Safety and efficacy of ERCP after recent myocardial infarction or unstable angina

Outcomes of Hospitalized Patients Undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) With and Without a History of Peripheral Artery Disease

Introduction

Peripheral artery disease (PAD) is a common illness associated with an increased risk of complications and mortality. Gastroenterologists considering endoscopic retrograde cholangiopancreatography (ERCP) in these patients should weigh the benefits and risks carefully. Our goal is to analyze the hospital burden and complication rates in patients with PAD undergoing ERCP.

Methods

Using data from the National Inpatient Sample (NIS), patients over the age of 18 with and without PAD undergoing ERCP were identified utilizing the International Classification of Diseases (ICD)-9 codes. Primary outcomes included inpatient mortality, length of stay, and hospital charges. Secondary outcomes included rates of bile duct perforation, post-ERCP bleeding, acute pancreatitis, and cholangitis. Supplemental data, including household income and primary payer, were also analyzed. Independent t-tests were used for continuous data, chi-square tests for categorical data, and confounding variables (diabetes, age, gender, race) were controlled via multiple logistic regression.

Results

Most of the PAD group were male, while those in the non-PAD group were female (adjusted p<0.05). Mortality was higher in the PAD group (11.2% versus 8%; adjusted p<0.05). Members of the PAD group had longer lengths of stay (11.6 days versus 11 days; adjusted p<0.05) and more costly hospital stays ($108,006.49 versus $94,399.09; p<0.05). Members of the PAD group had higher rates of post-ERCP bleeding (5.2% versus 3.7%; adjusted p<0.05) and lower rates of cholangitis (6% versus 4%; adjusted p<0.05) and acute pancreatitis (6.9% versus 3.4%; adjusted p<0.05). 

Conclusion

Patients with PAD had an increased hospital burden but had a decreased risk of post-ERCP complications, including cholangitis and pancreatitis. Physicians performing risk stratification for patients with PAD undergoing ERCP must consider these specific complications and ensure that patients undergoing this procedure are fully aware of the dangers and benefits of ERCP prior to consenting to the procedure.

Endoscopic Retrograde Cholangiopancreatography in Patients With Versus Without Prior Myocardial Infarction or Coronary Revascularization: A Nationwide Cohort Study

Background

Endoscopic retrograde cholangiopancreatography (ERCP) can be associated with complications, including precipitation of peri-procedural myocardial ischemia. However, data regarding the trends and impact of previous myocardial infarction (MI) and/or percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) on ERCP outcomes remains unknown.

Methods

Using the National Inpatient Sample (2007-2014) and relevant ICD-9-CM codes, we identified adults who underwent ERCP with (Group 1) and without (Group 2) prior history of MI/PCI/CABG, and compared their demographics, comorbidities, and inpatient outcomes. Primary endpoints were inpatient mortality and post-ERCP complications. The secondary endpoints were discharge disposition, the mean length of stay, and total hospital charges.

Results

Of 1,374,773 ERCP procedures performed, 120,418 (8.8%) were performed in adult patients with a prior history of MI/PCI/CABG with an increasing trend from 2007-2014 (7.5% to 9.5%, p_trend=0.022). Group 1 consisted of older, white, males compared to Group 2. Group 1 demonstrated a higher prevalence of all-cause mortality (1.7% vs. 1.5%, p<0.001), other cardiovascular comorbidities, post-ERCP cardiopulmonary complications (5.6% vs. 3.8%, p<0.001), sepsis (10.2% vs. 8.2%, p<0.001) and hemorrhage (1.5% vs.1.2%, p<0.001) as compared to Group 2. However, post-ERCP pancreatitis (14.1% vs. 15.4%, p<0.001) was lower in Group 1 without any difference in frequency of cholecystitis (0.4% vs. 0.4%, p=0.180). The mean length of stay was marginally higher in Group 1, without any difference in the hospitalization charges between the groups.

Conclusions

This nationwide study revealed higher inpatient mortality, sepsis, and hemorrhage in adult patients who underwent ERCP with a prior history of MI/PCI/CABG.

Wellens' syndrome: a rare presentation after an endoscopic retrograde cholangiopancreatography

Wellens' syndrome is a pattern of ECG changes typically seen in patients with unstable angina that has a high positive predictive value for critical left anterior descending coronary artery stenosis. Recognition of this syndrome can allow for intervention before the patient develops myocardial infarction. We report a case of Wellens' syndrome that was observed after an endoscopic retrograde cholangiopancreatography, which highlights risk factors that needs consideration in evaluating patients with these ECG findings after undergoing procedures even when asymptomatic.

