Knowledge, Attitude, and the Practices in Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis (PEP) Among Advanced Endoscopists

Introduction: Post endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most dreaded complication of endoscopic retrograde cholangiopancreatography (ERCP). We sought to capture the various practice methods amongst advanced endoscopists regarding measures taken for prevention of PEP. Methods: An anonymous online 31-item survey was sent to advanced endoscopists by digital medium like WhatsApp, Twitter and E-mail. The responses were collected over a period of 2 weeks. Results: Of the 600 endoscopists who were invited to participate, 123 responded. Eighty-seven percentage of endoscopists believe their PEP rate was around 0 to 5 %. Thirty seven percent use intravenous hydration only in patients deemed as high risk for PEP. Majority (91.8%) use Ringer’s lactate solution for the prevention of PEP. Standard hydration was the norm in using IV fluids in prevention of PEP amongst most endoscopists (67.5%). Forty percentage endoscopists put pancreatic ductal (PD) stent after more than 2 inadvertent PD cannulation. About eleven percentage endoscopists felt that there was no therapeutic benefit of PD stenting after inadvertent cannulation. Fifty-eight percentage of the endoscopists perform X-ray abdomen before removing PD stent & 54% of them remove the PD stent within 2 weeks. Most commonly (93%) the 5F PD stent was used and more than half (58%) used the 5cm length of the PD stent. Fifty-three percentage endoscopists preferred the straight PD stent. About ninety-seven percentage endoscopists use rectal nonsteroidal anti-inflammatory drugs (NSAIDs) if there are no contraindication to use. Sixty-nine percentage endoscopists use rectal NSAIDs in high-risk patients only. About sixty percentage endoscopists use rectal NSAIDs after ERCP. Diclofenac 100 mg was the most commonly used rectal NSAID. Eighty-nine percentage of endoscopists use combined therapy for PEP. The most commonly used combination is rectal NSAID with standard hydration. If pancreatic ductal stenting is done due to inadvertent cannulation, 72 % endoscopists would still use intravenous hydration with rectal NSAID as additional mode of prophylaxis. Eighty-seven percentage endoscopists believe, 1-5 % patients develop PEP even after using appropriate prophylactic measures. Conclusion: As per our survey, rectal NSAIDs was the most common method and standard hydration was the least common method used to prevent PEP amongst practicing endoscopists.