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Bergeron E, Doyon T, Manière T, Désilets É. Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event. Surg Endosc 2023; 37:9546-9555. [PMID: 37726412 PMCID: PMC10709473 DOI: 10.1007/s00464-023-10423-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/31/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Gallstone disease will affect 15% of the adult population with concomitant common bile duct stone (CBDS) occurring in up to 30%. Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for removal of CBDS, as cholecystectomy for the prevention of recurrent biliary event (RBE). RBE occurs in up to 47% if cholecystectomy is not done. The goal of this study was to evaluate the timing of occurrence of RBE after common bile duct clearance with ERCP and associated outcomes. METHODS The records of all patients who underwent ERCP for gallstone disease followed by cholecystectomy, in a single center from 2010 to 2022, were reviewed. All RBE were identified. Actuarial incidence of RBE was built. Patients with and without RBE were compared. RESULTS The study population is composed of 529 patients. Mean age was 58.0 (18-95). There were 221 RBE in 151 patients (28.5%), 39/151 (25.8%) having more than one episode. The most frequent RBE was acute cholecystitis (n = 104) followed by recurrent CBDS (n = 95). Median time for first RBE was 34 days. Actuarial incidence of RBE started from 2.5% at 7 days to reach 53.3% at 1 year. Incidence-rate of RBE was 2.9 per 100 person-months. Patients with RBE had significant longer hospitalisation time (11.7 vs 6.4 days; P < 0.0001), longer operative time (66 vs 48 min; P < 0.0001), longer postoperative stay (2.9 vs 0.9 days; P < 0.0001), higher open surgery rate (7.9% vs 1.3%; P < 0.0001), and more complicated pathology (23.8% vs 5.8%; P < 0.0001) and cholecystitis (64.2% vs 25.9%; P < 0.0001) as final diagnoses. CONCLUSIONS RBE occurred in 28.5% of the subjects at a median time of 34 days, with an incidence of 2.5% as early as 1 week. Cholecystectomy should be done preferably within 7 days after common bile duct clearance in order to prevent RBE and adverse outcomes.
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Affiliation(s)
- Eric Bergeron
- Department of Surgery, Charles-LeMoyne Hospital, 3120, Boulevard Taschereau, Greenfield Park, QC, J4V 2H1, Canada.
| | - Théo Doyon
- Department of Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, QC, Canada
| | - Thibaut Manière
- Department of Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, QC, Canada
| | - Étienne Désilets
- Department of Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, QC, Canada
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Nelson AC, Bhogadi SK, Hosseinpour H, Stewart C, Anand T, Spencer AL, Colosimo C, Magnotti LJ, Joseph B. There Is No Such Thing as Too Soon: Long-Term Outcomes of Early Cholecystectomy for Frail Geriatric Patients with Acute Biliary Pancreatitis. J Am Coll Surg 2023; 237:712-718. [PMID: 37350474 DOI: 10.1097/xcs.0000000000000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Early cholecystectomy (CCY) for acute biliary pancreatitis (ABP) is recommended but there is a paucity of data assessing this approach in frail geriatric patients. This study compares outcomes of frail geriatric ABP patients undergoing index admission CCY vs nonoperative management (NOM) with endoscopic retrograde cholangiopancreatography (ERCP). STUDY DESIGN Retrospective analysis of the Nationwide Readmissions Database (2017). All frail geriatric (65 years or older) patients with ABP were included. Patients were grouped by treatment at index admission: CCY vs NOM with endoscopic retrograde cholangiopancreatography. Propensity score matching was performed in a 1:2 ratio. Primary outcomes were 6-month readmissions, mortality, and length of stay. Secondary outcomes were 6-month failure of NOM defined as readmission for recurrent ABP, unplanned pancreas-related procedures, or unplanned CCY. Subanalysis was performed to compare outcomes of unplanned CCY vs early CCY. RESULTS A total of 29,130 frail geriatric patients with ABP were identified and 7,941 were matched (CCY 5,294; NOM 2,647). Patients in the CCY group had lower 6-month rates of readmission for pancreas-related complications, unplanned readmissions for pancreas-related procedures, overall readmissions, and mortality, as well as fewer hospitalized days (p < 0.05). NOM failed in 12% of patients and 7% of NOM patients were readmitted within 6 months to undergo CCY, of which 56% were unplanned. Patients who underwent unplanned CCY had higher complication rates and hospital costs, longer hospital lengths of stay, and increased mortality compared with early CCY (p < 0.05). CONCLUSIONS For frail geriatric patients with ABP, early CCY was associated with lower 6-month rates of complications, readmissions, mortality, and fewer hospitalized days. NOM was unsuccessful in nearly 1 of 7 within 6 months; of these, one-third required unplanned CCY. Early CCY should be prioritized for frail geriatric ABP patients when feasible.
