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Lee SY, Park SH, Do MY, Lee DK, Jang SI, Cho JH. Increased ERCP-related adverse event from premature urgent ERCP following symptom onset in acute biliary pancreatitis with cholangitis. Sci Rep 2024; 14:13663. [PMID: 38871990 DOI: 10.1038/s41598-024-64644-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 06/11/2024] [Indexed: 06/15/2024] Open
Abstract
Acute biliary pancreatitis (ABP) with cholangitis requires endoscopic retrograde cholangiopancreatography (ERCP) within 24 h to resolve ductal obstruction. However, this recommendation is based on the timing of emergency room (ER) visits. We wanted to determine the optimal timing of ERCP for ABP based on the timing of symptom onset, not the timing of the ER visit. We retrospectively reviewed 162 patients with ABP with cholangitis who underwent urgent ERCP (within 24 h of ER admission). Area under the receiver operating characteristic (ROC) curve (AUC) was analyzed to determine differences in complication rates according to time from symptom onset. A difference in ERCP-related adverse events (AEs) was identified, and Youden's J statistic was used to determine a cutoff time from symptom onset (18 h). We compared mortality and complications based on this cutoff. Based on time to symptom onset, significantly higher rates of aspiration pneumonia (odds ratio [OR] 4.00, 95% confidence interval [CI] 1.15-13.92, P = 0.021) and post-ERCP hypotension (OR 11.9, 95% CI 1.39-101.33, P = 0.005) were observed in the ≤ 18-h group than in the > 18-h group. The study found that patients who underwent ERCP within 18 h of symptom onset is associated with an increased risk of ERCP-related AEs.
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Affiliation(s)
- See Young Lee
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Ho Park
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Min Young Do
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Lee
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Ill Jang
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea.
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Jae Hee Cho
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea.
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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2
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Wu PH, Yu MW, Chuang SC, Wang SN, Kuo KK, Chang WT, Chuang SH, Su WL, Huang JW, Chen LA. Comparison of laparoscopic common bile duct exploration plus cholecystectomy and endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy for elderly patients with common bile duct stones and gallbladder stones. J Gastrointest Surg 2024; 28:719-724. [PMID: 38503593 DOI: 10.1016/j.gassur.2024.02.026] [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: 12/14/2023] [Revised: 02/02/2024] [Accepted: 02/17/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Common bile duct (CBD) stones commonly occur in cholecystectomy cases. The management options include laparoscopic CBD exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Although ERCP is fully developed, it has complications, and LCBDE is a proven alternative. This study aimed to evaluate the safety and efficacy of these treatments in elderly individuals aged ≥70 years. METHODS A retrospective study between January 2015 and July 2022 included 160 elderly patients (aged ≥70 years) diagnosed with cholelithiasis and choledocholithiasis. The patients were divided into 1-stage (LCBDE [n = 80]) or 2-stage (ERCP followed by LC [n = 80]) treatment groups. Data collected encompassed comorbidities, symptoms, bile duct clearance, postoperative complications, and long-term outcomes for systematic analysis. RESULTS This study analyzed 160 patients treated for CBD stones, comparing 1-stage and 2-stage groups. The 1-stage group had more female patients than the 2-stage group (57.5% vs 37.5%, respectively). The 1-stage group had a mean age of 80.55 ± 7.00 years, which was higher than the mean age in the 2-stage group. American Society of Anesthesiologists classification, Charlson Comorbidity Index, and laboratory findings were similar. Pancreatitis and cholangitis occurred after ERCP in the 2-stage group. Stone clearance rates (92.35% [1-stage group] vs 95.00% [2-stage group]) and biliary leakage incidence (7.5% [1-stage group] vs 3.0% [2-stage group]) were similar, as were postoperative complications and long-term recurrence rates (13.0% [1-stage group] vs 12.5% [2-stage group]). CONCLUSION Our research indicates that both the combination of LCBDE and LC and the sequence of ERCP followed by LC are equally efficient and secure when treating CBD stones in elderly patients. Consequently, the 1-stage procedure may be considered the preferred treatment approach for this demographic.
