GIE Associate Editor Shivangi T. Kothari, MD, FACG, FASGE, highlights this article from the March issue: “Impact of difficult biliary cannulation on post-ERCP pancreatitis: secondary analysis of the stent versus indomethacin trial dataset” by Samuel Han, MD, MS, et al.

Post-ERCP pancreatitis (PEP) remains one of the most unpredictable, humbling, and challenging adverse events of ERCP. This study highlights novel points in the causality of PEP, such as the number of pancreatic duct (PD) wire passages was found to be a stronger predictor of PEP risk than traditionally considered factors such as precut sphincterotomy, cannulation attempts, or PD contrast injections.

PEP rates with ≥4 PD wire passages were noted to be approaching >50% with the patients randomized to rectal indomethacin alone without a PD stent placement. The finding that PEP risk increases significantly after ≥4 PD wire passages provides a new metric for clinicians to monitor during ERCP and, rather than advancing the guidewire against resistance or through side branches, it may be better practice to inject a small amount of contrast to delineate the anatomy and then safely advance the wire.

This study suggests that although contrast injection is often avoided to reduce PEP risk, limited use may aid in wire placement and improve procedural efficiency and thereby improve PEP rates and overall procedural technique and outcomes. The study also reinforces the effectiveness of combining rectal indomethacin with prophylactic PD stent placement, especially in cases of multiple PD wire passages.

This finding may influence clinical practice to lower the threshold for PD stent placement in patients experiencing inadvertent wire passages into the PD. Current guidelines recommend PD stents for high-risk patients, but this study suggests that even patients with a few unintended PD wire passages might benefit. The study raises the need for further investigation into the optimal type, length, and safety of PD stents, particularly in nontertiary hospital settings.

This study gives crucial insights into the key procedural factors contributing to PEP in patients with difficult biliary cannulation or those at high risk for PEP, particularly emphasizing the overlooked role of PD wire passages. This research challenges traditional assumptions by demonstrating that repeated PD wire passages, rather than the number of cannulation attempts or contrast injections, are the strongest predictors of PEP risk. Also, performing a biliary, pancreatic, or precut sphincterotomy was not associated with an increased risk of PEP in the difficult biliary cannulation cohort.

Furthermore, it reinforces the protective role of combining rectal indomethacin with prophylactic PD stent placement, suggesting a potential need to revise current practices to lower the threshold for PD stenting even in the absence of a difficult cannulation with a few inadvertent wire passages into the PD. By shedding light on these critical factors, the study offers valuable implications for improving ERCP techniques, optimizing PEP prevention strategies, and guiding future research on stent selection and procedural best practices.

My key takeaway from the study is to maintain a low threshold for placing a PD stent if the guidewire advances into the PD more than once. In addition, administering rectal indomethacin (when not contraindicated) is essential for reducing PEP risk.

Finally, in our clinical practice, we keep a stent log, and I strongly recommend that diligent follow-up is crucial to ensure timely PD stent removal or confirmation of its passage via x-ray.

The rate of PEP stratified by number of PD wire passages and prophylaxis intervention. PEP, Post-ERCP pancreatitis; PD, pancreatic duct.

Read the full article online.

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