Safety of Digestive Endoscopy following Acute Coronary Syndrome: A Systematic Review

Background. The safety of endoscopy after an acute coronary syndrome (ACS) is poorly characterized. We thus performed a systematic review assessing the safety of endoscopy following ACS. Methods. Searches in EMBASE, Medline, and Web of Science identified articles for inclusion. Data abstraction was completed by two independent reviewers. Results. Fourteen retrospective studies yielded 1178 patients (mean 71.3 years, 59.0% male) having suffered an ACS before endoscopy. Patients underwent 1188 endoscopies primarily to investigate suspected gastrointestinal bleeding (81.2%). Overall, 810 EGDs (68.2%), 191 colonoscopies (16.1%), 100 sigmoidoscopies (8.4%), 64 PEGs (5.4%), and 22 ERCPs (1.9%) were performed 9.0 ± 5.2 days after ACS, showing principally ulcer disease (25.1%; 95% CI 22.2-28.3%) and normal findings (22.9%; 95% CI 20.1-26.0%). Overall, 108 peri- and postprocedural complications occurred (9.1%; 95% CI 7.6-10.9%), with hypotension (24.1%; 95% CI 17.0-32.9%), arrhythmias (8.1%; 95% CI 4.5-18.1%), and repeat ACS (6.5%; 95% CI 3.1-12.8%) as the most frequent. All-cause mortality was 8.1% (95% CI 6.3-10.4%), with 4 deaths attributed to endoscopy (<24 hours after ACS, 3.7% of all complications; 95% CI 1.5-9.1%). Conclusion. A significant proportion of possibly endoscopy-related negative outcomes occur following ACS. Further studies are required to better characterize indications, patient selection, and appropriate timing of endoscopy in this cohort.

Endoscopic retrograde cholangiopancreatography in patients with previous acute coronary syndrome

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is considered a high-risk procedure in patients with previous acute coronary syndrome (ACS); however, clinical studies are rare in the literature. The aim of this study was to investigate the safety and efficacy of ERCP in patients with previous ACS.

Methods

We retrospectively reviewed the medical records of patients with previous ACS who underwent ERCP between January 2007 and August 2012. The clinical characteristics, ERCP diagnoses, treatment results, and complications were analyzed.

Results

Fifty patients underwent ERCP an average of 41.6 months after ACS. The most common indication for ERCP was calculous cholangitis. After deep biliary cannulation, endoscopic sphincterotomy, biliary stone removal and endoscopic biliary drainage were successfully performed. Immediate postsphincterotomy bleeding occurred in seven patients, which was successfully controlled using endoscopic therapy. Elevation of cardiac troponin I levels were observed in three patients (6%) before ERCP, and all of these patients were diagnosed with pancreatobiliary disease combined with recurrent ACS, which was treated with coronary artery stent insertion (n=2) and balloon angioplasty (n=1).

Conclusions

Therapeutic ERCP is effective and safe in patients with previous ACS. Cardiac troponin I elevation should be considered a warning sign for recurrent ACS in patients who undergo ERCP.

Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

Biliary and pancreatic diseases are common in the elderly; however, few studies have addressed the occurrence of adverse events in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Our objective was to determine the incidence rates of specific adverse events in this group and calculate incidence rate ratios (IRRs) for selected comparison groups.

PATIENTS AND METHODS

Bibliographical searches were conducted in Medline, EMBASE, and Cochrane library databases. The studies included documented the incidence of adverse events (perforation, pancreatitis, bleeding, cholangitis, cardiopulmonary adverse events, mortality) in patients aged ≥ 65 who underwent ERCP. Pooled incidence rates were calculated for each reported adverse event and IRRs were determined for available comparison groups. A parallel analysis was performed in patients aged ≥ 80 and ≥ 90.

RESULTS

Our literature search yielded 7429 articles, of which 69 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 ERCPs) in patients aged ≥ 65 were as follows: perforation 3.8 (95 %CI 1.8 - 7.0), pancreatitis 13.1 (95 %CI 11.0 - 15.5), bleeding 7.7 (95 %CI 5.7 - 10.1), cholangitis 16.1 (95 %CI 11.7 - 21.7), cardiopulmonary events 3.7 (95 %CI 1.5 - 7.6), and death 7.1 (95 %CI 5.2 - 9.4). Patients ≥ 65 had lower rates of pancreatitis (IRR 0.3, 95 %CI 0.3 - 0.4) compared with younger patients. Octogenarians had higher rates of death (IRR 2.4, 95 %CI 1.3 - 4.5) compared with younger patients, whereas nonagenarians had increased rates of bleeding (IRR 2.4, 95 %CI 1.1 - 5.2), cardiopulmonary events (IRR 3.7, 95 %CI 1.0 - 13.9), and death (IRR 3.8, 95 %CI 1.0 - 14.4). Conclusions ERCP appears to be safe in elderly patients, except in the very elderly who are at higher risk of some adverse events. These data on adverse event rates can help to inform clinical decision-making, the consent process, and comparative effectiveness analyses.