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Affiliation(s)
- Po-Hsuan Wu
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Min-Wei Yu
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan.
| | - Shih-Chang Chuang
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Shen-Nien Wang
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Kung-Kai Kuo
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Wen-Tsan Chang
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Shu-Hung Chuang
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Wen-Lung Su
- Department of Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung City, Taiwan
| | - Jian-Wei Huang
- Department of Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung City, Taiwan
| | - Ling-An Chen
- Department of Surgery, Ministry of Health and Welfare Pingtung Hospital, Pingtung County, Taiwan
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3
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Basida SD, Dahiya DS, Yousaf MN, Basida B, Pinnam BSM, Gangwani MK, Ali H, Singh S, Shah YR, Ahluwalia D, Shah MP, Chandan S, Sharma NR, Thakkar S. Impact of frailty on endoscopic retrograde cholangiopancreatography outcomes in nonagenarians: A United States national experience. World J Gastrointest Endosc 2024; 16:148-156. [PMID: 38577647 PMCID: PMC10989256 DOI: 10.4253/wjge.v16.i3.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/19/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is an essential therapeutic tool for biliary and pancreatic diseases. Frail and elderly patients, especially those aged ≥ 90 years are generally considered a higher-risk population for ERCP-related complications.
AIM To investigate outcomes of ERCP in the Non-agenarian population (≥ 90 years) concerning Frailty.
METHODS This is a cohort study using the 2018-2020 National Readmission Database. Patients aged ≥ 90 were identified who underwent ERCP, using the international classification of diseases-10 code with clinical modification. Johns Hopkins’s adjusted clinical groups frailty indicator was used to classify patients as frail and non-frail. The primary outcome was mortality, and the secondary outcomes were morbidity and the 30 d readmission rate related to ERCP. We used univariate and multivariate regression models for analysis.
RESULTS A total of 9448 patients were admitted for any indications of ERCP. Frail and non-frail patients were 3445 (36.46%) and 6003 (63.53%) respectively. Indications for ERCP were Choledocholithiasis (74.84%), Biliary pancreatitis (9.19%), Pancreatico-biliary cancer (7.6%), Biliary stricture (4.84%), and Cholangitis (1.51%). Mortality rates were higher in frail group [adjusted odds ratio (aOR) = 1.68, P = 0.02]. The Intra-procedural complications were insignificant between the two groups which included bleeding (aOR = 0.72, P = 0.67), accidental punctures/lacerations (aOR = 0.77, P = 0.5), and mechanical ventilation rates (aOR = 1.19, P = 0.6). Post-ERCP complication rate was similar for bleeding (aOR = 0.72, P = 0.41) and post-ERCP pancreatitis (aOR = 1.4, P = 0.44). Frail patients had a longer length of stay (6.7 d vs 5.5 d) and higher mean total charges of hospitalization ($78807 vs $71392) compared to controls (P < 0.001). The 30 d all-cause readmission rates between frail and non-frail patients were similar (P = 0.96).
CONCLUSION There was a significantly higher mortality risk and healthcare burden amongst nonagenarian frail patients undergoing ERCP compared to non-frail. Larger studies are warranted to investigate and mitigate modifiable risk factors.