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Affiliation(s)
- Adam C Nelson
- From the Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
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3
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Li S, Gao L, Gong H, Cao L, Zhou J, Ke L, Liu Y, Tong Z, Li W. Recurrence rates and risk factors for recurrence after first episode of acute pancreatitis: A systematic review and meta-analysis. Eur J Intern Med 2023; 116:72-81. [PMID: 37330318 DOI: 10.1016/j.ejim.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/09/2023] [Accepted: 06/10/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND There are a certain number of acute pancreatitis (AP) patients who may suffer from multiple episodes and develop recurrent acute pancreatitis (RAP), but recurrence rates and associated risk factors for RAP vary significantly in the published literature. METHODS We searched PubMed, Web of Science, Scopus, and Embase databases to identify all publications reporting AP recurrence until October 20th, 2022. Meta-analysis and meta-regression were performed to calculate the pooled estimates using the random-effects model. RESULTS A total of 36 studies met the inclusion criteria and all were used in pooled analyses. The overall rate of recurrence after first-time AP was 21% (95% CI, 18%- 24%), and pooled rates in biliary, alcoholic, idiopathic, and hypertriglyceridemia etiology patients were 12%, 30%, 25%, and 30%, respectively. After managing underlying causes post-discharge, the recurrence rate decreased (14% versus 4% for biliary, 30% versus 6% for alcoholic, and 30% versus 22% for hypertriglyceridemia AP). An increased risk of recurrence was reported in patients with a smoking history (odds ratio [OR] = 1.99), alcoholic etiology (OR = 1.72), male sex (hazard ratio [HR] = 1.63), and local complications (HR = 3.40), while biliary etiology was associated with lower recurrence rates (OR = 0.38). CONCLUSION More than one-fifth of AP patients experienced recurrence after discharge, with the highest recurrence rate in alcoholic and hypertriglyceridemia etiologies, and managing underlying causes post-discharge was related to decreased incidence. In addition, smoking history, alcoholic etiology, male gender, and presence of local complications were independent risks for the recurrence.
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Affiliation(s)
- Shuai Li
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China
| | - Lin Gao
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China
| | - Haowen Gong
- Department of Medical Statistics, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu 210002, China
| | - Longxiang Cao
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China
| | - Jing Zhou
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China; Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China.
| | - Lu Ke
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China; Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China; National Institute of Healthcare Data Science, Nanjing University, Nanjing, Jiangsu 210010, China
| | - Yuxiu Liu
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China; Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China; Department of Medical Statistics, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu 210002, China
| | - Zhihui Tong
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China; Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China
| | - Weiqin Li
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China; Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University, No. 305 Zhongshan East Road, Nanjing, Jiangsu 210002, China; National Institute of Healthcare Data Science, Nanjing University, Nanjing, Jiangsu 210010, China.
