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Singh I, Chou JF, Capanu M, Park J, Yu KH, Varghese AM, Park W, Zervoudakis A, Keane F, Rolston VS, Gerdes H, Wei AC, Shah P, Covey A, Schattner M, O'Reilly EM. Morbidity and mortality in patients with stage IV pancreatic adenocarcinoma and acute cholangitis: Outcomes and risk prognostication. Pancreatology 2024; 24:608-615. [PMID: 38749803 PMCID: PMC11164623 DOI: 10.1016/j.pan.2024.05.515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/05/2024] [Accepted: 05/06/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Acute cholangitis (AC) is a common complication of pancreatic ductal adenocarcinoma (PDAC). Herein, we evaluated outcomes after the first AC episode and predictors of mortality and AC recurrence in patients with stage IV PDAC. METHODS We conducted a single-center, retrospective observational study using institutional databases. Clinical data and outcomes for patients with stage IV PDAC and at least one documented episode of AC, were assessed. Overall survival (OS) was estimated using the Kaplan-Meier method, and Cox regression model was employed to identify predictors of AC recurrence and mortality. RESULTS One hundred and twenty-four patients with stage IV PDAC and AC identified between January 01, 2014 and October 31, 2020 were included. Median OS after first episode of AC was 4.1 months (95 % CI, 4.0-5.5), and 30-day, 6, and 12-month survival was 86.2 % (95 % CI, 80.3-92.5), 37 % (95 % CI, 29.3-46.6 %) and 18.9 % (95 % CI, 13.1-27.3 %), respectively. Primary tumor in pancreatic body/tail (HR 2.29, 95 % CI: 1.26 to 4.18, p = 0.011), concomitant metastases to liver and other sites (HR 1.96, 95 % CI: 1.16 to 3.31, p = 0.003) and grade 3 AC (HR 2.26, 95 % CI: 1.45 to 3.52, p < 0.001), predicted worse outcomes. Intensive care unit admission, sepsis, systemic therapy, treatment regimen, and time to intervention did not predict survival or risk of recurrence of AC. CONCLUSIONS AC confers significant morbidity and mortality in advanced PDAC. Worse outcomes are associated with higher grade AC, primary tumor location in pancreatic body/tail, and metastases to liver and other sites.
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Affiliation(s)
- Isha Singh
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, 26505, USA
| | - Joanne F Chou
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Marinela Capanu
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Jennifer Park
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Kenneth H Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Anna M Varghese
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Wungki Park
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Alice Zervoudakis
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Fergus Keane
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Vineet Syan Rolston
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Hans Gerdes
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Pari Shah
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Anne Covey
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Mark Schattner
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Eileen M O'Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; David M. Rubenstein Center for Pancreas Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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Tsou YK, Su YT, Lin CH, Liu NJ. Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the clinical presentation and outcomes? World J Clin Cases 2023; 11:6984-6994. [PMID: 37946763 PMCID: PMC10631399 DOI: 10.12998/wjcc.v11.i29.6984] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/02/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Whether clinical outcomes of acute cholangitis (AC) vary by etiology is unclear. AIM To compare outcomes in AC caused by malignant biliary obstruction (MBO) and common bile duct stones (CBDS). METHODS This retrospective study included 516 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) due to AC caused by MBO (MBO group, n = 56) and CBDS (CBDS group, n = 460). Clinical and laboratory parameters were compared between the groups. Propensity score matching (PSM) created 55 matched pairs. Confounders used in the PSM analysis were age, sex, time to ERCP, and technical success of ERCP. The primary outcome comparison was 30-d mortality. The secondary outcome comparisons were intensive care unit (ICU) admission rate, length of hospital stay (LOHS), and 30-d readmission rate. RESULTS Compared with the CBDS group, the MBO group had significantly lower body temperature, percentage of abnormal white blood cell counts, and serum levels of aspartate aminotransferase, alanine aminotransferase, and creatinine. Body temperature, percent abnormal white blood cell count, and serum aspartate aminotransferase levels remained significantly lower in the MBO group in the PSM analysis. Platelet count, prothrombin time/international normalized ratio, and serum levels of alkaline phosphatase and total bilirubin were significantly higher in the MBO group. The MBO group had a significantly higher percentage of severe AC (33.9% vs 22.0%, P = 0.045) and received ERCP later (median, 92.5 h vs 47.4 h, P < 0.001). However, the two differences were not found in the PSM analysis. The 30-d mortality (5.4% vs 0.7%, P = 0.019), ICU admission rates (12.5% vs 4.8%, P = 0.028), 30-d readmission rates (23.2% vs 8.0%, P < 0.001), and LOHS (median, 16.5 d vs 7.0 d, P < 0.001) were significantly higher or longer in the MBO group. However, only LOHS remained significant in the PSM analysis. Multivariate analysis revealed that time to ERCP and multiple organ dysfunction were independent factors associated with 30-d mortality. CONCLUSION MBO patients underwent ERCP later and thus had a worse prognosis than CBDS patients. Therefore, clinicians should remain vigilant in MBO patients with clinically suspected AC, and perform ERCP for biliary drainage as soon as possible.
