Aspectos técnicos de la colangiopancreatografía retrógrada endoscópica y de la ecoendoscopia

Abstract

Background and aims: diagnostic and treatment of biliopancreatic diseases are progressively improving due to the development of ERCP and EUS and the increasingly frequent combination of both techniques. Despite being rapidly growing techniques, specially EUS, there are still lots of unanswered technical questions. Mainly these technical aspects are about their efficacy and safety. It is mandatory to determine a proper and consensual definition and classification of the adverse events in order to evaluate those safety issues. Two of the most important technical aspects needed to be defined are the biliary cannulation failure management during ERCP and antibiotic prophylaxis efficacy for EUS FNA of pancreatic cystic lesions. First, we evaluated the efficacy, safety, and factors related to a second ERCP after failed cannulation using a precut sphincterotomy. Secondly, we investigate whether the EUS-FNA of pancreatic cystic lesions without antimicrobial prophylaxis is associated with an increased risk of infection compared with the same procedure without prophylaxis. Patients and methods: we designed two independent studies. The first study is a retrospective review of all patients who underwent an ERCP with native papilla at two tertiary institutions with failed canulation after a precut technique. Efficacy was based on the cannulation rate of the second ERCP, and safety was assessed in terms of adverse events. In the second study we performed a multicenter, randomized, non inferiority trial to compare prophylaxis with ciprofloxacin vs placebo in patients with a pancreatic cyst requiring EUS-FNA. Patients were followed for 21 days. The primary outcome was FNA- related infection. Results: The first study included 112 patients with failed cannulation after precut. Among them a second ERCP was performed in 72 (64.3%). Median time between procedures was 7 days (IQR 5–11). Biliary cannulation was achieved in 54 cases (75%). The only factor associated with cannulation failure was an ERCP within 4 days after the initial precut (cannulation success 44.4 vs. 79.4% after 4 days, p = 0.026). After the first ERCP thirteen of 112 patients (11.8%) presented an adverse event. After the second ERCP, three of 72 patients (4.2%) presented adverse events. The second study included 226 patients (antibiotic group n= 112 and placebo group n=114). Among those, 205 completed the trial medication (90.7%). There was only case of suspected FNA-related infection (0.44%) in a patient in the placebo group (0.87%). Prevention of infection was not inferior in the control group; the difference between proportions was 0.87% (95% confidence interval, –0.84% to 2.59%). CONCLUSIONS: A second ERCP after failure of initial biliary cannulation with precut technique appears to be safe and effective. A second ERCP should be delayed at least 4 days if feasible. In a randomized trial of patients undergoing EUS-FNA for pancreatic cyst evaluation, we found the risk of infection to be low. The incidence of infections was not significantly different with or without antibiotic prophylaxis using ciprofloxacin