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US Nationwide Insight Into All-cause 30-day Readmissions following Inpatient Endoscopic Retrograde Cholangiopancreatography. J Clin Gastroenterol 2022; 57:515-523. [PMID: 35537131 DOI: 10.1097/mcg.0000000000001709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/16/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a high risk for morbidity, mortality, and hospital readmission. Data regarding those risks in the United States is scarce. We assessed post-ERCP 30-day readmission rates, their etiologies, and impact on the health care system using national data. METHODS Using the National Readmission Database 2016, we identified patients who underwent inpatient ERCP from January 2016 to December 2016 using ICD-10-CM procedure codes. The primary endpoint was all-cause 30-day readmission rate. Etiologies of readmission were identified by tallying primary diagnosis. Multivariable logistic regression with complex survey design was used to identify independent risk factors associated with readmission. RESULTS A total of 130,145 patients underwent ERCP, 16,278 (12.5%) were readmitted within 30 days, with an associated cost of 268 million dollars. Nearly 40% of readmissions occurred within 7 days, and 47.9% were related to gastrointestinal etiologies. Male gender, increased comorbidities, cirrhosis, Medicare insurance, and pancreatitis or pancreatitis-related indications for ERCP were readmission risk factors. Performance of cholecystectomy on index hospitalization decreased odds of readmission by 50% (adjusted odds ratio: 0.48, 95% confidence interval: 0.45-0.52,P<0.0001). While academic and nonacademic centers had similar readmission rates, high ERCP volume centers had higher rates compared with low-volume centers (adjusted odds ratio:1.10,P=0.008). CONCLUSION All-cause 30-day readmission rates after inpatient ERCPs are high, mostly occur shortly postdischarge, and impose a heavy health care system burden. Large, multicenter prospective studies assessing the impact of center procedure volume on complications and readmission rates are needed.
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Brinne Roos J, Bergenzaun P, Groth K, Lundell L, Arnelo U. Telepresence-teleguidance to facilitate training and quality assurance in ERCP: a health economic modeling approach. Endosc Int Open 2020; 8:E326-E337. [PMID: 32118106 PMCID: PMC7035055 DOI: 10.1055/a-1068-9153] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/16/2019] [Indexed: 02/08/2023] Open
Abstract
Background and study aims The aims of this study was to document the clinical and training relevance of endoscopic retrograde cholangiopancreaticography (ERCP) teleguidance (as a clinical model for applied telemedicine) with health economic modeling methodologies. Methods Probabilities and consequences of complications after ERCP performed by either a novice-trainee or supported through teleguidance (TM) by an expert formed the basis of the health economic model. Results The main clinical and economic outcomes originated from the base case scenario representing a low-volume center. In the cohort the patient age was 62 years, 58 % were females, the expert was doing ≥ 250 ERCPs per year and 50 for the novice-trainee. The expert knowledge transferred was set to 50 % and the average complexity grade to 1.98. Given a willingness to pay threshold of 56,180 USD/ quality-adjusted life years (QALY), the probability of cost-effectiveness of TM assistance was 98.9 %. The probability of a QALY gain for patients having an ERCP, to which was added TM, was 91.6 %. Adding TM saved on an average 111.2 USD (95 % CI 959 to 1021 SEK) per patient, and remained cost-effective basically insensitive to the level of willingness to pay. Conclusion Teleguidance during an ERCP procedure has the potential to be the prefered option in many low- to medium-volume hospitals. The main mechanisms behind these effects are positive impact on several adverse patient outcomes, QALY increase, and decreased costs. TM should be considered for integration into future teaching curriculums in advanced upper gastrointestinal endoscopy.