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Affiliation(s)
- Sanket Dhirubhai Basida
- Department of Internal Medicine, University of Missouri-Columbia, Columbia, MO 65212, United States
| | - Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology & Motility, The University of Kansas School of Medicine, Kansas City, KS 66160, United States
| | - Muhammad Nadeem Yousaf
- Division of Gastroenterology and Hepatology, University of Missouri, Columbia, MO 65212, United States
| | - Brinda Basida
- Department of Rheumatology, Medical College of Georgia, Augusta University, North Augusta, GA 30912, United States
| | - Bhanu Siva Mohan Pinnam
- Department of Internal Medicine, John H. Stroger Hospital of Cook County, Chicago, IL 60612, United States
| | - Manesh Kumar Gangwani
- Department of Internal Medicine, The University of Toledo, Toledo, OH 43606, United States
| | - Hassam Ali
- Division of Gastroenterology and Hepatology, East Carolina University/Brody School of Medicine, Greenville, NC 27858, United States
| | - Sahib Singh
- Department of Internal Medicine, Sinai Hospital, Baltimore, MD 21215, United States
| | - Yash R Shah
- Department of Internal Medicine, Trinity Health Oakland/Wayne State University, Pontiac, MI 48341, United States
| | - Daksh Ahluwalia
- Department of Internal Medicine, John H. Stroger Hospital of Cook County, Chicago, IL 60612, United States
| | - Mihir Prakash Shah
- Department of Internal Medicine, John H. Stroger Hospital of Cook County, Chicago, IL 60612, United States
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, NE 68131, United States
| | - Neil R Sharma
- Division of Interventional Oncology & Surgical Endoscopy, GI Oncology Tumor Site Team, Parkview Cancer Institute, Parkview Health, Fort Wayne, IN 46845, United States
| | - Shyam Thakkar
- Section of Gastroenterology & Hepatology, West Virginia University School of Medicine, Morgantown, WV 26505, United States
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4
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Angsuwatcharakon P, Thongsuwan C, Ridtitid W, Piyachaturawat P, Kulpatcharapong S, Kongkam P, Rerknimitr R. Morphology of the major duodenal papilla for the selection of advanced cannulation techniques in difficult biliary cannulation. Surg Endosc 2023:10.1007/s00464-023-10058-1. [PMID: 37055667 DOI: 10.1007/s00464-023-10058-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 04/01/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Morphology of the major duodenal papilla (MDP) influences the outcome of standard biliary cannulation. However, those data on advanced cannulation techniques are scarce. We aimed to study the impact of MDP morphology on the outcome of both standard and advanced cannulation methods. METHODS Images of naïve papilla were retrospectively reviewed and independently classified into 4 types (1: classic appearance, 2: small, 3: bulging, and 4: ridged papillae). All cannulation was started with guidewire cannulation. After failure, advanced cannulation including double guidewire (DG) and/or precut sphincterotomy (PS) was performed. Outcomes including success rate and complications were analyzed. RESULTS A total 805 naïve papilla were included. The overall advanced cannulation rate was 23.2%. The MPD type 2 (OR 1.8, 95% CI 1.8-2.9) and type 4 (OR 2.1, 95% CI 1.1-3.8) required advanced cannulation technique at a higher rate than type 1. Type 3 significantly needed a higher proportion of PS when compared with type 1 (59.09% vs 27.03%, OR 3.90, 95% CI 1.51-10.06). Overall post-ERCP pancreatitis (PEP) was 8% and was not different among MDP types. PEP was significantly increased in difficult cannulation group (15.38% vs 5.71%, p-value < 0.001). Multivariate analysis demonstrated that DG independently increased risk of PEP (OR 3.6, 95% CI 2.0-6.6). CONCLUSIONS MDP type 2 and type 4 were related to difficult cannulation. Although DG and PS can be used as advanced cannulation in all types, DG carries risk of PEP and PS may be preferred over DG in MDP type 3.
