Follow-up to determine unplanned hospitalization and complications after endoscopic retrograde cholangiopancreatography

ERCP in patients with prior sphincterotomy has a 50% lower rate of post-ERCP pancreatitis and fewer unplanned hospital admissions

OBJECTIVES

ERCP is essential in managing pancreaticobiliary disease, with well-documented complications. Rates of clinically significant complications are about 10%, approximately half of which is related to post-ERCP pancreatitis (PEP). We aimed to quantify the effect of previous sphincterotomy on post-endoiscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

MATERIALS AND METHODS

Data were collated from a contemporaneously collected database of 2876 consecutive ERCP procedures of a single operator in a tertiary referral centre. Analysis was conducted using R software, and logistic regression models.

RESULTS

Of 2876 procedures (mean age 63 years, 56% female), 120 (4.2%) developed PEP and 268 (9.3%) had prolonged/unplanned hospital admission. Univariate analysis showed patients with previous sphincterotomy 28/1054 (2.7%) had decreased risk of PEP compared with those without sphincterotomy 92/1822 (5.0%) (OR 0.52, p = .0021). This difference was not evident when multivariate analysis for age, sex and indication was undertaken due to a particularly low risk of PEP in stent change patients (1.4%), which were disproportionately represented in the previous sphincterotomy group. The rate of prolonged/unplanned hospital admission was recorded for a total of 2876 patients, occurring in 184/1802 (10.1%) in the native ampulla group, versus 84/1045 (8.0%) in the previous sphincterotomy group.

CONCLUSIONS

The risk of PEP is halved by prior sphincterotomy. The presence of a biliary stent conferred an even lower risk of PEP (1.4%), but those without an in situ stent at the time of ERCP had a similar risk of PEP (4.6%) of prolonged/unplanned hospitalisation to those with a native ampulla.

Prolonged endoscopic retrograde cholangiopancreatography results in higher rates of pancreatitis and unplanned hospitalisation

BACKGROUND AND AIM

Although complications from endoscopic retrograde cholangiopancreatography (ERCP) are well described, procedure duration has received scant attention. The relationship between ERCP duration and patient demographics, indications, results and complications were examined.

METHODS

A contemporaneously recorded database of 2572 consecutive ERCPs performed between 2008 and 2018 by a single endoscopist was analysed. Those taking under 40 min were compared with those taking over 40 min.

RESULTS

Of 2572 cases, 2213 took under 40 min and 359 took over 40 min. Emergency cases (relative risk 2.10), older age (66.6 vs 61.6 years p value < 0.01) and no previous sphincterotomy (relative risk 1.94) were factors which resulted in prolonged procedures. The indication of change or removal of stent for benign conditions resulted in fewer prolonged procedures (relative risk 0.37). Indications of pancreatitis, cholangitis and positive intraoperative cholangiogram were not associated with procedure length. Findings of biliary stricture(s) (relative risk 2.02) and failure to cannulate desired duct (relative risk 3.69) were associated with prolonged procedures. Choledocholithiasis (relative risk 0.62), dilated bile duct without stricture/stone (relative risk 0.46) and normal ductal anatomy (relative risk 0.50) resulted in fewer prolonged procedures. Procedures taking over 40 min had increased risks of complications resulting in unplanned or prolongation of hospitalisation (relative risk 1.41) and pancreatitis (relative risk 1.74).

CONCLUSIONS

Prolonged procedures had increased rates of pancreatitis and unplanned/prolonged hospitalisation. Failed access to desired duct, advanced age, biliary strictures, no previous sphincterotomy and unplanned emergency cases were associated with prolonged procedures.

Consequences of Stenting and Endoscopic Papillary Balloon Dilatation in Treatment of Large and Multiple Common Bile Duct Stones

BACKGROUND Although stenting for the treatment of large and multiple common bile duct stones has been acceptable to everyone, its efficacy and outcome have not been studied in comparison with other endoscopic procedures. The purpose of this study was to compare the consequences of stenting and endoscopic papilla balloon dilatation for the treatment of large and multiple common bile duct stones. METHODS In a double-blind clinical trial, of 431 patients with bile duct stones referred to the treatment center, 64 patients with multiple common bile duct stones ( ≥ 3) and more than 15 cm were selected for the study, then by random allocation rule the participants were allocated in two groups. They were entered into two different endoscopic papillary balloon dilatation (EPBD) and common bile ducts stenting treatments so that both procedures were performed by a person. Both groups were assessed from the point of views therapeutic outcomes such as duct cleaning, pancreatitis, isolated pain, and duct rupture. Data were collected by a self-made questionnaire that was used before and after the procedure to obtain the needed information. Then data were analyzed using SPSS software version 22 and descriptive and analytical tests were used as appropriated. RESULTS Although the duct cleaning and the complete removal of the stones in the stenting treatment procedure was 93.8%, and in EPBD was 78.3%, no significant difference was observed between the two groups (p = 0.14). Pancreatitis significantly increased after the first and second endoscopic retrograde cholangiopancreatography (ERCP) in the stent group compared with EPBD (p = 0.02). Also, the most frequent cases of isolated pain were in the endoscopic group EPBD (p = 0.0). However, the occurrence of perforation after first ERCP and EPBD was zero, but in the second stage of ERCP, 3.3% of the patients had perforations (p = 0.99). The results indicated that the shape of the stone (circular and angled) was not effective in the result of treatment in the two groups. CONCLUSION The results of this study indicated that in case of experience and skill in conducting the ERCP, common bile duct stenting is still the first line of treatment for large and multiple stones of the common bile ducts.

New classification system for indications for endoscopic retrograde cholangiopancreatography predicts diagnoses and adverse events

BACKGROUND

Indications for endoscopic retrograde cholangiopancreatography (ERCP) have received little attention, especially in scientific or objective terms.

AIM

To review the prevailing ERCP indications in the literature, and to propose and evaluate a new ERCP indication system, which relies on more objective pre-procedure parameters.

METHODS

An analysis was conducted on 1758 consecutive ERCP procedures, in which contemporaneous use was made of an a-priori indication system. Indications were based on the objective pre-procedure parameters and divided into primary [cholangitis, clinical evidence of biliary leak, acute (biliary) pancreatitis, abnormal intraoperative cholangiogram (IOC), or change/removal of stent for benign/malignant disease] and secondary [combination of two or three of: pain attributable to biliary disease ('P'), imaging evidence of biliary disease ('I'), and abnormal liver function tests (LFTs) ('L')]. A secondary indication was only used if a primary indication was not present. The relationship between this newly developed classification system and ERCP findings and adverse events was examined.

RESULTS

The indications of cholangitis and positive IOC were predictive of choledocholithiasis at ERCP (101/154 and 74/141 procedures, respectively). With respect to secondary indications, only if all three of 'P', 'I', and 'L' were present there was a statistically significant association with choledocholithiasis (χ²(1) = 35.3, p < .001). Adverse events were associated with an unusual indication leading to greater risk of unplanned hospitalization (χ²(1) = 17.0, p < .001).

CONCLUSIONS

An a-priori-based indication system for ERCP, which relies on pre-ERCP objective parameters, provides a more useful and scientific classification system than is available currently.