STRATEGIES EMERGE FOR PREVENTING POST-ERCP PANCREATITIS

University of Michigan Health System (U-M) researchers guided by James M. Scheiman, MD, professor of internal medicine and GI lead in the hospi­tal’s Multidisciplinary Pancreatic Cancer Destination Program, have been actively engaged in studies designed to identify ways to improve the standard of care in patients undergoing endoscopic retrograde cholan­giopancreatography (ERCP).

In 2012, the team published the results of a groundbreaking study in The New England Journal of Medicine (2012;366:1414-1422) that found indo­methacin administered rectally was a highly effective approach to prevent post-ERCP pancreatitis (PEP).

An analysis of that trial further suggested that indomethacin was more effective and more cost-effective for preventing PEP than pancreatic duct stents or a combination of the two (The American Journal of Gastroenterology 2013;108:410-415). This has led to an increased use of the drug—a less-inva­sive approach—at U-M and elsewhere. Dr. Scheiman noted the insertion of prophylactic pancreatic duct stents, an approach used in patients considered to be at high risk for complications after ERCP, can be difficult, and injury to the pancreatic orifice is a possibility.

INDOMETHACIN AND PANCREATIC DUCT STENTS

“ERCP is the most dangerous procedure we do as gastroenterologists.” -James M. Scheiman, MD

Dr. Scheiman and his team are seeking to build on these findings with new research into whether the use of stents further reduces the risk for PEP in ERCP patients who also are receiving indomethacin prophylaxis, and to explore why there is significant interin­dividual variability in patient response to ERCP. Ultimately, the primary goal is to develop a method for identifying and pretreating patients at increased risk for postprocedural complications.

“ERCP is the most dangerous proce­dure we do as gastroenterologists,” Dr. Scheiman explained. “Our initial research led to more widespread use of indomethacin in our institution and nationally, and has helped patients tremendously. Now, we are trying to understand why patients get pancre­atitis following ERCP and how to best reduce this risk. Our group is committed to groundbreaking research in this area, and to training gastroenterologists at an extraordinarily high skill level to practice state-of-the-art ERCP.”

Pursuant to this goal, Dr. Scheiman served as one of the co-authors of a paper published in the American Journal of Gastroenterology (2015;110:48-59) that proposed metrics for assessing quality and efficiency in training programs for endoscopic procedures such as ERCP and endoscopic ultrasound (EUS). In addition, Dr. Scheiman’s team is collaborating with U-M biomedical engi­neering faculty in National Institutes of Health–funded research on the potential for characterization of pancreatic tissue using optical spectroscopy. They hope the technology will assist in the “differ­entiation of various pancreatic diseases,” Dr. Scheiman explained, and in better patient selection for procedures such as ERCP and EUS, ultimately making these procedures safer.

“We have been involved in studying the process by which we learn these various endoscopic procedures and are involved in an ongoing study that assesses training programs nationally,” Dr. Scheiman said.

“Our in-depth understanding of the risks and benefits of invasive procedures involving the pancreas has really helped us target the safest and most-effective approach to diagnosing patients with pancreatic disease. Because we have high-quality, less-risky alternatives such as EUS, we’ve been able to use these approaches to make sure ERCP is the right procedure to do and, if it is, we’ve pioneered approaches to make that procedure safer.”

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