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Affiliation(s)
- Phonthep Angsuwatcharakon
- Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chompoonuch Thongsuwan
- Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Wiriyaporn Ridtitid
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Panida Piyachaturawat
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Santi Kulpatcharapong
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pradermchai Kongkam
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
- Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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5
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Ben Abdallah K, Hamzaoui L, Mahmoudi M, Cherif I, Ben Mohamed A, Yakoubi M, Khsiba A, Medhioub M, Azouz M. Predictive factors of difficult biliary cannulation: An experience of a tunisian tertiary center. Heliyon 2022; 8:e12526. [PMID: 36619425 PMCID: PMC9812703 DOI: 10.1016/j.heliyon.2022.e12526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/03/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Selective biliary cannulation is a prerequisite for a successful endoscopic retrograde cholangiopancreatography (ERCP). However, conventional biliary access can be difficult. The aims of our study were to determine the prevalence of difficult biliary cannulation (DBC) and its associated factors and to describe the efficiency and safety of used standard and advanced cannulation techniques. Methods We conducted a single-center retrospective study including all patients with naïve papilla who had an ERCP procedure in Gastroenterology department of Mohamed Taher Maamouri Hospital from June 2019 to December 2021. Efficiency was defined as successful selective deep biliary cannulation. DBC was defined based on the presence of one or more of the European Society of Gastrointestinal Endoscopy (ESGE) criteria (5-5-1): more than five cannulation attempts, more than 5 min before cannulation and more than one accidental passage in the wirsung. Prevalence was measured using ESGE 5-5-1 cutoffs and chinese set cutoffs 15-10-2. Predictors of DBC were sought by univariate and multivariate analysis (SPSS software, p significant if < 0.05). Results We included 664 patients (mean age 62 years and sex ratio M/W = 0.8). Main indication for ERCP was choledocholithiasis (67%, n = 442) followed by malignant biliary stenosis (21%, n = 138). Based on ESGE criteria, prevalence of DBC was 42.62% (n = 283). Prevalence was 21.15% when 15-10-2 cutoffs are applied in trainee-involved procedure. Cumulative biliary success rate was 96.46%. Standard cannulation method achieved access in 98.2% while advanced methods permitted success in 92.2% in fistulotomy, 94.1% in papillotomy and 77.3% in transpancreatic sphincterotomy. Independent predictive factors of DBC in multivariate analysis were: Trainee presence OR 1.80 [1.24-2.65], SOD OR 4.71 [1.11-19.88], biliary stenosis found on imaging examinations (OR 2.53 [1.63-3.92], small papilla OR 4.09 [1.82-9.17] and difficult orientation of the papilla OR 14.90 [3.28-67.62]. Conclusion DBC is a frequent endoscopic situation. Predictors of DBC can be related to trainee involvement in the procedure, anatomical and clinical factors. A thorough understanding of these factors can actively contribute to ERCP management plans.
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Affiliation(s)
- K. Ben Abdallah
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia,Corresponding author.
| | - L. Hamzaoui
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M. Mahmoudi
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - I. Cherif
- Laboratory of Medical Epidemiology, Institut Pasteur de Tunis, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - A. Ben Mohamed
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M. Yakoubi
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - A. Khsiba
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M. Medhioub
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M.M. Azouz
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Chen CC, Lin WT, Tung CF, Lee SW, Chang CS, Peng YC. Safety of Nonagenarians Receiving Therapeutic ERCP, Single Center Experience. J Clin Med 2022; 11:jcm11175197. [PMID: 36079126 PMCID: PMC9456670 DOI: 10.3390/jcm11175197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: The complication rates for nonagenarians receiving therapeutic endoscopic retrograde cholangiopancreatography (ERCP) remain poorly understood. We aimed to determine whether nonagenarians were at an increased risk of ERCP-related complications. (2) Methods: We performed a retrospective study on therapeutic ERCP in nonagenarians from 2011 to 2016 at Taichung Veterans General Hospital. A control group comprising patients aged 65 to 89 years was used to compare demographic data and the outcomes of therapeutic ERCP with the nonagenarians. The risk factors for complications were determined by logistic regression model. (3) Results: There were 35 nonagenarians and 111 patients in the control group. Overall, complication rates were not statistically different between the two groups. However, advanced age was an independent predictor of complications in the multivariate analysis (odds ratio [OR] = 1.06; 95% confidence interval [CI] = 1.01-1.12; p = 0.049). End stage renal disease (ESRD) was another independent predictor of complications (OR = 4.87; 95% CI = 1.11-21.36; p = 0.036). Post-ERCP pancreatitis and bleeding were more common in ESRD patients than patients without ESRD. (4) Conclusions: Although nonagenarians receiving ERCP did not have more complications compared to elderly patients younger than 90 years, advanced age and comorbidity still affect the outcome of therapeutic ERCP in the elderly patients.