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Readmission in acute pancreatitis: Etiology, risk factors, and opportunities for improvement. Surg Open Sci 2022; 10:232-237. [DOI: 10.1016/j.sopen.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 09/19/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
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Szatmary P, Grammatikopoulos T, Cai W, Huang W, Mukherjee R, Halloran C, Beyer G, Sutton R. Acute Pancreatitis: Diagnosis and Treatment. Drugs 2022; 82:1251-1276. [PMID: 36074322 PMCID: PMC9454414 DOI: 10.1007/s40265-022-01766-4] [Citation(s) in RCA: 103] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 11/11/2022]
Abstract
Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.
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Affiliation(s)
- Peter Szatmary
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Tassos Grammatikopoulos
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Wenhao Cai
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,West China Centre of Excellence for Pancreatitis and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- West China Centre of Excellence for Pancreatitis and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Rajarshi Mukherjee
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Department of Molecular Physiology and Cell Signalling, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool , UK
| | - Chris Halloran
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Georg Beyer
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Robert Sutton
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK. .,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK. .,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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Maire F, Steuer N, Aubert A, Vullierme MP, Rebours V, Lévy P. Enteral feeding followed by biliary sphincterotomy may prevent recurrence of biliary pancreatitis in patients who are not candidates for cholecystectomy. Dig Liver Dis 2022; 54:1137-1139. [PMID: 35691794 DOI: 10.1016/j.dld.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/19/2022] [Accepted: 05/23/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Frédérique Maire
- Université de Paris, Department of Pancreatology and Digestive Oncology, Beaujon Hospital (APHP), Clichy, France.
| | - Nils Steuer
- Université de Paris, Department of Pancreatology and Digestive Oncology, Beaujon Hospital (APHP), Clichy, France
| | - Alain Aubert
- Université de Paris, Department of Pancreatology and Digestive Oncology, Beaujon Hospital (APHP), Clichy, France
| | | | - Vinciane Rebours
- Université de Paris, Department of Pancreatology and Digestive Oncology, Beaujon Hospital (APHP), Clichy, France
| | - Philippe Lévy
- Université de Paris, Department of Pancreatology and Digestive Oncology, Beaujon Hospital (APHP), Clichy, France
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Index Admission Cholecystectomy and Recurrence of Pediatric Gallstone Pancreatitis: Multicenter Cohort Analysis. J Am Coll Surg 2022; 234:352-358. [PMID: 35213498 DOI: 10.1097/xcs.0000000000000062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND We aim to evaluate recurrence rates of gallstone pancreatitis in children undergoing early vs interval cholecystectomy. STUDY DESIGN A multicenter, retrospective review of pediatric patients admitted with gallstone pancreatitis from 2010 through 2017 was performed. Children were evaluated based on timing of cholecystectomy. Early cholecystectomy was defined as surgery during the index admission, whereas the delayed group was defined as no surgery or surgery after discharge. Outcomes, recurrence rates, and complications were evaluated. RESULTS Of 246 patients from 6 centers with gallstone pancreatitis, 178 (72%) were female, with mean age 13.5 ± 3.2 years and a mean body mass index of 28.9 ± 15.2. Most (90%) patients were admitted with mild pancreatitis (Atlanta Classification). Early cholecystectomy was performed in 167 (68%) patients with no difference in early cholecystectomy rates across institutions. Delayed group patients weighed less (61 kg vs. 72 kg, p = 0.003) and were younger (12 vs. 14 years, p = 0.001) than those who underwent early cholecystectomy. However, there were no differences in clinical, radiological, or laboratory characteristics between groups. There were 4 (2%) episodes of postoperative recurrent pancreatitis in the early group compared with 22% in the delayed group. More importantly, when cholecystectomy was delayed more than 6 weeks from index discharge, recurrence approached 60%. There were no biliary complications in any group. CONCLUSIONS Cholecystectomy during the index admission for children with gallstone pancreatitis reduces recurrent pancreatitis. Recurrence proportionally increases with time when patients are treated with a delayed approach.
