Dear Editor
We thank Dr. İbrahim Ethem GÜVEN for his interest and constructive letter regarding our study entitled ‘Early intervention with rescue ERCP and pancreatic stenting for unanticipated post-ERCP pancreatitis: a comparative study’ [1]. The issues raised highlighted current challenges in studies related to this technique and provided valuable directions for future investigations.
We fully agree that the retrospective, single-center design and modest sample size are important limitations, as we explicitly acknowledged in the Discussion section of our paper. These factors preclude definitive conclusions and introduce the possibility of selection bias. Larger prospective, ideally multicenter randomized controlled trials (RCTs) are clearly needed to validate our findings, and we hope our exploratory data will serve as a foundation for such studies.
Regarding safety and guideline recommendations, no procedure-related adverse events occurred in the stent group, and none of these patients progressed to severe acute pancreatitis (SAP), whereas 3 of 29 patients in the conservative group developed SAP. We recognize that our sample size is too small to reliably detect rare complications, and these results align with prior small series on rescue endoscopic retrograde cholangiopancreatography (ERCP). We note the ESGE guideline’s position against routine rescue pancreatic stenting in the established post-ERCP pancreatitis (PEP) [2]; however, our cohort consisted exclusively of unanticipated PEP cases without initial prophylactic pancreatic stent placement and with progressive symptoms meeting all three Atlanta diagnostic criteria. Rescue ERCP was performed early (median 6 h after onset) and always combined with conservative therapy. We believe this specific context justifies further investigation to clarify the risk-benefit profile.
The approximate 7-hour therapeutic window was identified through analyses comparing outcomes for rescue ERCP performed within versus after 5, 6 and 7 h. Statistically significant improvements in systemic inflammatory response syndrome (SIRS) duration and time to resume oral diet were observed only at the 7-hour threshold. We fully concur that the small sample sizes limit statistical robustness and render this finding hypothesis-generating rather than conclusive. It nevertheless provides a clinically plausible timeframe that merits prospective validation in adequately powered studies.
Finally, during the study period at our Chinese center, periprocedural rectal non-steroidal anti-inflammatory drugs were not routinely used; instead, somatostatin was given immediately after the index ERCP, in line with a large Chinese RCT, meta-analyses, and national expert consensus demonstrating its preventive efficacy in our population [3–5]. Both study arms received identical conservative management (including somatostatin), enabling a direct comparison of the added value of rescue ERCP. We acknowledge that current international guidelines strongly recommend rectal indomethacin for PEP prevention and that future protocols should incorporate it where appropriate. Regional practice variations do not invalidate the internal comparative benefit we observed.
In summary, our study demonstrated clinically meaningful improvements – lower 48-hour pain scores, shorter durations of elevated amylase and SIRS, and faster resumption of oral diet – with early rescue ERCP plus conservative therapy versus conservative therapy alone. We are grateful to Dr. GÜVEN for highlighting avenues for improvement and agree that high-quality prospective research is required to refine indications, timing and safety. We look forward to continued dialogue and collaborative efforts to optimize care for patients with unanticipated PEP.
Funding Statement
No funding was received in this study.
Disclosure statement
The authors report no conflict of interest.
Data availability statement
Data sharing is not applicable to this article as no new data were created or analyzed in this study.
References
- 1.An Y, Xu S, Wang S, et al. Early intervention with rescue ERCP and pancreatic stenting for unanticipated post-ERCP pancreatitis: a comparative study. Ann Med. 2025;57(1):2527363. doi: 10.1080/07853890.2025.2527363. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Dumonceau J-M, Kapral C, Aabakken L, et al. ERCP-related adverse events: european Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020;52(2):127–149. doi: 10.1055/a-1075-4080. [DOI] [PubMed] [Google Scholar]
- 3.Bai Y, Li F, Wang SL, et al. Chinese expert consensus on perioperative medications for endoscopic retrograde cholangiopancreatography (ERCP). J Dig Dis. 2019;20(3):103–113. doi: 10.1111/1751-2980.12699. [DOI] [PubMed] [Google Scholar]
- 4.Bai Y, Ren X, Zhang X-F, et al. Prophylactic somatostatin can reduce incidence of post-ERCP pancreatitis: multicenter randomized controlled trial. Endoscopy. 2015;47(5):415–420. doi: 10.1055/s-0034-1391227. [DOI] [PubMed] [Google Scholar]
- 5.Hu J, Li PL, Zhang T, et al. Role of Somatostatin in Preventing Post-endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis: an Update Meta-analysis. Front Pharmacol. 2016;7:489. doi: 10.3389/fphar.2016.00489. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data sharing is not applicable to this article as no new data were created or analyzed in this study.