A prospective, randomized, placebo-controlled trial of transdermal glyceryl trinitrate in ERCP: effects on technical success and post-ERCP pancreatitis

Background: Despite the recent improvement in techniques and patient selection, post-ERCP pancreatitis remains the most frequent and dreaded complication of ERCP Recent studies suggest that pretreatment with glycetyl trinitrate (GTN) may prevent post-ERCP pancreatitis and improve cannulation success. Objective: To evaluate the effect of transdermal GTN on ERCP cannulation success and post-ERCP pancreatitis. Design: Prospective, double-blind, placebo-controlled trial. Setting: Tertiary referral university hospital. Patients: A total of 318 patients (mean age 62 years, 61% women) were randomized to either active (n = 155) or placebo (n = 163) arms. Interventions: Active patch (GTN) versus placebo patch. Main Outcome Measurements: Cannulation time and success. Post-ERCP pancreatitis rates. Results: There was no significant difference between the active or placebo arms for the following: successful initial cannulation (96.8% vs 98.8%), deep cannulation (96.1% vs 98.8%), time to successful cannulation, use of guidewire (27% vs 25%) or needle knife (13% vs 13%), and post-ERCP pancreatitis (7.4% of placebo patients and 7.7% active patients). Multivariate analysis identified women, younger patients, pancreatogram, number of attempts on papilla, and poor pancreatic-duct emptying after opacification as risk factors for post-ERCP pancreatitis. Transdermal GTN did not reduce post-ERCP pancreatitis in any of the identified high-risk groups. Conclusions: Transdermal GTN did not improve the rate of success in ERCP cannulation or prevent post-ERCP pancreatitis in either average or high-risk patient groups.