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A THREE-STAGE THERAPEUTIC AND DIAGNOSTIC ALGORITHM IN MECHANICAL JAUNDICE OF DIFFERENT GENESIS AND THE MOST EFFECTIVE MINI-INVASIVE METHOD OF ITS TREATMENT. WORLD OF MEDICINE AND BIOLOGY 2022. [DOI: 10.26724/2079-8334-2022-2-80-119-124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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9
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National Trends in Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography During Index Hospitalization for Mild Gallstone Pancreatitis. World J Surg 2021; 46:524-530. [PMID: 34817621 DOI: 10.1007/s00268-021-06389-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Guidelines call for cholecystectomy during the index hospitalization for patients with gallstone pancreatitis. Therefore, the study sought to determine the trends for cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (ERCP) for mild gallstone pancreatitis. METHODS A retrospective analysis of the 2010-2018 Nationwide Readmission Database (NRD) was performed to identify patients with mild gallstone pancreatitis. The primary aim was to identify the trends in the use of cholecystectomy in these patients, and the secondary aim was to assess if ERCP alone was protective against readmission. RESULTS A total of 510,470 patients with mild gallstone pancreatitis were identified. There has been an increasing trend in ERCP use (25% in 2018 vs. 22% in 2010; p-0.001) and a decline in cholecystectomy (37% in 2018 vs. 46% in 2010; p-0.001) prior to discharge. Multivariate analysis revealed higher 30-day readmission for patients who underwent ERCP without cholecystectomy (odds ratio1.3; 95% confidence interval, 1.1-3.5) during the index admission. CONCLUSIONS There has been a decline in the use of cholecystectomy during index hospitalization for mild gallstone pancreatitis. In addition, ERCP was not protective against 30-day readmission from mild gallstone pancreatitis.
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Chu BK, Gnyawali B, Cloyd JM, Hart PA, Papachristou GI, Lara LF, Groce JR, Hinton A, Conwell DL, Krishna SG. Early unplanned readmissions following same-admission cholecystectomy for acute biliary pancreatitis. Surg Endosc 2021; 36:3001-3010. [PMID: 34159465 DOI: 10.1007/s00464-021-08595-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/06/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Same-admission cholecystectomy (CCY) is recommended for mild acute biliary pancreatitis (biliary-AP). However, there is a paucity of research investigating reasons for early (30-day) unplanned readmissions in patients who undergo CCY for biliary-AP. Hence, we sought to investigate this gap using a large population database. METHODS Using the Nationwide Readmission Database (2010-2014), we identified all adults (age ≥ 18 years) with a principal diagnosis of biliary-AP who had undergone CCY during the index hospitalization. Multivariable logistic regression models were obtained to assess independent predictors for 30-day readmission. Principal diagnosis for all readmissions was collected to ascertain the indications for early readmission. RESULTS During the study period, 118,224 patients underwent same-admission CCY for biliary-AP. Three-fourths of all patients underwent invasive cholangiography during the hospitalization (intraoperative cholangiogram (IOC) = 57,038, ERCP = 31,500). The rate of early (30-day) readmission was 7.25% (n = 8574). Exacerbation of prior medical conditions (42.2%), sequelae of biliary-AP (resolving and recurrent pancreatitis, pseudocysts) (27.6%), surgical site and other postoperative complications (16%), choledocholithiasis and/or bile leak (9.6%), and preventable hospital-acquired conditions (4.6%) accounted for early readmissions. On multivariable analysis, predictors for readmission included male sex (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.28), insurance type (Medicare insurance [OR 1.26, 95% CI 1.13-1.40]; Medicaid [OR 1.22, 95% CI 1.09-1.38]), outside-facility discharge (OR 1.35, 95% CI 1.16-1.57), severe AP (OR 1.35, 95% CI 1.21-1.50), and ≥ 3 Elixhauser comorbidities (OR 1.55, 95% CI 1.41-1.69). Performance of IOC (OR 0.90, 95% CI 0.82-0.97) and ERCP (OR 0.81, 95% CI 0.73-0.89) were associated with decreased risk of early readmission. CONCLUSION In this study, using a national population database evaluating patients who underwent same-admission CCY after biliary-AP, we identified potentially modifiable risk factors and causes for early readmission as well as opportunities to improve clinical care.