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Affiliation(s)
- Chia-Chang Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Wan-Tzu Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Chun-Fang Tung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Shou-Wu Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Chi-Sen Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Yen-Chun Peng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11230, Taiwan
- Department of Internal Medicine, Taichung Veterans General Hospital Chiayi Branch, Chiayi 60090, Taiwan
- Correspondence:
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7
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Zhang DY, Zhai YQ, Zhang GJ, Chen SX, Wu L, Chen DX, Li MY. Risk factors for complications in elderly patients aged 85 years and over undergoing endoscopic biliary stone removal. Front Surg 2022; 9:989061. [PMID: 36303850 PMCID: PMC9592906 DOI: 10.3389/fsurg.2022.989061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background and aim The number of elderly patients with biliary stones is increasing. Endoscopic retrograde cholangiography (ERCP) is considered to be an effective treatment for biliary stones. Having a sound knowledge of the risk factors can help reduce the incidence and severity of complications for ERCP. Furthermore, limited research has been published on patients aged over 85 years undergoing endoscopic biliary stone removal. This study aims to determine the risk factors that lead to complications of ERCP in patients over 85 years of age. Methods This was a single-center retrospective study. We analyzed 156 patients aged ≥ 85 years with biliary stones who underwent their first ERCP at Chinese PLA General Hospital from February 2002 to March 2021. Logistic regression models were employed to identify the independent risk factors for complications. Results A total of 13 patients (8.3%) had complications. Thereinto, pancreatitis, cholangitis, bleeding, and other complications occurred in 4 cases (2.6%), 1 cases (0.6%), 4 cases (2.6%), and 4 cases (2.6%), respectively. There was no perforation or death related to ERCP. Independent risk factors for complications were acute biliary pancreatitis (ABP) (P = 0.017) and Charlson Comorbidity Index (CCI) (P = 0.019). Significantly, reasons for incomplete stone removal at once were large stone (>10 mm) (P < 0.001) and higher acute physiology and chronic health evaluation scoring system (APACHE-II) (P = 0.005). Conclusions ERCP was recommended with caution in patients ≥ 85 years of age with ABP or higher CCI undergoing endoscopic biliary stone removal. In patients with ABP without cholangitis or biliary obstruction we recommend against urgent (within 48 h) ERCP. Patients with higher CCI who can tolerate ERCP can undergo rapid ERCP biliary stenting or nasobiliary implantation with later treatment of stones, and patients who cannot tolerate ERCP are treated promptly with PTCD and aggressive conservative treatment.
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Affiliation(s)
- Da-Ya Zhang
- Graduate School of PLA General Hospital, Beijing, China
| | - Ya-Qi Zhai
- Department of Gastroenterology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | | | | | - Lang Wu
- Graduate School of PLA General Hospital, Beijing, China
| | - De-Xin Chen
- Graduate School of PLA General Hospital, Beijing, China
| | - Ming-Yang Li
- Department of Gastroenterology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
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8
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Kabanov MY, Glushkov NI, Sementsov KV, Degterev DB, Savchenkov DK, Koshelev TE, Fokina AA, Bryzgalov DK. [Endoscopic treatment of choledocholithiasis in patients over 80 years old]. Khirurgiia (Mosk) 2021:45-51. [PMID: 34608779 DOI: 10.17116/hirurgia202110145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze endoscopic treatment of choledocholithiasis in patients over 80 years old. MATERIAL AND METHODS A single-center retrospective study included 90 consecutive patients aged ≥80 years and 58 patients aged 60-79 years. Early outcomes including efficacy of calculus removal, incidence of complications and their risk factors were evaluated. RESULTS In 75 patients aged ≥80 years (83.3%), endoscopic treatment was effective definitive single procedure. Between-group differences were insignificant (p=0.163). Patients aged ≥80 years were characterized by higher percentage of ASA classes 2-4 (p<0.001), age-adjusted mean Charlson comorbidity index (p=0.004), and ≥2 calculi (64.4% vs. 32.8%, p<0.001). Postoperative morbidity was similar (7.8% vs. 6.9%, p=0.842). Multivariate logistic regression analysis of potential risk factors did not reveal significant correlations: Chi-square test was 14.94 at 15 degrees of freedom (p=0.463). CONCLUSION Similar postoperative morbidity determines safety of endoscopic lithoextraction in patients aged over 80 years. We should emphasize higher percentage of advanced age patients with «difficult» choledocholithiasis that requires appropriate training of specialists, adequate equipment of hospitals and routing of patients.
