Research On The Risk Factors Of Post-ERCP Pancreatitis In Patients After Accidental Wire-guided Pancreatic Duct Cannulation During ERCP And The Preventive Effect Of Pancreatic Duct Stent

Objective(s): During Endoscopic Retrograde Cholangiopancreatography(ERCP)in the diagnosis and treatment of biliary tract diseases,guidewires may enter the pancreatic duct,especially in patients with difficult cannulation.The mechanical stimulation of the pancreatic duct by the guidewire is a high-risk factor for post-ERCP pancreatitis(PEP),but not all patients with accidental wire-guided into the pancreatic duct will progress to PEP.In recent years,many authoritative studies have confirmed that pancreatic duct stent(PDS)placement can effectively prevent PEP and reduce the severity of pancreatitis by draining pancreatic fluid and relieving intrapancreatic hypertension.However,it is not clear which patients are susceptible to PEP after guidewire accidentally entered the pancreatic duct.This retrospective study aimed to investigate the risk factors of PEP in patients after the guidewire accidentally entered the pancreatic duct during ERCP and the effect of PDS on PEP prevention.Methods: This study retrospectively collected the data of patients who received ERCP treatment for biliary tract diseases from the Digestive Endoscopy Room of the Second Affiliated Hospital of Kunming Medical University from March 2019 to June2022.Patients who accidentally entered the pancreatic duct during the ERCP operation were selected as the research objects.195 patients were collected through inclusion and exclusion criteria.According to whether the pancreatic duct stent was inserted or not,the patients were divided into the pancreatic duct stent implantation group(PDS group)and the stent-free group(N group).Basic data of patients in the two groups were analyzed: gender,age,body mass index,basic diseases,and previous history(hypertension,diabetes,cardiovascular and cerebrovascular diseases,chronic lung diseases,acute or chronic pancreatitis,cirrhosis,history of gastrointestinal surgery,history of cholecystectomy.Preoperative diagnosis: choledocholithiasis,intrahepatic choledocholithiasis,choledocholithiasis,malignant biliary obstruction,constrictive papillitis,common bile duct stricture.ERCP surgical record: the frequency of guide wire entering the pancreatic duct,suspected sphincter of Oddi dysfunction(SOD),papillary duodenal diverticulum,and endoscopic sphincterotomy(EST),endoscopic papillary balloon dilation(EPBD),pancreatic duct angiography,etc.Preoperative and postoperative laboratory test results: liver function(alanine aminotransferase,aspartate aminotransferase,alkaline phosphatase,γ-glutamyl transpeptidase,total bilirubin),blood routine(white blood cell count,neutrophil percentage),emergency pancreatic function(blood amylase,blood lipase).Postoperative complications of ERCP: PEP,post-ERCP hyperamylasemia(PEH),bleeding,and perforation.The basic data,preoperative diagnosis,laboratory test results,surgical data,and incidence of complications were compared between the two groups.Binary Logistic regression analysis was used to analyze patient-related,diagnosis-related,and surgery-related risk factors of PDS,and to analyze the risk factors of PEP and the preventive effect of PDS after guidewire accidentally entered into the pancreatic duct.To explore the benefit population of PDS implantation.SPSS 25.0 was used for statistical analysis of the data,and P < 0.05 was statistically significant.Results:1.According to the inclusion and exclusion criteria,a total of 195 patients were enrolled,68 patients were treated with PDS during ERCP,and 127 patients were not.PEP occurred in 38 patients in the two groups,and the overall incidence of PEP was19.4%(38/195).Most of them were mild pancreatitis,and only 2 cases progressed to moderate to severe pancreatitis.2.The incidence of PEP in the PDS group was 7.4%(5/68),all of which were mild pancreatitis,and the incidence of PEP in the N group was 26%(33/127),including31 cases of mild pancreatitis and 2 cases of moderate to severe pancreatitis.The incidence of PEP in the PDS group was 18.6% lower than that in the N group,and the difference was statistically significant [OR=0.226,95% CI : 0.084-0.610,P=0.002].All patients with PEP improved after conservative treatment.3.There was no significant difference in bleeding,infection,and PEH between the two groups.There was no perforation and no death due to adverse events in the two groups.The incidence of PEH was 8.8%(6/68)in the PDS group and 11.8%(15/127)in the N group.The incidence of PEH in the PDS group was lower than that in the N group,but the difference was not statistically significant(P=0.521).4.In the PDS group,there were 4 patients with stent shedding,no stent displacement,perforation,and other adverse events occurred,and no pancreatitis occurred after PDS removal.5.Risk factors for PEP were malignant biliary obstruction [OR=10.675,95%CI:1.091-104.491,P=0.042],number of guidewire entries into the pancreatic duct[OR=2.078,95%CI: 1.517-2.847,P=0.000],while pancreatic stent was an independent protective factor for PEP [OR=0.057,95%CI: 0.013-0.248,P=0.000].6.It was found that among patient-related risk factors,females were risk factors for PEP [OR= 2.862,95% CI:1.271-6.441,P=0.011],and the pancreatic stent was an independent protective factor for PEP [OR=0.225,95%CI:0.082-0.619,P=0.004].7.It was found that malignant biliary obstruction was an independent risk factor for PEP among diagnosis-related risk factors[OR=8.414,95%CI:1.205-58.774,P=0.032].The pancreatic stent was an independent protective factor for PEP[OR=0.175,95%CI:0.058-0.531,P=0.002].8.It was found that among surgery-related risk factors,the number of guidewire entries into the pancreatic duct was an independent risk factor for PEP [OR=2.122,95%CI:1.566-2.877,P=0.000].The pancreatic stent was an independent protective factor for PEP [OR=0.086,95%CI:0.023-0.322,P=0.000].Conclusion(s):1.PDS implantation after accidental wire-guided pancreatic duct cannulation during ERCP can effectively reduce the incidence and severity of PEP.2.Pancreatic duct stenting is an effective measure to prevent PEP after accidental wire-guided pancreatic duct cannulation.PDS placement may be a safe and feasible surgery.3.Accidental wire-guided pancreatic duct cannulation may lead to the occurrence of PEH,but PDS placement can not reduce the incidence of PEH.4.Females are an independent risk factor for PEP in patients with related risk factors.Malignant biliary obstruction is an independent risk factor for PEP among diagnosis-related risk factors.The number of guidewire entries into the pancreatic duct is an independent risk factor for PEP in surgery-related risk factors.