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Affiliation(s)
- Brandon K Chu
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Bipul Gnyawali
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, James Cancer Center and Solove Research Institute, Columbus, OH, USA
| | - Phil A Hart
- Section of Pancreatic Disorders and Advanced Endoscopy, Division of Gastroenterology, Hepatology, & Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, Columbus, OH, 43210, USA
| | - Georgios I Papachristou
- Section of Pancreatic Disorders and Advanced Endoscopy, Division of Gastroenterology, Hepatology, & Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, Columbus, OH, 43210, USA
| | - Luis F Lara
- Section of Pancreatic Disorders and Advanced Endoscopy, Division of Gastroenterology, Hepatology, & Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, Columbus, OH, 43210, USA
| | - Jeffrey R Groce
- Section of Pancreatic Disorders and Advanced Endoscopy, Division of Gastroenterology, Hepatology, & Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, Columbus, OH, 43210, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Darwin L Conwell
- Section of Pancreatic Disorders and Advanced Endoscopy, Division of Gastroenterology, Hepatology, & Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, Columbus, OH, 43210, USA
| | - Somashekar G Krishna
- Section of Pancreatic Disorders and Advanced Endoscopy, Division of Gastroenterology, Hepatology, & Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, Columbus, OH, 43210, USA.
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Abstract
Geriatric patients tend to have subtle presentations of biliary disorders and, if untreated, can decompensate acutely. Each biliary disorder warrants formulation of an individualized treatment plan with a multidisciplinary approach. Acute cholecystitis, a common complication of gallstones, is initially managed by conservative measures and subsequently, among patients with optimal surgical risk, through laparoscopic or open cholecystectomy. High-risk patients undergo temporization, percutaneous or endoscopic, followed by definitive intervention. Acute cholecystitis with complications (ie, perforation, gangrene, or small bowel obstruction) warrants emergent cholecystectomy. Gallstone migration into the biliary system can cause choledocholithiasis, often complicated by biliary pancreatitis or cholangitis if not intervened. Therapy for choledocholithiasis is based on biliary clearance through endoscopic and, infrequently, surgical approaches.
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12
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Liao WC, Tu TC, Lee KC, Tseng JH, Chen MJ, Sun CK, Wang SY, Chang WK, Chang PY, Wu MS, Lin TJ, Lee HL, Chen JH, Yuan KC, Liu NJ, Wu HC, Liang PC, Wang HP, Hwang TL, Lee CL. Taiwanese consensus recommendations for acute pancreatitis. J Formos Med Assoc 2020; 119:1343-1352. [PMID: 31395463 DOI: 10.1016/j.jfma.2019.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/11/2019] [Accepted: 07/17/2019] [Indexed: 12/12/2022] Open
Abstract
The incidence of acute pancreatitis and related health care utilization are increasing. Acute pancreatitis may result in organ failure and various local complications with risks of morbidity and even mortality. Recent advances in research have provided novel insights into the assessment and management for acute pancreatitis. This consensus is developed by Taiwan Pancreas Society to provide an updated, evidence-based framework for managing acute pancreatitis.