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Affiliation(s)
- Johanna Brinne Roos
- Innovation Centre, Division of Innovation and Development, Karolinska University Hospital, Stockholm, Sweden
| | - Per Bergenzaun
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Kristina Groth
- Innovation Centre, Division of Innovation and Development, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Lundell
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
- CLINTEC, Karolinska Institutet, Stockholm Sweden
- Department of Surgery, Odense University Hospital, J.B. Winsloews Vej 4, 5000 Odense, Denmark
| | - Urban Arnelo
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
- CLINTEC, Karolinska Institutet, Stockholm Sweden
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Richards S, Kyle S, White C, El-Haddawi F, Farrant G, Henderson N, Fancourt M, Gilkison W. Outcomes of endoscopic retrograde cholangiopancreatography: a series from a provincial New Zealand hospital. ANZ J Surg 2016; 88:207-211. [PMID: 27599119 DOI: 10.1111/ans.13734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 07/20/2016] [Accepted: 07/20/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is an essential tool in the management of pancreaticobiliary pathology. It is technically demanding and has the potential to cause significant morbidity and mortality. Several trials have identified small centres and lower hospital volume as risk factors for lower success rates and higher complication rates. Taranaki Base Hospital (TBH) is a provincial hospital with a catchment of 100 000, providing its population with an on-site ERCP service. Transporting patients to the nearest tertiary centre would incur significant costs to both the patient and district health board. AIMS To determine the outcomes of performing ERCP at TBH and compare these with published figures. To determine if it is a safe and effective option for patients in this region. METHODS An ambi-directional study of all ERCP procedures at TBH between January 2011 and December 2015 was conducted. Patient demographics, procedure indication and procedural details were captured via ProVation® MD and endoscopist's notes. Complications were identified through patient's notes and recorded if occurring within 30 days of the procedure. All complications were graded mild, moderate or severe based on a grading system described by Cotton et al. RESULTS A total of 445 procedures were performed. Bile duct cannulation rate was 92.3% and therapeutic success rate was 89.9%. Complications occurred in 8.99% of patients and ERCP-specific mortality was 0.22%. Haemorrhage occurred in 1.35% of patients, pancreatitis in 5.2% and perforation in 0.45%. Success and complication rates are similar to other published studies. CONCLUSION ERCP can be safely and successfully performed in a provincial centre.
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Affiliation(s)
- Simon Richards
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Stephen Kyle
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Campbell White
- Department of Gastroenterology, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Falah El-Haddawi
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Glenn Farrant
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Nigel Henderson
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Michael Fancourt
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
| | - William Gilkison
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is performed commonly for therapy. Its role in pancreaticobiliary diagnostic imaging has significantly decreased over time. Despite advances in our knowledge of the risk factors, complications, (especially post-ERCP pancreatitis), remain a significant problem. This review highlights the risk factors as related to the patient, procedure and the endoscopist, and the possible means to prevent complications. The best way to avoid any complication is "to avoid any procedure where the indication is not strong" and especially to refrain from doing diagnostic ERCP when alternate noninvasive imaging such as magnetic resonance cholangiopancreatography is available.
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Affiliation(s)
- Nalini M Guda
- St. Luke's Medical Center and University of Wisconsin School of Medicine and Public Health, Milwaukee, USA
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Muraki T, Arakura N, Kodama R, Yoneda S, Maruyama M, Itou T, Watanabe T, Maruyama M, Matsumoto A, Kawa S, Tanaka E. Comparison of carbon dioxide and air insufflation use by non-expert endoscopists during endoscopic retrograde cholangiopancreatography. Dig Endosc 2013; 25:189-96. [PMID: 23368405 DOI: 10.1111/j.1443-1661.2012.01344.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is subject to several complications that include a lengthy procedure time, technical difficulty, and active bowel movement induced by air insufflation. In ERCP carried out by non-expert endoscopists who are prone to excessive luminal insufflation, insufflation with carbon dioxide (CO2 ) may provide better and safer outcomes. We aimed to assess the efficacy and safety of CO2 insufflation during ERCP by non-expert endoscopists. METHODS This study included 208 consecutive patients who received ERCP, excluding those in poor general health or with obstructive lung disease. The first operator for each patient was a non-expert endoscopist having done 50 or fewer ERCP procedures. Primary outcomes were the changes in cardiopulmonary state during ERCP. Secondary outcomes were ERCP complications. We designed a single-center, randomized, prospective, double-blind, controlled trial with CO2 and air insufflation during ERCP. RESULTS CO2 insufflation did not affect overall procedure progression or results. A positive correlation was observed between procedure time and change in maximal systolic blood pressure from baseline among patients in the air insufflation group, but not in the CO2 insufflation group (correlation coefficient 0.408 vs 0.114, change in the maximal systolic blood pressure from baseline +4.2 vs+1.2 mmHg/10 min). This was consistent with our findings in patients treated by the first operator alone. The occurrence rate of post-ERCP pancreatitis tended to be lower in the CO2 group than the air group (4/102 [3.9%]vs 0/106 [0%], P = 0.056). CONCLUSIONS CO2 insufflation during ERCP by non-expert endoscopists is recommended from the standpoints of efficacy and safety.
