Han Samuel, Zhang Jingwen, Durkalski-Mauldin Valerie, Foster Lydia D, Serrano Jose, Coté Gregory A, Bang Ji Young, Varadarajulu Shyam, Singh Vikesh K, Khashab Mouen, Kwon Richard S, Scheiman James M, Willingham Field F, Keilin Steven A, Groce J Royce, Lee Peter J, Krishna Somashekar G, Chak Amitabh, Slivka Adam, Mullady Daniel, Kushnir Vladimir, Buxbaum James, Keswani Rajesh, Gardner Timothy B, Wani Sachin, Edmundowicz Steven A, Shah Raj J, Forbes Nauzer, Rastogi Amit, Ross Andrew, Law Joanna, Yachimski Patrick, Chen Yen-I, Barkun Alan, Smith Zachary L, Petersen Bret T, Wang Andrew Y, Saltzman John R, Spitzer Rebecca L, Spino Cathie, Elmunzer B Joseph, Papachristou Georgios I
Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.
Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA.
Gastrointest Endosc. 2025 Mar;101(3):617-628. doi: 10.1016/j.gie.2024.10.003. Epub 2024 Oct 9.
Difficult biliary cannulation (DBC) is a known risk factor for developing post-ERCP pancreatitis (PEP). To better understand how DBC increases PEP risk, we examined the interplay between technical aspects of DBC and known PEP risk factors.
This was a secondary analysis of a multicenter, randomized controlled trial comparing rectal indomethacin alone with the combination of rectal indomethacin and prophylactic pancreatic duct (PD) stent placement for PEP prophylaxis in high-risk patients. Participants were categorized into 3 groups: DBC with high preprocedure risk for PEP, DBC without high preprocedure risk for PEP, and non-DBC at high preprocedure risk for PEP.
In all, 1601 participants (84.1%) experienced DBC, which required a mean of 12 cannulation attempts (standard deviation, 10) and mean duration of 14.7 minutes (standard deviation, 14.9). PEP rate was highest (20.7%) in DBC with a high preprocedure risk, followed by non-DBC with a high preprocedure risk (13.5%), and then DBC without a high preprocedure risk (8.8%). Increasing number of PD wire passages (adjusted odds ratio [aOR], 1.97; 95% confidence interval [CI], 1.25-3.1) was associated with PEP in DBC, but PD injection, pancreatic sphincterotomy, and number of cannulation attempts were not associated with PEP. Combining indomethacin with PD stent placement lowered the risk of PEP (aOR, .61; 95% CI, .44-.84) in DBCs. This protective effect was evident in up to at least 4 PD wire passages.
DBC confers higher PEP risk in an additive fashion to preprocedural risk factors. PD wire passages appear to add the greatest PEP risk in DBCs, but combining indomethacin with PD stent placement reduces this risk, even with increasing PD wire passages.
困难胆管插管（DBC）是已知的发生内镜逆行胰胆管造影术后胰腺炎（PEP）的危险因素。为了更好地理解DBC如何增加PEP风险，我们研究了DBC的技术因素与已知PEP危险因素之间的相互作用。
这是一项多中心随机对照试验的二次分析，该试验比较了单独使用直肠吲哚美辛与直肠吲哚美辛联合预防性胰管（PD）支架置入术对高危患者预防PEP的效果。参与者被分为3组：术前PEP风险高的DBC组、术前PEP风险不高的DBC组和术前PEP风险高的非DBC组。
共有1601名参与者（84.1%）经历了DBC，平均需要12次插管尝试（标准差为10），平均持续时间为14.7分钟（标准差为14.9）。术前PEP风险高的DBC组PEP发生率最高（20.7%），其次是术前PEP风险高的非DBC组（13.5%），然后是术前PEP风险不高的DBC组（8.8%）。在DBC中，增加PD导丝通过次数（调整优势比[aOR]为1.97；95%置信区间[CI]为1.25 - 3.1）与PEP相关，但PD注射、胰括约肌切开术和插管尝试次数与PEP无关。在DBC中，将吲哚美辛与PD支架置入术联合使用可降低PEP风险（aOR为0.61；95%CI为0.44 - 0.84）。这种保护作用在至少4次PD导丝通过时都很明显。
DBC以累加方式使PEP风险高于术前危险因素。在DBC中，PD导丝通过似乎增加了最大的PEP风险，但将吲哚美辛与PD支架置入术联合使用可降低这种风险，即使PD导丝通过次数增加。