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Affiliation(s)
- M Yu Kabanov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia.,St. Petersburg Hospital for War Veterans, St. Petersburg, Russia
| | - N I Glushkov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - K V Sementsov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia.,St. Petersburg Hospital for War Veterans, St. Petersburg, Russia
| | - D B Degterev
- St. Petersburg Hospital for War Veterans, St. Petersburg, Russia
| | - D K Savchenkov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia.,St. Petersburg Hospital for War Veterans, St. Petersburg, Russia
| | - T E Koshelev
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - A A Fokina
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - D K Bryzgalov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
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9
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Is Cholecystectomy a cause of difficult biliary cannulation in endoscopic retrograde cholangiopancreatography? Acta Gastroenterol Belg 2021; 84:563-569. [PMID: 34965037 DOI: 10.51821/84.4.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND STUDY AIM In European Society of Gastrointestinal Endoscopy guidelines, biliary cannulation of naive papillae is defined as difficult in the presence of more than 5 papilla contacts, more than 5min cannulation time or more than one unintended pancreatic duct cannulation or opacification. It is not known whether cholecystectomy is a cause of difficult biliary cannulation. This study aimed to investigate whether cholecystectomy (CCY) is a cause of difficult biliary cannulation in patients who have undergone Endoscopic Retrograde Cholangiopancreatography (ERCP) for choledocholithiasis. PATIENTS AND METHODS Adult patients with naive papillae and those who underwent ERCP for common bile duct stones and/or sludge were included in this retrospective study. Patient demographics, clinical presentation (acute cholangitis, biliary pancreatitis or biliary colic), periprocedural data including laboratory and radiological findings and ERCP results were compared between no-CCY and post-CCY groups. RESULTS 438 patients were included in the present study and 347 of these patients were in the no-CCY group and 91 patients were in post-CCY group. A statistically significant difference was found in the number of patients with difficult cannulation in the post-CCY group (n=30, 33.0%) patients compared to the no- CCY group (n=67, 19.3%) (p=0.011). According the multivariate analyses results, presence of history of cholecystectomy was found an independent risk factor of difficult cannulation (Odds ratio: 2.014; 95 % Cl 1.205-3.366; p=0.008). CONCLUSIONS The results showed that biliary cannulation was significantly more difficult in patients with cholecystectomy who underwent ERCP for common bile duct stones.
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Fung BM, Pitea TC, Tabibian JH. Difficult Biliary Cannulation in Endoscopic Retrograde Cholangiopancreatography: Definitions, Risk Factors, and Implications. EUROPEAN MEDICAL JOURNAL. HEPATOLOGY 2021; 9:64-72. [PMID: 34621527 PMCID: PMC8494185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Over the past 50 years, endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred minimally invasive method of treating a vast array of pancreatobiliary diseases. An initial sine qua non for ERCP success is selective ductal cannulation. Despite significant progress in the optimisation of ERCP methods and accessories, selective biliary cannulation using conventional techniques remains unsuccessful in approximately 15% of native papilla cases. Furthermore, difficult biliary cannulation has been associated with an increased risk of post-ERCP pancreatitis, among other adverse events. Here, in the first of a two-part series, the authors provide a primer on standard biliary cannulation techniques and discuss the definition, risk factors, and implications of difficult biliary cannulation. The second part of the series will provide an overview of the existing advanced techniques used in cases of difficult biliary cannulation as well as the approach to their selection.