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Affiliation(s)
- Takashi Muraki
- Department of Medicine, Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan.
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Jeurnink SM, Siersema PD, Steyerberg EW, Dees J, Poley JW, Haringsma J, Kuipers EJ. Predictors of complications after endoscopic retrograde cholangiopancreatography: a prognostic model for early discharge. Surg Endosc 2011; 25:2892-900. [PMID: 21455806 PMCID: PMC3160559 DOI: 10.1007/s00464-011-1638-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Accepted: 02/01/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Several studies have evaluated predictors for complications of endoscopic retrograde cholangiopancreatography (ERCP), but their relative importance is unknown. In addition, currently used blood tests to detect post-ERCP pancreatitis are inconsistent. The aim of this study was to determine predictors of post-ERCP complications that could discriminate between patients at highest and lowest risk of post-ERCP complications and to develop a model that is able to identify patients that can safely be discharged shortly after ERCP. METHODS In a single-center, retrospective analysis over the period 2002-2007, predictors of post-ERCP complications were evaluated in a multivariable analysis and compared with those identified from a literature review. A prognostic model was developed based on these risk factors, which was further evaluated in a prospective patient population. RESULTS From our retrospective analysis and literature review, we selected the eight most important risk factors for post-ERCP pancreatitis and cholangitis. In the prognostic model, the risk factors (precut) sphincterotomy, sphincter of Oddi dysfunction, younger age, female gender, history of pancreatitis, pancreas divisum, and difficult cannulation accounted for a score of 1 each, whereas primary sclerosing cholangitis (PSC) accounted for a score of 2. A sum score of 4 or more in the prognostic model was associated with a high risk of developing pancreatitis and cholangitis (27%; 6/22) in the prospective patient population, whereas a sum score of 3 or less was associated with a low to intermediate risk (8%; 20/252). CONCLUSIONS We identified specific patient- and procedure-related factors that are associated with post-ERCP complications. The prognostic model based on these factors is able to identify patients who can be safely discharged the same day after ERCP.
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Affiliation(s)
- S M Jeurnink
- Department of Gastroenterology and Hepatology, Erasmus MC/University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Predictors of complications after endoscopic retrograde cholangiopancreatography: a prognostic model for early discharge. Surg Endosc 2011. [PMID: 21455806 DOI: 10.1007/s00464-011-1638-9:21455806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Several studies have evaluated predictors for complications of endoscopic retrograde cholangiopancreatography (ERCP), but their relative importance is unknown. In addition, currently used blood tests to detect post-ERCP pancreatitis are inconsistent. The aim of this study was to determine predictors of post-ERCP complications that could discriminate between patients at highest and lowest risk of post-ERCP complications and to develop a model that is able to identify patients that can safely be discharged shortly after ERCP. METHODS In a single-center, retrospective analysis over the period 2002-2007, predictors of post-ERCP complications were evaluated in a multivariable analysis and compared with those identified from a literature review. A prognostic model was developed based on these risk factors, which was further evaluated in a prospective patient population. RESULTS From our retrospective analysis and literature review, we selected the eight most important risk factors for post-ERCP pancreatitis and cholangitis. In the prognostic model, the risk factors (precut) sphincterotomy, sphincter of Oddi dysfunction, younger age, female gender, history of pancreatitis, pancreas divisum, and difficult cannulation accounted for a score of 1 each, whereas primary sclerosing cholangitis (PSC) accounted for a score of 2. A sum score of 4 or more in the prognostic model was associated with a high risk of developing pancreatitis and cholangitis (27%; 6/22) in the prospective patient population, whereas a sum score of 3 or less was associated with a low to intermediate risk (8%; 20/252). CONCLUSIONS We identified specific patient- and procedure-related factors that are associated with post-ERCP complications. The prognostic model based on these factors is able to identify patients who can be safely discharged the same day after ERCP.
