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Alternative to prophylactic pancreatic stent placement in high-risk ERCP? 

This month's issue of the American Journal of Gastroenterology exmines the need for prophylactic pancreatic stent placement in patients undergoing high-risk ERCP?

News image

A recent large-scale randomized controlled trial demonstrated that rectal indomethacin administration is effective in addition to pancreatic stent placement for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk cases.

Dr Joseph Elmunzer from Michigan, USA performed a post hoc analysis of this randomized controlled trial to explore whether rectal indomethacin can replace PSP in the prevention of pancreatitis and to estimate the potential cost savings of such an approach.

The team retrospectively classified randomized controlled trial subjects into 4 prevention groups.

Group 1 included no prophylaxis, Group 2 involved pancreatic stent placement alone, Group 3 received rectal indomethacin alone, and Group 4 included the combination of pancreatic stent placement and indomethacin.

Multivariable logistic regression was used to adjust for imbalances in the prevalence of risk factors for pancreatitis between the groups.

Based on these adjusted pancreatitis rates, the research team conducted an economic analysis comparing the costs associated with pancreatitis prevention strategies employing rectal indomethacin alone, pancreatic stent placement alone, or the combination of both.

A prevention strategy employing rectal indomethacin alone could save about $150 million annually
American Journal  of  Gastroenterology

ogyAfter adjusting for risk using 2 different logistic regression models, rectal indomethacin alone appeared to be more effective for preventing  pancreatitis than no prophylaxis, pancreatic stent placement alone, and the combination of indomethacin and pancreatic stent placement .

The doctors found that indomethacin alone was a cost-saving strategy in 96% of Monte Carlo trials.

A prevention strategy employing rectal indomethacin alone could save approximately $150 million annually in the United States compared with a strategy of pancreatic stent placement alone, and $85 million compared with a strategy of indomethacin and pancreatic stent placement.

Dr Joseph's team commented, "This hypothesis-generating study suggests that prophylactic rectal indomethacin could replace pancreatic stent placement  in patients undergoing high-risk preventing post-endoscopic retrograde cholangiopancreatography, potentially improving clinical outcomes and reducing healthcare costs."

"A randomized controlled trial comparing rectal indomethacin alone vs indomethacin plus pancreatic stent placement is needed."

Am J Gastroenterol 2013; 108: 410–415
21 March 2013

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