Douglas G. Adler, MD, FACG, FASGE

Douglas G. Adler, MD, FACG, FASGEProfessor of Medicine

Director of Therapeutic EndoscopyUniversity of Utah School of Medicine

Patient Selection If you forget everything else I say in this talk… Must have a solid indication such as:

Obstructive Jaundice Confirmed choledocholithiasis Bile or pancreatic duct leak Malignancy Ascending cholangitis

2016 ACG Governors/ASGE Best Practices Course Copyright 2016 American College of Gastroenterology

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Douglas G. Adler, MD, FACG, FASGE

Patient Selection I lean HEAVILY on pre-ERCP imaging CT

Pancreatic cancer MRI

Suspected stones PSC Cholangiocarcinoma

EUS Suspected stones Questionable IOC

Question A 35-year-old female is referred to you for removal of a

5mm bile duct stone. She has never undergone an ERCP previously. Should you administer her rectal NSAIDS?

A) No, she is likely low risk with regards to PEP B) Yes, she should get rectal NSAIDs but BEFORE the ERCP C) Yes, she should get rectal NSAIDs but AFTER the ERCP D) Why would you put NSAIDs in somebody’s rectum?

2016 ACG Governors/ASGE Best Practices Course Copyright 2016 American College of Gastroenterology

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Douglas G. Adler, MD, FACG, FASGE

Rectal NSAIDS to reduce PEP An old idea being given new life

Pharmacologic prevention of PEP= “Holy Grail” NSAID’s inhibit prostaglandins, phospholipase A2, and

neutrophil/endothelial interactions Studies of NSAIDS to reduce PEP have been performed

for well over a decade A 2008 meta-analysis of 4 RCTs by Elmunzer showed

that patients who received rectal NSAIDs were: 64% less likely to develop PEP 90% less likely to develop moderate to severe PEP

Elmunzer et al NEJM 2012 Multicenter, randomized, placebo-controlled, double-

blind trial of rectal indomethacin to reduce PEP 602 patients

295 received rectal indomethacin 307 received placebo

PEP: 27/295 (9.2%) in indomethacin group PEP: 52/308 (16.9%) in placebo group

800 pound gorilla

2016 ACG Governors/ASGE Best Practices Course Copyright 2016 American College of Gastroenterology

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Douglas G. Adler, MD, FACG, FASGE

Elmunzer et al NEJM 2012

But wait a second… 82% of patients in Elmunzer NEJM study had known

or suspected SOD 81 Type 1 274 Type 2 140 Type 3

Elmunzer NEJM study overwhelmingly studied very high risk patient cohort

Most ERCP’s do not involve SOD patients

2016 ACG Governors/ASGE Best Practices Course Copyright 2016 American College of Gastroenterology

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Douglas G. Adler, MD, FACG, FASGE

Risk Assessment? How accurately can we predict risk pre-ERCP?

Has the patient has PEP before? Will cannulation be easy or challenging? Will the pancreatic duct get injected during the case? Does the patient have aberrant anatomy? Will you have to use a needle knife? Will the patient need a PD stent?

To think or not to think…Use NSAIDs selectively Use NSAIDs universally Reserve for high risk patients Avoids an unnecessary

medication By an unpopular route

Saves money Nurses will like you more

Safe Cheap No need to risk-stratify prior

to ERCP Value in lower risk patients

may be less clear

2016 ACG Governors/ASGE Best Practices Course Copyright 2016 American College of Gastroenterology

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Douglas G. Adler, MD, FACG, FASGE

Timing of NSAID administration? Puig et al Plos One 2014 Meta-analysis of 9 RCT’s including 2133 patients Included studies of diclofenac and indomethacin NNT: 14 Risk of pancreatitis lower in the NSAID group

(RR 0.51; 95%CI 0.39–0.66) No benefit seen in older patients and in men No difference if NSAIDs given BEFORE or

IMMEDIATELY AFTER ERCP Wiggle room

Do Rectal NSAIDS obviate PD stents? An interesting question, but one not answered at this

time A 2013 meta analysis of 29 studies suggests that rectal

NSAIDs may be superior to prophylactic pancreatic duct stents in reducing PEP rates

Are rectal NSAIDs and PD stents better than either? If you think a PD stent is warranted, rectal NSAIDs are

not a reason not to go ahead and place one

Akbar et al CHG

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Douglas G. Adler, MD, FACG, FASGE

Question During ERCP of a patient with a confirmed bile leak

(s/p CCY), 15 minutes of attempts to cannulate the CBD with a sphincterotome do not result in deep access to either duct. The sphincterotome appears to be in a duct but you cannot get deep access.