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Evaluation of recombinant platelet-activating factor acetylhydrolase for reducing the incidence and severity of post-ERCP acute pancreatitis. Gastrointest Endosc 2009; 69:462-72. [PMID: 19231487 DOI: 10.1016/j.gie.2008.07.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Accepted: 07/22/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatitis is the most common major complication of diagnostic and therapeutic ERCP. Platelet-activating factor (PAF) has been implicated in the pathophysiologic events associated with acute pancreatitis. Animal and human studies suggested that recombinant PAF acetylhydrolase (rPAF-AH) might ameliorate the severity of acute pancreatitis. OBJECTIVE Our purpose was to determine whether prophylactic rPAF-AH administration reduces the frequency or severity of post-ERCP pancreatitis in high-risk patients. DESIGN Randomized, multicenter, double-blind, placebo-controlled study. INTERVENTIONS Patients received rPAF-AH at a dose of either 1 or 5 mg/kg or placebo. Patients were administered a single intravenous infusion over 10 minutes of study drug or placebo <1 hour before ERCP. MAIN OUTCOME MEASUREMENTS Standardized criteria were used to diagnose and grade the severity of post-ERCP pancreatitis. Adverse events were prospectively recorded. RESULTS A total of 600 patients were enrolled. There were no statistically significant differences among the treatment groups with respect to patient demographics, ERCP indications, and patient and procedure risk factors for post-ERCP pancreatitis with the following exceptions: the rPAF-AH 5 mg/kg group had significantly fewer patients younger than 40 years old and scheduled to undergo a therapeutic ERCP involving the pancreatic sphincter or duct. Post-ERCP pancreatitis occurred in 17.5%, 15.9%, and 19.6% of patients receiving rPAF-AH (1 mg/kg), rPAF-AH (5 mg/kg), and placebo, respectively (P = .59 for rPAF-AH 1 mg/kg vs placebo and P = .337 for rPAF-AH 5 mg/kg vs placebo). There was no statistically significant difference between the groups with regard to the severity of pancreatitis, frequency of amylase/lipase elevation more than 3 times normal, or abdominal pain. CONCLUSIONS There was no apparent benefit of rPAF-AH treatment compared with placebo in reducing the incidence of post-ERCP pancreatitis in subjects at increased risk.
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Samper JMA, Montalt IO, Vera JCV, Ibáñez JDA. [Cardiorespiratory arrest in a patient undergoing endoscopic retrograde cholangiopancreatography]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2008; 55:319-320. [PMID: 18661697 DOI: 10.1016/s0034-9356(08)70581-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Dundee PE, Chin-Lenn L, Syme DBY, Thomas PR. Outcomes of ERCP: prospective series from a rural centre. ANZ J Surg 2008; 77:1013-7. [PMID: 17931269 DOI: 10.1111/j.1445-2197.2007.04300.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure for the investigation and management of pancreaticobiliary disease. There is a recognized potential for significant morbidity, and a number of studies have identified patient and operator risk factors for the development of complications, including small case volume. We look at the outcomes of ERCP from a single operator at a rural centre and compare these with published figures. METHOD Findings from 700 consecutive ERCP were collected prospectively between August 1997 and May 2006. Patients were included on an intention to treat basis, and all predetermined morbidity criteria were recorded. RESULTS Five hundred and forty-four therapeutic and 156 diagnostic ERCP were included in the study. There were a total of 40 complications (5.71%), with three cases of ERCP-specific mortality (0.4%). The success of therapeutic intervention was 94.3%. CONCLUSIONS The importance of comparing personal audit to published prospective studies has been emphasized. This has provided quality assurance finding, confirming that comparable success rates, morbidity and mortality are possible in a low-volume rural centre with an operator who has been properly trained and has ongoing ties with a tertiary hepatobiliary unit, a dedicated and skilled local team and suitable patient selection.
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Affiliation(s)
- Philip E Dundee
- Department of Surgery, Northeast Health Wangaratta, Victoria, Australia.
