. PMID: 26990509.
Davee T, Garcia JA, Baron TH. Precut sphincterotomy for selective biliary duct cannulation during endoscopic retrograde cholangiopancreatography. Ann Gastroenterol. 2012;25(4):291-302. ​PMID: 24714256; PMCID: PMC3959408.

Introduction

Acute pancreatitis (AP) often has unpredictable and complicated clinical course. Numerous biochemical predictors may aid in the risk stratification of AP (including interleukin 6 (IL-6)), but none of them are accurate. YKL-40 is glycoprotein playing mayor role in inflammation and angiogenesis, with reported average serum concentrations of ≥ 190 ng/mL in inflammatory diseases. It has been shown that IL-6 stimulates the production of YKL-40 and, in reverse, YKL-40 (at least in some tissues) induces the production of IL-6.

Aims & Methods

The aim of our study is to assess whether combined concentrations of both YKL-40 and IL-6 could be more informative in risk stratification of developing more severe form of AP than concentrations of either biomarker alone.
We included 150 consecutive consenting adults with AP admitted to Sestre milosrdnice UHC, Zagreb (June 2020-June 2023). Patients with any acute/chronic diseases known to be associated with dysregulated expression of YKL-40 were excluded. Alongside routine laboratory studies (including C-reactive protein (CRP)), 7 mLs of blood were withdrawn for determining YKL-40 and IL-6 concentrations on admission and 48h after. Severity of disease was defined using revised Atlanta classification. Blood samples for YKL-40 and IL-6 quantification in 30 consenting non-AP adults consistent with previously mentioned exclusion criteria were withdrawn. They were matched 1:1 by age and sex to randomly selected 10 patients from each of AP severity categories. Analysis were performed using enzyme-linked immunosorbent assays. AP patients were classified into 2 categories for each biomarker (based on YKL-40 and IL-6 concentrations on admission and 48h after): 1. for YKL-40: low (<190 ng/mL) and high (≥190 ng/mL); 2. for IL-6: low (<42 pg/mL) and high (≥42 pg/mL). Cumulative multimodal logit models were fitted to ordinal outcome “AP severity” – using raw data, and data after entropy balancing undertaken to balance the two categories of YKL-40 and IL-6 concentrations on age, sex, time between symptom onset and admission, and CRP concentrations.

Results

The results showed lower YKL-40 (<50 ng/mL) and IL-6 (<20 pg/mL) concentrations in 30 non-AP adults compared to AP patients. At both time points (on admission and 48h after), odds of more severe AP were clearly higher with YKL-40 and IL-6 concentrations above vs. below the cut-off values (190 ng/mL and 42 pg/mL, respectively), and were particulary higher in patients with both cytokines above the cut-off vs. patients with both cytokines below the cut-off. The same relationship was maintained with adjustments for age, body mass index, days elapsed since symptom onset and admission, and for CRP concentrations – however, the strength of association was lower. This is in line with the fact that high CRP concentration predicts more strongly severe AP forms when taken 48h after compared to admission. This phenomenon was apparent also when the interaction term was included in the model: at CRP concentrations 45 mg/L, neither YKL-40, or IL-6 or their combination above the cut-off values were associated with the outcome; at CRP concentrations 90 mg/L, odds were higher, and were particularly high for a combination of high YKL-40 and high IL-6. The same was observed at CRP concentrations 180 mg/L.

Conclusion

Overall, data suggest that combined YKL-40 and IL-6 concentrations in acute AP, taken either on admission or 48h after, predict more strongly moderate and/or severe (vs. mild) AP than either cytokine alone, and do so 'on-top' of the CRP concentrations.

References

1. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG et al. Classification of acute pancreatitis - 2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102–111.
2. van den Berg FF, de Bruijn AC, van Santvoort HC, Issa Y, Boermeester MA. Early laboratory biomarkers for severity in acute pancreatitis; A systematic review and meta-analysis. Pancreatology. 2020;20(7):1302-1311.
3. Tizaoui K, Yang JW, Lee KH, Kim JH, Kim M, Yoon S et al. The role of YKL-40 in the pathogenesis of autoimmune diseases: a comprehensive review. Int J Biol Sci. 2022;18(9):3731-3746. doi: 10.7150/ijbs.67587.
4. Blazevic N, Rogic D, Pelajic S, Miler M, Glavcic G, Ratkajec V et al. YKL-40 as a biomarker in various inflammatory diseases: A review. Biochem Med. 2023;34(1):010502.