Prophylactic Sphincterotomy in Acute Biliary Pancreatitis Patients Unfit for Surgery

NCT07238296 | Not Yet Recruiting DMC

• 1 other identifier: NNGYK/34436-6/2025
• Study Type: interventional
• Target: 92
• Locations: 0 countries
• Sites: N/A

Brief Summary

This is a prospective, multicenter, open-label, randomized controlled trial designed to evaluate the efficacy and safety of prophylactic endoscopic sphincterotomy (ES) in frail patients unfit for cholecystectomy following an episode of acute biliary pancreatitis (ABP). Eligible patients will be randomized in a 1:1 ratio to either prophylactic ES during the index admission or conservative treatment. The primary endpoint is the time from randomization to the first occurrence of a recurrent pancreatobiliary event within 12 months, including recurrent ABP, cholangitis, choledocholithiasis requiring endoscopic retrograde cholangiopancreatography (ERCP), or cholangiogenic liver abscess. Secondary outcomes include mortality, pancreatobiliary events requiring intensive care unit admission, post-ERCP complications, cholecystitis, and length of hospitalization. A total of 92 patients will be enrolled. The trial will be led by the Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary, and conducted in accordance with Good Clinical Practice.

Conditions

Acute Biliary Pancreatitis

Keywords

ERCP; prophylactic sphincterotomy; cholecystectomy

Outcome Measures

Primary Outcomes (1)

• Recurrent pancreatobiliary events

  Composite time-to-first-event endpoint including: * cholangitis - Tokyo guidelines * recurrent acute biliary pancreatitis - revised Atlanta criteria * choledocholithiasis - imaging/ERCP confirmation * cholangiogenic liver abscess - imaging plus clinical diagnosis

  1 year

Secondary Outcomes (8)

• Number of participants with recurrent acute biliary pancreatitis, cholangitis, choledocholithiasis, or cholangiogenic liver abscess (individual components of the composite primary outcome)

  At 3, 6, 9, and 12 months.

• Length of hospitalization

  From enrollment to one month.

• Pancreatobiliary events requiring intensive care unit admission

  At 3, 6, 9, and 12 months.

• Mortality associated with pancreatobiliary events

  At 3, 6, 9, and 12 months.

• All-cause mortality

  At 3, 6, 9, and 12 months.

Study Arms (2)

Prophylactic endoscopic sphincterotomy

ACTIVE COMPARATOR

Papillary cannulation and sphincterotomy techniques will be performed in adherence to the recommendations outlined in the ESGE (European Society of Gastrointestinal Endoscopy) guideline. All recommended measures for post-ERCP (Endoscopic Retrograde Cholangiopancreatography) pancreatitis prevention must be implemented, including the use of prophylactic pancreatic stents, rectal nonsteroidal anti-inflammatory drugs, and optimal hydration protocols where appropriate. All rescue techniques may be utilized if necessary, in accordance with clinical judgment and guideline recommendations. ERCP/ES (endoscopic sphincterotomy) will be performed by an experienced endoscopist, defined as someone who has performed more than 300 ERCPs in their lifetime and maintains a native papilla cannulation success rate of at least 90%. If the ES cannot be performed during the initial ERCP, the number of further attempts is under the discretion of the endoscopist.

Procedure: Prophylactic endoscopic sphincterotomy

Conservative treatment

NO INTERVENTION

This study arm will follow a conservative treatment strategy, and no endoscopic procedures will be performed.

Interventions

Prophylactic endoscopic sphincterotomy PROCEDURE

Participants in this arm will undergo prophylactic endoscopic sphincterotomy performed by experienced endoscopists, with all recommended preventive measures against post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) applied according to international guidelines.

Prophylactic endoscopic sphincterotomy

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• adult patients (above 18 years)
• naïve papilla
• evidence of AP based on the Atlanta criteria:
• pain in the upper abdomen
• serum amylase or lipase concentration \> 3 times the upper limit of normal
• imaging features of acute pancreatitis on abdominal imaging
• high probability of a biliary etiology:
• gallstones or biliary sludge on imaging (any type)
• dilated common bile duct on imaging defined as \> 8 mm in patients ≤ 75 years or \> 10 mm in patients \> 75 years
• abnormal liver enzymes (alanine aminotransferase \[ALT\] two times the upper limit of normal)
• patients unfit for surgery due to the attending physician's decision e.g. American Society of Anesthesiologists (ASA) class ≥ III; severe heart failure with reduced ejection fraction \<40%, severe uncontrolled hypertension, chronic kidney disease stage four or five

You may not qualify if:

• previous cholecystectomy
• previous endoscopic sphincterotomy or pancreatobiliary stenting
• ERCP/ES is recommended by the guidelines (3)
• sign of cholangitis
• presence of CBD stone on any imaging
• signs of stone in endoscopic ultrasonography or magnetic resonance imaging in case of abnormal liver enzymes (persistently elevated ALT and aspartate aminotransferase (AST) with less than a 20% decrease over four days) or dilated CBD (defined as above)
• chronic pancreatitis
• estimated life expectancy \< 12 months
• ERCP is contraindicated, e.g. the procedure cannot be carried out safely due to the patient's comorbidities or physical status; high risk of bleeding or contraindication of the discontinuation of the anticoagulation therapy.
• ERCP is technically not feasible due to altered anatomy, e.g., total gastrectomy, Roux-en-Y gastric bypass anatomy
• pancreatobiliary malignancy

Sponsors & Collaborators

• Semmelweis University: lead

Related Publications (9)

• Hajibandeh S, Jurdon R, Heaton E, Hajibandeh S, O'Reilly D. The risk of recurrent pancreatitis after first episode of acute pancreatitis in relation to etiology and severity of disease: A systematic review, meta-analysis and meta-regression analysis. J Gastroenterol Hepatol. 2023 Oct;38(10):1718-1733. doi: 10.1111/jgh.16264. Epub 2023 Jun 27.