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Freeman ML. Pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Clin Gastroenterol Hepatol 2007; 5:1354-65. [PMID: 17981248 DOI: 10.1016/j.cgh.2007.09.007] [Citation(s) in RCA: 160] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Placement of pancreatic stents is a relatively new and increasingly adopted approach to reduce the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Evidence for the efficacy of pancreatic stents in reducing post-ERCP pancreatitis continues to accumulate. Routine use of pancreatic stents in high-risk cases at advanced centers has changed the complexion of ERCP, reducing the incidence and severity of post-ERCP pancreatitis to a more acceptable level, and eliminating some of the fear factor surrounding previously prohibitively risky settings, such as treatment of sphincter of Oddi dysfunction (SOD). On the other hand, the adoption of prophylactic pancreatic stenting into some practices has been sporadic. Problems with pancreatic stent placement include technical difficulty with placement, need for follow-up evaluation to ensure passage or removal, and potential for inducing pancreatic ductal injury. There remain many challenges and unanswered questions which will be addressed in this review, including which patients are at risk for post-ERCP pancreatitis, how might pancreatic stents reduce risk, what is the evidence supporting efficacy of pancreatic stenting in reducing risk; and based on those data, which ERCPs are at sufficiently high risk to warrant a stent; at what point in an ERCP should a pancreatic stent be placed; how long pancreatic stents need to remain in place to be effective, the risk of inducing pancreatic duct injury by placement of a stent; the frequency and consequences of failure at attempted stent placement, and effectiveness of pancreatic stent placement in the hands of those with limited experience. Current recommendations for use of pancreatic stents and areas requiring further investigation are discussed.
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Affiliation(s)
- Martin L Freeman
- Minnesota Pancreas and Liver Center, Division of Gastroenterology, University of Minnesota, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA.
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Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, Pilotto A, Forlano R. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007; 102:1781-8. [PMID: 17509029 DOI: 10.1111/j.1572-0241.2007.01279.x] [Citation(s) in RCA: 720] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To provide health-care providers, patients, and physicians with an exhaustive assessment of prospective studies on rates of complications and fatalities associated with endoscopic retrograde cholangiopancreatography (ERCP). METHODS We searched MEDLINE (1977-2006) for prospective surveys on adult patients undergoing ERCP. "Grey literature" was sought by looking at cited references to identify further relevant studies. Data on postprocedural pancreatitis, bleeding, infections, perforations, and miscellaneous events as well as their associated fatalities were extracted independently by two reviewers. Sensitivity analysis was performed to test for data consistency between multicenter versus single center studies, and old (1977-1996) versus recent (1997-2005) reports. RESULTS In 21 selected surveys, involving 16,855 patients, ERCP-attributable complications totaled 1,154 (6.85%, CI 6.46-7.24%), with 55 fatalities (0.33%, CI 0.24-0.42%). Mild-to-moderate events occurred in 872 patients (5.17%, CI 4.83-5.51%), and severe events in 282 (1.67%, CI 1.47-1.87%). Pancreatitis occurred in 585 subjects (3.47%, CI 3.19-3.75%), infections in 242 (1.44%, CI 1.26-1.62%), bleeding in 226 (1.34%, CI 1.16-1.52%), and perforations in 101 (0.60%, CI 0.48-0.72%). Cardiovascular and/or analgesia-related complications amounted to 173 (1.33%, CI 1.13-1.53%), with 9 fatalities (0.07%, CI 0.02-0.12%). As compared with old reports, morbidity rates increased significantly in most recent studies: 6.27%versus 7.51% (P(c)= 0.029). CONCLUSIONS ERCP remains the endoscopic procedure that carries a high risk for morbidity and mortality. Complications continue to occur at a relatively consistent rate. The majority of events are of mild-to-moderate severity.