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Affiliation(s)
- Yung-Kuan Tsou
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Yi-Tse Su
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Cheng-Hui Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Nai-Jen Liu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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Hedjoudje A, Cheurfa C, Et Talby M, Levy P, Prat F, Piton G. Outcomes and predictors of delayed endoscopic biliary drainage for severe acute cholangitis due to choledocholithiasis in an intensive care unit. Dig Liver Dis 2023; 55:763-770. [PMID: 36842843 DOI: 10.1016/j.dld.2023.01.158] [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: 09/27/2022] [Revised: 12/17/2022] [Accepted: 01/20/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Acute cholangitis (AC) is an infection of the biliary tract secondary to biliary obstruction requiring biliary drainage through endoscopic retrograde cholangiopancreatography. This study aims to compare the outcome between the early and delayed ERCP in patients with severe AC. METHODS Patient with severe AC due to choledocholithiasis admitted to intensive care unit were included. Early ERCP was defined was as ERCP performed within 24 h following hospital admission. Propensity-score matching was used to reduce the imbalance between groups. The primary outcome was 30-day mortality. Secondary outcomes included length of hospital and ICU stay, onset or persistent organ failure. RESULTS The delayed ERCP group had a higher mortality rate at 30 days (45,5 versus 13%, <0.001) and at 1 year (59,7% versus 15,6%, p <0.001). Delayed ERCP had also a higher rate of respiratory adverse events (54,5 versus 27,8%, p = 0,002), longer ICU (7.41 versus 4.61, p = 0,004) and hospital (11,88 versus 9,22, p = 0,042) length of stay. Predictors of delayed ERCP were cardiac arrythmias, liver disease, creatinine value and white blood cell count at baseline. CONCLUSIONS Delays in ERCP for patients with severe AC appear to be associated with higher mortality rate and prolonged ICU and hospital stays.
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Affiliation(s)
- Abdellah Hedjoudje
- Assistance Publique des Hôpitaux de Paris, DMU Digestif, Hôpital Beaujon, Clichy, France; Equipe d'Accueil 3920, Université de Bourgogne-Franche Comté, France
| | - Chérifa Cheurfa
- Service de réanimation chirurgicale, Hôpital Cochin, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Mohamed Et Talby
- Service de réanimation chirurgicale, Hôpital Cochin, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Philippe Levy
- Assistance Publique des Hôpitaux de Paris, DMU Digestif, Hôpital Beaujon, Clichy, France
| | - Frédéric Prat
- Assistance Publique des Hôpitaux de Paris, DMU Digestif, Hôpital Beaujon, Clichy, France
| | - Gaël Piton
- Equipe d'Accueil 3920, Université de Bourgogne-Franche Comté, France; Service de réanimation médicale, CHRU Jean Minjoz, Besançon, France.
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Park N, Jung MK, Kim EJ, Paik WH, Cho JH. In-stent radiofrequency ablation with uncovered metal stent placement for tumor ingrowth/overgrowth causing self-expandable metal stent occlusion in distal malignant biliary obstruction: multicenter propensity score-matched study. Gastrointest Endosc 2023; 97:694-703.e2. [PMID: 36460085 DOI: 10.1016/j.gie.2022.11.017] [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: 08/24/2022] [Revised: 10/29/2022] [Accepted: 11/18/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND AND AIMS In patients with unresectable malignant biliary obstruction (MBO), endoscopic drainage with a self-expandable metal stent (SEMS) is a well-established treatment, but stent patency is limited. This study aimed to evaluate the efficacy of in-stent radiofrequency ablation (IS-RFA) followed by uncovered SEMS placement for the management of occluded SEMSs. METHODS From 2016 to 2020, 48 patients with recurrent biliary obstruction due to tumor ingrowth or overgrowth after SEMS placement for pancreatobiliary cancer in 3 tertiary hospitals were analyzed. For distal MBO, patients in the RFA group were treated with IS-RFA and uncovered SEMS placement, and those in the control group were treated with uncovered SEMS placement alone. Patients in both groups were matched on the basis of propensity scores in a 1:1 ratio. RESULTS The median time to recurrent biliary obstruction (TRBO) was 117 days in the RFA group and 82.5 days in the control group (P = .029). No significant differences in median overall survival were detected between the 2 groups (170 days vs 72 days; P = .902). No significant adverse events were reported after the second SEMS placement in either group, but 2 cases of mild cholangitis were reported in the control group. Ablation was interrupted in 5 patients (35.7%) of the RFA group owing to in-stent contact, but sufficient ablative energy was delivered in the majority of the patients (92.9%) after IS-RFA was repeated in the same session. CONCLUSIONS IS-RFA followed by an uncovered SEMS is safe and feasible and may improve TRBO as a stent revision for occluded SEMSs in pancreatobiliary cancer.