At this point you should: A) Switch to a needle knife B) Inject to see where you are C) Attempt to pass a guidewire into the CBD D) Abort the procedure

Answer: C (probably) Most high-volume ERCP performers would likely

attempt utilize guidewire cannulation techniques to access the biliary and/or pancreatic ducts.

The gentle injection of contrast in an attempt to visualize ductal anatomy is not wrong per se, but may increase your risk of pancreatitis, especially if it is performed repeatedly.

You could consider a needle knife at this point, but most would not.

2016 ACG Governors/ASGE Best Practices Course Copyright 2016 American College of Gastroenterology

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Douglas G. Adler, MD, FACG, FASGE

Guidewire cannulation Guidewire advancement into the papilla

Must use a soft-tipped wire Can be done will all sizes of guidewires

0.018, 0.025, 0.035 wires all acceptable Contact is with tip of tome or tip of wire

No “pencil tips” “A weapon”

Risks Intramural extension, PD injury, perforation

2016 ACG Governors/ASGE Best Practices Course Copyright 2016 American College of Gastroenterology

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Douglas G. Adler, MD, FACG, FASGE

What is Guidewire Cannulation? Guidewire cannulation (GC): A set of techniques

utilizing catheters/sphincterotomes and guidewires to access the biliary and pancreatic ducts without the use of contrast dye.

If you are using dye injection in any form during cannulation attempts, this is not considered guidewire cannulation

2016 ACG Governors/ASGE Best Practices Course Copyright 2016 American College of Gastroenterology

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Douglas G. Adler, MD, FACG, FASGE

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Douglas G. Adler, MD, FACG, FASGE

Post-ERCP pancreatitisPost-ERCP Pancreatitis

No pancreatitis

StandardCannulationN=195

8 6 mild1 moderate1 severe

187

Guidewire-cannulationN=197

0 197

Lella GIE 2004

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Douglas G. Adler, MD, FACG, FASGE

Adler et al JCG 2009822 patientsSingle operatorPhysician controlled guidewireAlmost 100% of cases with 0.025” wires and

narrow-tipped sphincterotomes

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Douglas G. Adler, MD, FACG, FASGE

Guidewire CannulationCheung et al GIE 2009 Meta analysis of 7 RCT’s GWC associated with Higher Cannulation Success

(89% vs 78%, RR: 1.19, 95% CI: 1.05-1.35)

GWC associated with a lower rate of PEP (3.2% vs 8.7%, RR: 0.38, 95% CI: 0.19-0.76) PEP correlated w/ PD injection vs GW entry PEP after 2° precut - less w/ GW vs Contrast

Other AE’s comparable 89% vs 78%; RR 1.19; 95% CI, 1.05-1.35

* Cheung, Meta-analysis. GIE 2009.

Meta-Analysis: GW vs. Dye: Cannulation Success Rates

Cheung J GIE 2009

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Douglas G. Adler, MD, FACG, FASGE

Meta-Analysis: GW vs. Dye: Cannulation Success Rates

Cheung J GIE 2009

Reverse Two Wire Technique Can use the opposite of the Two Wire Technique if

attempts at PD cannulation only result in biliary access

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Douglas G. Adler, MD, FACG, FASGE

Question A 28-year-old woman with choledocholithiasis presents to

you for ERCP for sphincterotomy and stone extraction. What should you write as a fluid order for her?

A) IV to KVO B) Normal Saline, 1L, over the course of the procedure C) Lactated Ringer’s Solution, 1.5 mL/kg/h during and for 8

hours after procedure D) Lactated Ringer’s Solution, 3 mL/kg/h during the

procedure, a 20-mL/kg bolus after the procedure, and 3 mL/kg/h for 8 hours after the procedure

Answer: D (Maybe) Buxbaum et al CGH 2014 Randomized patients to aggressive hydration (n=39) or

standard hydration with LR (N=23) Monitored amylase, pain score, and volume overload at

2,8, and 24 hours after ERCP 0% with aggressive hydration developed PEP 17% with standard hydration developed PEP No patient developed volume overload

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Douglas G. Adler, MD, FACG, FASGE

IV Hydration to Prevent PEP?Pro

Cheap Simple Safe May produce significant

reduction in PEP rate

Con Small study Protocol may not work for

outpatient ERCP Inpatient stay adds cost Striking results in small

studies often not borne out in larger studies

Risk of CHF PEP rate in control group

quite high…

Conclusions We CAN improve cannulation rates

Guidewire cannulation PD stenting during cannulation

We CAN reduce post-ERCP pancreatitis rates Proper patient selection Rectal NSAIDs Prophylactic PD stents Hydration

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