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Affiliation(s)
- Angelo Andriulli
- Gastroenterology Unit, "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
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Lee JK, Park JK, Yoon WJ, Lee SH, Lee KH, Ryu JK, Kim YT, Yoon YB. Risk for post-ERCP pancreatitis after needle knife precut sphincterotomy following repeated cannulation attempts. J Clin Gastroenterol 2007; 41:427-31. [PMID: 17413615 DOI: 10.1097/01.mcg.0000225695.46874.b5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
GOALS The aim of this study was to determine the risk and identify the factors associated with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in patients who undergo needle knife precut sphincterotomy (NKS). In addition, we evaluated the effect of gabexate for the prevention of post-ERCP pancreatitis. BACKGROUND NKS, after repeated cannulation attempts during ERCP, is known to increase the risk of post-ERCP pancreatitis. However, the specific risk factors for post-ERCP pancreatitis have not been identified, and the preventive role of protease inhibitors, such as gabexate, has not yet been established. STUDY The medical records of 200 patients who underwent NKS, after repeated cannulation attempts during ERCP, were reviewed retrospectively. The potential risk factors for post-ERCP pancreatitis were investigated. The effect of gabexate infused after the ERCP procedure was also evaluated. RESULTS Thirteen (6.5%) patients out of 200 developed post-ERCP pancreatitis. Sex, age, the presence of pancreatitis at procedure, underlying disease, direction of the sphincterotomy, success or failure of cannulation after NKS, diameter of common bile duct, pancreatic duct status, and the presence of acinar filling were not associated with the risk of pancreatitis. Gabexate infusion after ERCP increased the incidence of ERCP-associated pancreatitis. CONCLUSIONS We could not identify any risk factors associated with the development of post-ERCP pancreatitis in patients who underwent NKS after repeated cannulation attempts during ERCP. However, gabexate administered after the ERCP procedure was found to increase the incidence of pancreatitis.
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Affiliation(s)
- Jun Kyu Lee
- Department of Internal Medicine, Dongguk University International Hospital, Dongguk University College of Medicine, Goyang, Korea
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Katsinelos P, Kountouras J, Paroutoglou G, Beltsis A, Mimidis K, Zavos C. Intravenous N-acetylcysteine does not prevent post-ERCP pancreatitis. Gastrointest Endosc 2005; 62:105-11. [PMID: 15990827 DOI: 10.1016/s0016-5107(05)01574-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute pancreatitis remains the most common complication of ERCP. Prophylactic administration of N-acetylcysteine (NAC) probably decreases the incidence and the severity of experimental pancreatitis. The aim of the present study was to assess the efficacy of intravenous NAC for prevention of post-ERCP pancreatitis in humans, who represent an appropriate model to study the potential role of NAC in this setting. METHODS A prospective, double-blind, placebo-controlled trial was conducted in 256 patients who underwent ERCP. Patients were randomized to receive intravenous NAC at a loading dose of 70 mg/kg 2 hours before and 35 mg/kg at 4-hour intervals for a total of 24 hours after the procedure, or to receive normal saline solution as placebo. Patients were clinically evaluated, and serum amylase levels were measured before and 6 hours and 24 hours after the procedure. Standardized criteria were used to diagnose and to grade the severity of post-ERCP pancreatitis. RESULTS A total of 249 patients were included in the analysis. The two groups were matched for age, gender, underlying disease and indication for treatment, ERCP findings, and type of treatment. The overall incidence of post-ERCP acute pancreatitis was 10.8%, with 12.1% in the NAC group and 9.6% in the placebo group. There were no statistical differences in the incidence or severity grades between the groups. The mean duration of hospitalization for pancreatitis also was similar in the NAC group and the placebo group (3.6 +/- 0.9 and 3 +/- 1.5 days, respectively). CONCLUSIONS The results of this trial show the absence of any beneficial effect of NAC on the incidence and the severity of ERCP-induced pancreatitis.
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Kow L. Magnetic resonance imaging in the diagnosis of choledocholithiasis. ANZ J Surg 2004; 74:618. [PMID: 15315556 DOI: 10.1111/j.1445-1433.2004.03171.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Affiliation(s)
- Martin L Freeman
- Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota, MN 55415, USA
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Freeman ML. Adverse outcomes of endoscopic retrograde cholangiopancreatography: avoidance and management. Gastrointest Endosc Clin N Am 2003; 13:775-98, xi. [PMID: 14986798 DOI: 10.1016/s1052-5157(03)00107-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Adverse outcomes of endoscopic retrograde cholangiopancreatography (ERCP) include technical failures and complications. Complications cause significant morbidity to patients and anxiety to endoscopists. The key to preventing complications is to understand which patients and procedures are at highest risk so that appropriate decisions can be made as to whether ERCP should be performed at all, and if so, how. Patients who need ERCP the least are often the ones most likely to develop complications. For marginal indications, ERCP should be avoided. Success rates are higher and complication rates lower for endocopists performing large numbers by endoscopists with adequate experience.