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Affiliation(s)
- Brian M. Fung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine – Phoenix, Arizona, USA
- Banner – University Medical Center Phoenix, Arizona, USA
| | | | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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11
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Chan KS, Mohan R, Low JK, Junnarkar SP, Huey CWT, Shelat VG. Elderly patients (≥ 80 years) with acute calculous cholangitis have similar outcomes as non-elderly patients (< 80 years): Propensity score-matched analysis. World J Hepatol 2021; 13:456-471. [PMID: 33959227 PMCID: PMC8080552 DOI: 10.4254/wjh.v13.i4.456] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/06/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute cholangitis (AC) is a disease spectrum with varying extent of severity. Age ≥ 75 years forms part of the criteria for moderate (Grade II) severity in both the Tokyo Guidelines (TG13 and TG18). Aging is associated with reduced physiological reserves, frailty, and sarcopenia. However, there is evidence that age itself is not the determinant of inferior outcomes in elective and emergency biliary diseases. There is a paucity of reports comparing clinical outcomes amongst elderly patients vs non-elderly patients with AC.
AIM To investigate the effect of age (≥ 80 years) on AC's morbidity and mortality using propensity score matching (PSM).
METHODS This is a single-center retrospective cohort study of all patients diagnosed with calculous AC (January 2016 to December 2016) and ≥ 80 years old (January 2012 to December 2016) at a tertiary university-affiliated teaching hospital. Inclusion criteria were patients who were treated for suspected or confirmed AC secondary to biliary stones. Patients with AC on a background of hepatobiliary malignancy, indwelling permanent metallic biliary stents, or concomitant pancreatitis were excluded. Elderly patients were defined as ≥ 80 years old in our study. A 1:1 PSM analysis was performed to reduce selection bias and address confounding factors. Study variables include comorbidities, vital parameters, laboratory and radiological investigations, and type of biliary decompression, including the time for endoscopic retrograde cholangiopancreatography (ERCP). Primary outcomes include in-hospital mortality, 30-d and 90-d mortality. Length of hospital stay (LOS) was the secondary outcome.
RESULTS Four hundred fifty-seven patients with AC were included in this study (318 elderly, 139 non-elderly). PSM analysis resulted in a total of 224 patients (112 elderly, 112 non-elderly). The adoption of ERCP between elderly and non-elderly was similar in both the unmatched (elderly 64.8%, non-elderly 61.9%, P = 0.551) and matched cohorts (elderly 68.8% and non-elderly 58%, P = 0.096). The overall in-hospital mortality, 30-d mortality and 90-d mortality was 4.6%, 7.4% and 8.5% respectively, with no statistically significant differences between the elderly and non-elderly in both the unmatched and matched cohorts. LOS was longer in the unmatched cohort [elderly 8 d, interquartile range (IQR) 6-13, vs non-elderly 8 d, IQR 5-11, P = 0.040], but was comparable in the matched cohort (elderly 7.5 d, IQR 5-11, vs non-elderly 8 d, IQR 5-11, P = 0.982). Subgroup analysis of patients who underwent ERCP demonstrated the majority of the patients (n = 159/292, 54.5%) had delayed ERCP (> 72 h from presentation). There was no significant difference in LOS, 30-d mortality, 90-d mortality, and in-hospital mortality in patients who had delayed ERCP in both the unmatched and matched cohort (matched cohort: in-hospital mortality [n = 1/42 (2.4%) vs 1/26 (3.8%), P = 0.728], 30-d mortality [n = 2/42 (4.8%) vs 2/26 (7.7%), P = 0.618], 90-d mortality [n = 2/42 (4.8%) vs 2/26 (7.7%), P = 0.618], and LOS (median 8.5 d, IQR 6-11.3, vs 8.5 d, IQR 6-15.3, P = 0.929).