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Affiliation(s)
- Wei-Chih Liao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tien-Chien Tu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Cathay General Hospital, Taipei, Taiwan
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jseng-Hwei Tseng
- Department of Imaging & Intervention, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ming-Jen Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Cheuk-Kay Sun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Shang-Yu Wang
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wei-Kuo Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, Taiwan
| | - Pi-Yi Chang
- Department of Radiology, Taichung Veterans General Hospital, Taiwan
| | - Ming-Shun Wu
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tsung-Jung Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei City Hospital, Ren-Ai Branch, Taipei, Taiwan
| | - Hsiang-Lin Lee
- Department of Surgery, Chung Shan Medical University Hospital, Institute of Medicine4, Chung Shan Medical University, Taichung, Taiwan
| | - Jiann-Hwa Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Taipei, Taiwan
| | - Kuo-Ching Yuan
- Division of Acute Care Surgery and Trauma, Department of Surgery, Taipei Medical University Hospital, Taiwan
| | - Nai-Jen Liu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsing-Chien Wu
- Department of Internal Medicine, Taipei Hospital, Ministry of Health and Welfare, Taiwan
| | - Po-Chin Liang
- Department of Medical Imaging, National Taiwan University Hospital, Taiwan
| | - Hsiu-Po Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tsann-Long Hwang
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Lin-Kou, Taiwan
| | - Chia-Long Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Cathay General Hospital, Taipei, Taiwan.
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Kao LS, McCauley JS. Evidence-Based Management of Gallstone Pancreatitis. Adv Surg 2020; 54:173-189. [PMID: 32713429 DOI: 10.1016/j.yasu.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Lillian S Kao
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA.
| | - Jayne S McCauley
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA. https://twitter.com/JMcCauleyMD
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Qayed E, Mulki R. Frequency of Care Fragmentation and Its Impact on Outcomes in Acute and Chronic Pancreatitis in a Nationally Representative Sample. South Med J 2020; 113:254-260. [PMID: 32358621 DOI: 10.14423/smj.0000000000001094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Hospitalized patients with acute and chronic pancreatitis (AP and CP) are prone to frequent readmissions to different hospitals. The rate of care fragmentation and its impact on important outcomes are unknown. The aims of this study were to evaluate the rate and predictors of care fragmentation in patients hospitalized with AP and CP using a nationally representative sample, and to analyze the impact of care fragmentation on mortality, cost, and hospital readmissions. METHODS We identified all adult hospitalizations with a primary diagnosis of AP or CP in the 2010-2014 National Readmissions Database, which captures statewide readmissions. We calculated 30- and 90-day readmission and care fragmentation rates. Readmission to a nonindex hospital was considered care fragmentation. Logistic regression was used to determine hospital and patient factors independently associated with 30-day care fragmentation. Patients readmitted within 30 days were followed for 60 days postdischarge from the first readmission. Mortality during the first readmission, hospitalization costs, and rates of 60-day readmission were compared between those with and without care fragmentation. RESULTS There were 479,427 admissions with AP and 25,513 with CP. The rates of 30- and 90-day readmissions were 13.5% and 22.9% for AP and 26.9% and 44.7%% for CP. The rates of 30- and 90-day care fragmentation were 28% and 32% for AP and 33% and 38% for CP. Younger age (younger than 45 y), male patients, length of stay <5 days, ≥4 Elixhauser comorbidities, and self-pay or Medicaid insurance were associated with increased risk of 30-day care fragmentation. Large hospital size, routine discharge, and metropolitan location were associated with lower risk. Patients who had the first readmission to a nonindex hospital had a higher mortality (2% vs 1.6%, P = 0.005), length of stay (6.5 vs 5.6 days, P < 0.0001), mean hospitalization cost ($16,731 vs $13,368, P < 0.0001), and 60-day readmission (48.4% vs 42.9%) compared with those readmitted to the index hospital. CONCLUSIONS In patients with AP and CP, one-third of 90-day readmissions occur at a nonindex hospital. Care fragmentation is associated with increased mortality, readmissions, and cost of care.
