Conservative approach may be best treatment in predicted severe acute biliary pancreatitis
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Predicted severe acute biliary pancreatitis treated with early endoscopic retrograde cholangiography with sphincterotomy did not reduce major complications or mortality compared with conservative treatment, according to a presenter.
“A recent study, the APEC trial, has shown that in patients with a predicted severe disease course, urgent ERCP does not improve outcomes as compared to conservative treatments,” Nora D. Hallensleben, MD, of Erasmus Medical Center and St. Antonius Hospital in the Netherlands, said in her presentation at UEG Week. “However, in the APEC trial, ERCP was performed irrespective of the presence of common bile stones, and after finishing the trial we started to wonder if urgent ERCP might be useful when performed only in case of confirmed bile duct obstruction.”
Hallensleben and the Dutch Pancreatitis Study Group prospectively examined 82 patients with predicted severe acute biliary pancreatitis who underwent endoscopic ultrasound (EUS)-guided ERCP within 24 hours of hospital presentation of proven CBD stones or biliary sludge between August 2017 and August 2019. Only participants without cholangitis were included.
Within the multicenter study population, 80 patients had EUS at a median of 21 hours after hospital presentation and 29 hours after symptom onset; two patients had canceled EUS and ERCP due to organ failure.
Gallstones or biliary sludge were present in 48 participants (60%), who all underwent immediate ERCP with endoscopic sphincterotomy, while five patients did not have biliary cannulation. Of those who had confirmed sludge or gallstones, 42 patients (88%) had complete extraction at the initial ERCP, while one patient had incomplete removal and had a biliary stent placed.
The participants in the present trial and 113 patients from the APEC trial treated conservatively demonstrated similar rates of composite mortality or major complications which included pneumonia, cholangitis, bacteremia, pancreatic necrosis or insufficiency or new-onset persistent organ failure within 6 months (40% vs. 44%; RR = 0.91; 95% CI, 0.65-1.27).
On an individual basis, only exocrine pancreatic insufficiency differed (10% with EUS vs. 2% with conservative treatment; RR= 5.51; 95% CI, 1.2-25.28).
Adverse events occurred in 76% of the EUS group and 80% of the conservative treatment group.
“In patients with predicted severe acute biliary pancreatitis without cholangitis, urgent EUS-guided ERCP with sphincterotomy did not reduce the number of deaths and severe complications compared to conservative treatment,” Hallensleben said. “Therefore, primarily conservative treatment strategies seem indicated in patients with acute biliary pancreatitis.”
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Hallensleben ND, et al. Abstract OP131. Presented at: UEG Week; Oct. 3-5, 2021 (virtual meeting).
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