  PMID: 37366550 BACKGROUND

• Dedemadi G, Nikolopoulos M, Kalaitzopoulos I, Sgourakis G. Management of patients after recovering from acute severe biliary pancreatitis. World J Gastroenterol. 2016 Sep 14;22(34):7708-17. doi: 10.3748/wjg.v22.i34.7708.

  PMID: 27678352 BACKGROUND

• Testoni PA, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, Deviere J, Dinis-Ribeiro M, Dumonceau JM, Giovannini M, Gyokeres T, Hafner M, Halttunen J, Hassan C, Lopes L, Papanikolaou IS, Tham TC, Tringali A, van Hooft J, Williams EJ. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 Jul;48(7):657-83. doi: 10.1055/s-0042-108641. Epub 2016 Jun 14.

  PMID: 27299638 BACKGROUND

• Vazquez-Lglesias JL, Gonzalez-Conde B, Lopez-Roses L, Estevez-Prieto E, Alonso-Aguirre P, Lancho A, Suarez F F, Nunes R. Endoscopic sphincterotomy for prevention of the recurrence of acute biliary pancreatitis in patients with gallbladder in situ: long-term follow-up of 88 patients. Surg Endosc. 2004 Oct;18(10):1442-6. doi: 10.1007/s00464-003-9185-7. Epub 2004 Aug 26.

  PMID: 15791366 BACKGROUND

• Uomo G, Manes G, Laccetti M, Cavallera A, Rabitti PG. Endoscopic sphincterotomy and recurrence of acute pancreatitis in gallstone patients considered unfit for surgery. Pancreas. 1997 Jan;14(1):28-31. doi: 10.1097/00006676-199701000-00005.

  PMID: 8981504 BACKGROUND

• da Costa DW, Bouwense SA, Schepers NJ, Besselink MG, van Santvoort HC, van Brunschot S, Bakker OJ, Bollen TL, Dejong CH, van Goor H, Boermeester MA, Bruno MJ, van Eijck CH, Timmer R, Weusten BL, Consten EC, Brink MA, Spanier BWM, Bilgen EJS, Nieuwenhuijs VB, Hofker HS, Rosman C, Voorburg AM, Bosscha K, van Duijvendijk P, Gerritsen JJ, Heisterkamp J, de Hingh IH, Witteman BJ, Kruyt PM, Scheepers JJ, Molenaar IQ, Schaapherder AF, Manusama ER, van der Waaij LA, van Unen J, Dijkgraaf MG, van Ramshorst B, Gooszen HG, Boerma D; Dutch Pancreatitis Study Group. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet. 2015 Sep 26;386(10000):1261-1268. doi: 10.1016/S0140-6736(15)00274-3.

  PMID: 26460661 BACKGROUND

• Schreurs WH, Juttmann JR, Stuifbergen WN, Oostvogel HJ, van Vroonhoven TJ. Management of common bile duct stones: selective endoscopic retrograde cholangiography and endoscopic sphincterotomy: short- and long-term results. Surg Endosc. 2002 Jul;16(7):1068-72. doi: 10.1007/s00464-001-9104-8. Epub 2002 May 3.

  PMID: 11984690 BACKGROUND

• Manes G, Paspatis G, Aabakken L, Anderloni A, Arvanitakis M, Ah-Soune P, Barthet M, Domagk D, Dumonceau JM, Gigot JF, Hritz I, Karamanolis G, Laghi A, Mariani A, Paraskeva K, Pohl J, Ponchon T, Swahn F, Ter Steege RWF, Tringali A, Vezakis A, Williams EJ, van Hooft JE. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2019 May;51(5):472-491. doi: 10.1055/a-0862-0346. Epub 2019 Apr 3.

  PMID: 30943551 BACKGROUND

• Tari E, Vincze A, Czako L, Sandru V, Laursen SB, Cadoni S, Brunacci M, Kiss M, Hegyi P, Eross B. Prophylactic endoscopic sphincterotomy in patients unfit for cholecystectomy after an acute biliary pancreatitis episode (PROSECCO): study protocol for an open-label, two-armed, randomised controlled trial. BMJ Open. 2026 Apr 27;16(4):e114897. doi: 10.1136/bmjopen-2025-114897.

  PMID: 42044960 DERIVED

Central Study Contacts

Balint Eross, MD, PhD

CONTACT

+36308874028; dr.eross.balint@gmail.com

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: PREVENTION
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: September 22, 2025
• First Posted: November 20, 2025
• Study Start (Estimated): July 1, 2026
• Primary Completion (Estimated): July 1, 2028
• Study Completion (Estimated): July 1, 2028
• Last Updated: May 1, 2026

Record last verified: 2026-04

Data Sharing

• IPD Sharing: Will share
• Shared Documents: STUDY PROTOCOL, SAP
• Time Frame: It will be available from 6 months after publication of the primary results and will remain available for at least 5 years thereafter.
• Access Criteria: Researchers with a methodologically sound proposal may request access to the de-identified IPD. Requests should be submitted to the corresponding author. Data will be shared after approval of the request and signing a data-sharing agreement, through secure institutional data transfer.