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Practice Patterns and Use of Endoscopic Retrograde Practice patterns and use of endoscopic retrograde cholangiopancreatography in the management of recurrent acute pancreatitis Qiang Cai, Emory University Field Willingham, Emory University Steven Keilin, Emory University Vaishali Patel, Emory University Parit Mekaroonkamol, Emory University JB Reichstein, Duke University S Dacha, Emory University Journal Title: Clinical Endoscopy Volume: Volume 53, Number 1 Publisher: (publisher) | 2019-01-01, Pages 73-81 Type of Work: Article Publisher DOI: 10.5946/ce.2019.052 Permanent URL: https://pid.emory.edu/ark:/25593/vhjfb Final published version: http://dx.doi.org/10.5946/ce.2019.052 Accessed September 27, 2021 7:02 AM EDT ORIGINAL ARTICLE Clin Endosc 2020;53:73-81 https://doi.org/10.5946/ce.2019.052 Print ISSN 2234-2400 • On-line ISSN 2234-2443 Open Access Practice Patterns and Use of Endoscopic Retrograde Cholangiopancreatography in the Management of Recurrent Acute Pancreatitis Jonathan B. Reichstein1, Vaishali Patel2, Parit Mekaroonkamol2, Sunil Dacha2, Steven A. Keilin2, Qiang Cai2 and Field F. Willingham2 1Department of Medicine, Duke University, Durham, NC, 2Division of Digestive Disease, Department of Medicine, Emory University, Atlanta, GA, USA Background/Aims: There are conflicting opinions regarding the management of recurrent acute pancreatitis (RAP). While some physicians recommend endoscopic retrograde cholangiopancreatography (ERCP) in this setting, others consider it to be contraindicated in patients with RAP. The aim of this study was to assess the practice patterns and clinical features influencing the management of RAP in the US. Methods: An anonymous 35-question survey instrument was developed and refined through multiple iterations, and its use was approved by our Institutional Review Board. The survey was distributed via email to 408 gastroenterologists to assess the practice patterns in the management of RAP in multiple clinical scenarios. Results: The survey was completed by 65 participants representing 36 of the top academic/tertiary care centers across the country. Approximately 90.8% of the participants indicated that they might offer or recommend ERCP in the management of RAP. Multinomial logistic regression analysis revealed that ductal dilatation and presence of symptoms were the most predictive variables (p<0.001) for offering ERCP. Conclusions: A preponderance of the respondents would consider ERCP among patients with RAP presenting to tertiary care centers in the US. Ductal dilatation, presence of symptoms, and pancreas divisum significantly increased the likelihood of a recommendation for ERCP. Clin Endosc 2020;53:73-81 Key Words: Endoscopic retrograde cholangiopancreatography; Pancreas divisum; Practice patterns; Recurrent acute pancreatitis INTRODUCTION atitis.1 The estimated incidence of AP is between 15 and 45 per 100,000 persons per year, with a risk of recurrence of nearly Recurrent acute pancreatitis (RAP) is generally defined as 20%.1-6 While gallstone diseases and alcohol exposure are the presence of two or more episodes of AP without concom- generally accepted as the two primary causes of RAP, other itant clinical and/or radiographic evidence of chronic pancre- etiologies, including autoimmune, hereditary, metabolic, and anatomic variants and Sphincter of Oddi dysfunction (SOD), are also considered.7 It has been estimated that up to 30% of Received: February 15, 2019 Revised: April 11, 2019 8 Accepted: April 11, 2019 episodes of RAP are idiopathic in nature. Correspondence: Field F. Willingham The management of RAP has become a topic of debate, par- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1365 Clifton Road, NE, Building B – Suite 1200, Atlanta, GA ticularly among gastroenterologists, interventional endosco- 30322, USA pists, and medical pancreatologists. Some gastroenterologists Tel: +1-404-778-3184, Fax: +1-404-778-2925, E-mail: field.willingham@emory. edu recommend endoscopic retrograde cholangiopancreatography ORCID: https://orcid.org/0000-0002-7071-3001 (ERCP) in this setting, while some do not.9 Among patients cc This is an Open Access article distributed under the terms of the Creative who undergo ERCP, the specific procedural intervention may Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, vary widely, including biliary sphincterotomy, pancreatic and reproduction in any medium, provided the original work is properly cited. sphincterotomy, pancreatic stent placement, manometry, and Copyright © 2020 Korean Society of Gastrointestinal Endoscopy 73 minor papilla therapy for divisum depending on the clinical any independent information regarding the participants were context, local practice, and physicians’ preference.10-18 These collected. Responses were collected using a survey tool from more invasive strategies may follow an extensive diagnostic Google Forms (Alphabet Inc., Mountain View, CA, USA). evaluation with laboratory testing, imaging with computed tomography and/or magnetic resonance imaging or cholan- Statistical analysis giopancreatography with or without secretin enhancement, The standard χ2 test and Fisher’s exact test were used for endoscopic ultrasound (EUS), and Sphincter of Oddi manom- comparisons between groups. Multinomial logistic regression etry.13 testing was conducted to analyze further the effects of mul- In the setting of RAP, it is unclear which patients are being tiple variables, including ductal dilatation, pancreas divisum, referred for ERCP. In patients who undergo ERCP, it is un- symptomatology, and sex, on the decision to offer or recom- clear which interventions are being performed. To consider mend ERCP. All p-tests were two-sided, and a p-value of <0.05 the proper approach to RAP and to develop the proper trials was considered statistically significant. Statistical analysis was to determine the appropriate management, it is critical to un- performed using the statistical software JMP Pro 13 (SAS, derstand the current practice patterns. Within a subgroup of Cary, NC, USA). patients referred for ERCP, it is important to clarify the specif- ic procedural approaches that are being employed. This study examined the national practice patterns for patients present- RESULTS i n g w i t h R A P. Respondent demographics The survey was completed by 65 participants (15.9%) rep- MateriaLS and METHODS resenting 36 different academic/tertiary centers across the country, with 87.7% identified as having been in practice for Overview at least 6 years and 52.3% performing at least 250 ERCPs each The study protocol was reviewed and was approved by the year. Additionally, 73.8% of the respondents were identified as Institutional Review Board (IRB) at the Emory University a pancreatologist or specialized in pancreatology, and 70.8% School of Medicine. had completed a fellowship training in advanced endoscopy. Their demographics are summarized in Table 1. Survey instrument A 35-question survey instrument was developed and re- fined through multiple iterations to assess the current practice of gastroenterologists in the management of RAP. The final Table 1. Demographic Features of Survey Respondents survey was approved by the IRB. The first nine questions -as Demographic category n (%) sessed demographics, respondent training, type of practice, and experience with ERCP. A total of 20 questions asked the Number of respondents 65 (15.9) respondents to consider ERCP in the management of RAP Number of programs represented 36 considering various factors, including presence of symptoms, Average years in practice (mean±SD) 13.5±7.13 pancreatic ductal dilatation, and history of pancreas divisum. Completed fellowship in advanced endoscopy, n (%) 46 (70.8) Additional questions assessed how alcohol drinking and Considers self to be specialized in pancreatology, n (%) 48 (73.8) smoking history may influence the management (Appendix). Performs ERCP, n (%) 54 (83.1) Performs 251 + ERCPs per year, n (%) 34 (52.3) Participants Performs biliary sphincterotomy, n (%) 53 (81.5) The survey instrument was distributed via email to 408 gastroenterologists who were identified as leaders in their re- Performs pancreatic sphincterotomy, n (%) 50 (76.9) spective fields in various programs across the US. Emails were Performs pancreatic duct cannulation, n (%) 51 (78.5) sent out two additional times, i.e., at 3 and 6 weeks, to maxi- Performs minor papillotomy, n (%) 50 (76.9) mize the response rates. An online consent/information sheet, Performs EUS, n (%) 49 (75.4) as confirmed by the IRB at the Emory University School of Performs SOM, n (%) 17 (26.2) Medicine, accompanied each email that was sent. Consent ERCP, endoscopic retrograde cholangiopancreatography; EUS, to participate in the study was determined from voluntary endoscopic ultrasound; SD, standard deviation; SOM, sphincter of completion of the survey. No additional personal identifiers or Oddi manometry. 74 Reichstein JB et al. Practice Patterns and Use of ERCP in the Management of RAP Practice patterns to male patients in the same scenario. For asymptomatic fe- The respondents were asked to indicate their estimate of male patients with pancreas divisum and pancreatic ductal the most common etiologies for RAP. In response, 38.5% of dilatation, 72.3% (p=0.005) of the respondents would offer the participants reported that alcohol abuse was the primary ERCP; conversely, 78.5% (p<0.001) would offer ERCP to male etiology of RAP in their
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