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Affiliation(s)
- Martin L Freeman
- University of Minnesota, Hennepin County Medical Center, Minneapolis 55415, USA.
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Freeman ML. Understanding risk factors and avoiding complications with endoscopic retrograde cholangiopancreatography. Curr Gastroenterol Rep 2003; 5:145-53. [PMID: 12631456 DOI: 10.1007/s11894-003-0084-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Complications and technical failures of endoscopic retrograde cholangiopancreatography (ERCP) cause significant morbidity and, occasionally, mortality. An understanding of patient- and procedure-related risks is important for decision making with regard to whether or how ERCP should be performed. Instances in which ERCP is the least clearly indicated are often the most likely to cause complications. Patient-related risk factors include suspected sphincter of Oddi (SO) dysfunction, female sex, normal serum bilirubin, or previous history of post-ERCP pancreatitis, with multiple risk factors conferring especially high risk. Technique-related risk factors include difficult cannulation, pancreatic contrast injection, balloon sphincter dilation, and precut sphincterotomy performed by endoscopists of varied experience. Pancreatic stents may reduce the risk of pancreatitis in a number of settings including SO dysfunction. Hemorrhage and perforation are rare and can be avoided with endoscopic technique and attention to the patient's coagulation status. Cholangitis is avoidable with adequate biliary drainage. Because success rates are higher and complication rates lower for endoscopists performing large volumes of ERCP, ERCP should be concentrated as much as possible among endoscopists with adequate experience. Patients with a high risk for complications may be best served by referral to an advanced center.
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Affiliation(s)
- Martin L Freeman
- Division of Gastroenterology, University of Minnesota, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN 55415, USA.
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Aronson N, Flamm CR, Bohn RL, Mark DH, Speroff T. Evidence-based assessment: patient, procedure, or operator factors associated with ERCP complications. Gastrointest Endosc 2002. [PMID: 12447284 DOI: 10.1016/s0016-5107(02)70028-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Naomi Aronson
- Technology Evaluation Center, Blue Cross Blue Shield Association, Chicago, Illinois 60601-7680, USA
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Affiliation(s)
- Martin L Freeman
- University of Minnesota, Division of Gastroenterology, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA
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Toouli J, Brooke-Smith M, Bassi C, Carr-Locke D, Telford J, Freeny P, Imrie C, Tandon R. Guidelines for the management of acute pancreatitis. J Gastroenterol Hepatol 2002; 17 Suppl:S15-39. [PMID: 12000591 DOI: 10.1046/j.1440-1746.17.s1.2.x] [Citation(s) in RCA: 295] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- J Toouli
- Flinders University, Adelaide, Australia.
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Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of abnormalities demonstrated with CT. Radiographics 2001; 21:1441-53. [PMID: 11706215 DOI: 10.1148/radiographics.21.6.g01nv101441] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure that is performed to diagnose and treat pancreatic and biliary disease. In approximately 5%-10% of cases, the procedure itself causes adverse events. Diagnosis and management of ERCP-induced complications are performed with clinical, laboratory, and radiologic procedures. Evaluation of the type and severity of the complication is necessary and is successfully performed with computed tomography (CT). The most common causes of post-ERCP pain are acute pancreatitis and duodenal perforation. In severe pancreatitis, the pancreas is enlarged and enhances heterogeneously at CT. Pancreatic enhancement is diminished in areas of glandular necrosis. In duodenal perforation, CT may reveal extraluminal air or fluid. CT findings of acute duodenal hemorrhage are duodenal wall thickening and a high-attenuation mass in the duodenal wall. In infection, the bile ducts can be dilated and the attenuation of the bile can be increased at CT. Abscesses appear as hypoattenuating masses with enhancing capsules. CT findings of stent migration are an atypical location of the stent and bowel impaction. Other complications of ERCP are those related to endoscopy and include esophageal, liver, and splenic injury.
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Affiliation(s)
- H K Pannu
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA.
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