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Affiliation(s)
- Namyoung Park
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea; Department of Gastroenterology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Min Kyu Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Eui Joo Kim
- Division of Gastroenterology, Department of Internal Medicine, Gil Medical Center, College of Medicine Gachon University, Incheon, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Jae Hee Cho
- Department of Internal Medicine, Institute of Gastroenterology, Gangnam Severance Hospital, Yonsei University College of Medicine, Korea.
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Mukai S, Itoi T, Tsuchiya T, Ishii K, Tanaka R, Tonozuka R, Sofuni A. Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis. Dig Endosc 2023; 35:47-57. [PMID: 35702927 DOI: 10.1111/den.14379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/13/2022] [Indexed: 01/17/2023]
Abstract
Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.
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Affiliation(s)
- Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kentaro Ishii
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Huang YC, Wu CH, Lee MH, Wang SF, Tsou YK, Lin CH, Sung KF, Liu NJ. Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity. World J Gastroenterol 2022; 28:5602-5613. [PMID: 36304084 PMCID: PMC9594008 DOI: 10.3748/wjg.v28.i38.5602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/12/2022] [Accepted: 09/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis (AC) is uncertain, especially in patients with AC of varying severity.
AIM To report whether the timing of ERCP is associated with outcomes in AC patients with different severities.
METHODS According to the 2018 Tokyo guidelines, 683 patients who met the definite diagnostic criteria for AC were retrospectively identified. The results were first compared between patients receiving ERCP ≤ 24 h and > 24 h and then between patients receiving ERCP ≤ 48 h and > 48 h. Subgroup analyses were performed in patients with grade I, II or III AC. The primary outcome was 30-d mortality. Secondary outcomes were intensive care unit (ICU) admission rate, length of hospital stay (LOHS) and 30-d readmission rate.
RESULTS Taking 24 h as the critical value, compared with ERCP > 24 h, malignant biliary obstruction as a cause of AC was significantly less common in the ERCP ≤ 24 h group (5.2% vs 11.5%). The proportion of cardiovascular dysfunction (11.2% vs 2.6%), respiratory dysfunction (14.2% vs 5.3%), and ICU admission (11.2% vs 4%) in the ERCP ≤ 24 h group was significantly higher, while the LOHS was significantly shorter (median, 6 d vs 7 d). Stratified by the severity of AC, higher ICU admission was only observed in grade III AC and shorter LOHS was only observed in grade I and II AC. There were no significant differences in 30-d mortality between groups, either in the overall population or in patients with grade I, II or III AC. With 48 h as the critical value, compared with ERCP > 48 h, the proportion of choledocholithiasis as the cause of AC was significantly higher in the ERCP ≤ 48 h group (81.5% vs 68.3%). The ERCP ≤ 48 h group had significantly lower 30-d mortality (0 vs 1.9%) and shorter LOHS (6 d vs 8 d). Stratified by AC severity, lower 30-d mortality (0 vs 6.1%) and higher ICU admission rates (22.2% vs 10.2%) were only observed in grade III AC, and shorter LOHS was only observed in grade I and II AC. In the multivariate analysis, cardiovascular dysfunction and time to ERCP were two independent factors associated with 30-d mortality.
CONCLUSION ERCP ≤ 48 h conferred a survival benefit in patients with grade III AC. Early ERCP shortened the LOHS in patients with grade I and II AC.
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Affiliation(s)
- Yao-Chi Huang
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chi-Huan Wu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Mu Hsien Lee
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Sheng Fu Wang
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Yung-Kuan Tsou
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Cheng-Hui Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Kai-Feng Sung
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Nai-Jen Liu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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