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Affiliation(s)
- Emad Qayed
- From the Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Ramzi Mulki
- From the Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
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Krill TS, Crain R, Al-Saadi Y, Stubbs S, Roark R, Chatila A, Haddad C, Kaushik C, Marcondes F, Guturu P, Parupudi S. Predictors of 30-Day Readmission After Inpatient Endoscopic Retrograde Cholangiopancreatography: A Single-Center Experience. Dig Dis Sci 2020; 65:1481-1488. [PMID: 31587154 DOI: 10.1007/s10620-019-05870-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The 30-day hospital readmission rate is a nationally recognized quality measure. Nearly one-fifth of medicare beneficiaries are hospitalized within 30 days of discharge, resulting in a cost of over $26 billion dollars annually. Endoscopic retrograde cholangiopancreatography (ERCP) remains the endoscopic procedure with the highest risk of morbidity and mortality. We set out to analyze the clinical characteristics predictive of 30-day readmission after an inpatient ERCP. METHODS We performed a retrospective chart review of all inpatient ERCPs performed at our institution between 12/1/2014 and 9/30/2018. Clinical characteristics and outcomes of these patients were compared to determine predictors of 30-day readmission. RESULTS A total of 497 inpatient ERCP procedures done for biliary or pancreatic indications, constituting 483 patients, were identified. There were 52 readmissions that occurred among 48 patients within 30 days of discharge. Basic demographic characteristics were similar between both groups. Comorbidities were significantly higher in those who were readmitted. Multivariate analysis revealed significantly greater odds of readmission with prior liver transplantation (OR = 4.15), cirrhosis (OR = 3.20), and pancreatic duct stent placement (OR = 2.56). Subgroup analysis for biliary indications revealed cholecystectomy before discharge and early ERCP to be protective against readmission. CONCLUSION A history of liver transplantation and cirrhosis are predictive of increased 30-day readmission rates after an inpatient ERCP. Pancreatic duct stent placement is associated with readmission; however, this phenomenon is likely related to stenting for pancreatic endotherapy. Cholecystectomy before discharge and early ERCP are predictive of decreased need for readmission in procedures done for biliary indications.
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Affiliation(s)
- Timothy S Krill
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0570, USA.
| | - Rebecca Crain
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Yamam Al-Saadi
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Samantha Stubbs
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Russell Roark
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Ahmed Chatila
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Christina Haddad
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Chandni Kaushik
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Felippe Marcondes
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Praveen Guturu
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0570, USA
| | - Sreeram Parupudi
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0570, USA
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García de la Filia Molina I, García García de Paredes A, Martínez Ortega A, Marcos Carrasco N, Rodríguez De Santiago E, Sánchez Aldehuelo R, Foruny Olcina JR, González Martin JÁ, López Duran S, Vázquez Sequeiros E, Albillos A. Biliary sphincterotomy reduces the risk of acute gallstone pancreatitis recurrence in non-candidates for cholecystectomy. Dig Liver Dis 2019; 51:1567-1573. [PMID: 31151894 DOI: 10.1016/j.dld.2019.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/28/2019] [Accepted: 05/01/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Population aging and comorbidity are leading to an increase in patients unfit for cholecystectomy. AIMS To evaluate whether endoscopic biliary sphincterotomy after a first episode of acute gallstone pancreatitis reduces the risk of pancreatitis recurrence and gallstone-related events in non-surgical candidates. METHODS Retrospective study of patients admitted for a first episode of acute gallstone pancreatitis rejected for cholecystectomy between 2013-2018. The role of endoscopic sphincterotomy was evaluated by adjusting for age, severity of pancreatitis, and presence of choledocholithiasis. RESULTS We included 247 patients (mean age 80 ± 12 years; Charlson index: 5; severity of pancreatitis: 72% mild). Sphincterotomy was performed in 23.9%. Recurrence of pancreatitis occurred in 17.4% patients (median follow-up: 426 days). The one-year cumulative incidence of a new episode of pancreatitis was 1.8% (95% confidence interval [CI]: 0.2-12%) and 23% (95% CI: 17-31%) in patients with and without sphincterotomy, respectively (p = 0.006). In multivariate analysis, sphincterotomy showed a protective role for recurrence of pancreatitis (adjusted hazard ratio [HR]: 0.29, 95% CI: 0.08-0.92, p = 0.037) and for any gallstone-related event (HR 0.46, 95% CI: 0.21-0.98, p = 0.043). CONCLUSIONS Endoscopic biliary sphincterotomy reduced the risk of gallstone pancreatitis recurrence and other biliary-related disorders in patients with a first episode of pancreatitis non-candidates for cholecystectomy.
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Affiliation(s)
- Irene García de la Filia Molina
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Ana García García de Paredes
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain.
| | - Antonio Martínez Ortega
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Natalia Marcos Carrasco
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Enrique Rodríguez De Santiago
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain
| | - Rubén Sánchez Aldehuelo
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Jose Ramón Foruny Olcina
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain
| | - Juan Ángel González Martin
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain
| | - Sergio López Duran
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Enrique Vázquez Sequeiros
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain
| | - Agustín Albillos
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain; Biomedical Research Center in Liver and Digestive Diseases Network (CIBERehd), Carlos III Health Institute, Madrid, Spain
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Sánchez Rodríguez E, García García de Paredes A, Albillos A. Current management of acute idiopathic pancreatitis and acute recurrent pancreatitis. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sánchez Rodríguez E, García García de Paredes A, Albillos A. Manejo actual de la pancreatitis aguda idiopática y la pancreatitis aguda recurrente. Rev Clin Esp 2019; 219:266-274. [DOI: 10.1016/j.rce.2018.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/28/2018] [Indexed: 02/07/2023]
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Shah R, Haydek C, Mulki R, Qayed E. Incidence and predictors of 30-day readmissions in patients hospitalized with chronic pancreatitis: A nationwide analysis. Pancreatology 2018; 18:386-393. [PMID: 29703552 DOI: 10.1016/j.pan.2018.04.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 04/16/2018] [Accepted: 04/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with chronic pancreatitis are prone to frequent readmissions. The aim of this study is to evaluate the rate and predictors of 30-day readmissions in patients with chronic pancreatitis using the Nationwide Readmission Database (NRD). METHODS We performed a retrospective analysis of all adult patients with the principal discharge diagnosis of chronic pancreatitis from 2010 through 2014. We excluded patients who died during the hospitalization. Multivariate Cox proportional hazard regression was performed to identify demographic, clinical, and hospital factors that associated with 30-day unplanned readmissions. RESULTS During the study period, 25,259 patients had the principal discharge diagnosis of chronic pancreatitis and survived the index hospitalization. Of these, 6477 (26.7%) were readmitted within 30 days. Younger age group, males, length of stay >5 days, admission to a large, metropolitan hospital, and several comorbidities (renal failure, rheumatic disease, chronic anemia, heart failure, depression, drug abuse, psychosis, and diabetes) were independently associated with increased risk of 30-day readmission. ERCP, pancreatic surgery, and obesity were associated with lower risk. The most common reasons for readmissions were acute pancreatitis (30%), chronic pancreatitis (17%), pseudocyst (2%), and abdominal pain (6%). CONCLUSIONS One in four patients with chronic pancreatitis is readmitted within 30 days (26.7%). Pancreatic disease accounts for at least half of all readmissions. Several baseline comorbidities and characteristics are associated with 30-day readmission risk after index admission. Knowledge of these predictors can help design interventions to target high-risk patients and reduce readmissions and costs of care.
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Affiliation(s)
- Rushikesh Shah
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, 49 Jesse Hill Junior Drive, Atlanta, GA 30303, United States
| | - Christopher Haydek
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Ramzi Mulki
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, 49 Jesse Hill Junior Drive, Atlanta, GA 30303, United States
| | - Emad Qayed
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, 49 Jesse Hill Junior Drive, Atlanta, GA 30303, United States.
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