CONCLUSION Mortality is indifferent in the elderly (≥ 80 years old) and non-elderly patients (< 80 years old) with AC.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- MOH Holdings, Singapore 099253, Singapore
| | - Ramkumar Mohan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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12
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Tabak F, Wang F, Ji GZ, Miao L. Propensity score-matched analysis for comparing transpancreatic sphincterotomy and needle-knife precut in difficult biliary cannulation. Sci Rep 2021; 11:6059. [PMID: 33723297 PMCID: PMC7961145 DOI: 10.1038/s41598-021-84655-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 02/16/2021] [Indexed: 11/24/2022] Open
Abstract
Transpancreatic sphincterotomy (TPS) can be an alternative approach of difficult biliary access in endoscopic retrograde cholangiopancreatography (ERCP). We aimed to evaluate the efficacy and safety of TPS compared to needle-knife precut (NKP), considering the early and late outcomes of both techniques. The prospectively collected clinical data, ERCP procedure findings, and outcomes of patients who underwent ERCP with difficult biliary access in our hospital from July 2016 to January 2018 were retrospectively analyzed. The patients were divided into two groups according to the applied secondary cannulation techniques. The propensity score matching (PSM) was applied to reduce the potential selection bias and unify the preventive measures of post-ERCP pancreatitis (PEP) in both groups. A total of 125 patients were enrolled in this study, with 54.4% male and a mean age of 63.29 ± 16.33 years. NKP group included 82 patients, and 43 patients received TPS. Prophylactic pancreatic stents were placed in all patients with TPS and 58.5% of patients with NKP. After applying PSM, the cohort was comprised to 86 patients with 43 patients in each TPS and NKP groups. Successful selective cannulation was achieved by 95.3% using TPS and by 93% using NKP. The mean procedure time was shorter in the TPS group without significant difference. Compared to NKP, using TPS did not affect the rate of PEP. Moreover, TPS was associated with less frequent post-ERCP bleeding and perforation, but without significant differences (all p > 0.05). Patients who received TPS or NKP had no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period. In conclusion, using TPS in difficult cannulation cases was useful to achieve success cannulation with an acceptable PEP rate and less frequent post-ERCP bleeding and perforation compared to NKP. There were no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period.
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Affiliation(s)
- Fatema Tabak
- Institute of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, Jiangsu, China
| | - Fei Wang
- Institute of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, Jiangsu, China
| | - Guo-Zhong Ji
- Institute of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, Jiangsu, China
| | - Lin Miao
- Institute of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, Jiangsu, China.
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Impact of periampullary diverticulum on biliary cannulation and ERCP outcomes: a single-center experience. Surg Endosc 2020; 35:5953-5961. [PMID: 33029732 DOI: 10.1007/s00464-020-08080-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 10/01/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Periampullary diverticulum (PAD) is frequently come upon during endoscopic retrograde cholangiopancreatography (ERCP), especially in elderly patients. However, less is known about the role of PAD in biliary cannulation difficulty. AIM This study aims to investigate the association of PAD and difficult cannulation and evaluate the impact of different types of PAD on the cannulation success rate and adverse events. METHODS Prospectively collected data on a total of 636 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) were divided into two groups based on the presence or absence of PAD. Besides, the patients were classified based on the PAD types into three groups. The primary outcomes were cannulation success rate, cannulation time, and ERCP-related adverse events. Further, the difficult cannulation and presence of PAD were analyzed using logistic regression models. RESULTS Significant higher rates of biliary stones, cholangitis, and biliary pancreatitis were observed in the PAD group. Successful selective cannulation was achieved in 97.6% in the PAD group and 95.3% in the control group. The cannulation time was significantly longer in the presence of PAD. There was no significant difference in the rate of overall adverse events and post-ERCP pancreatic PEP. Multivariate analysis showed that type 1 PAD, biliary stones, and cholangitis were factors related to difficult cannulation. CONCLUSION The presence of PAD did not affect the duration or success of the ERCP procedure. However, it was associated with longer cannulation time and an increase in the cannulation difficulty, especially with PAD type 1. Clinical Trial Study Registration This study is approved by Nanjing Medical University and registered at ClinicalTrial.gov PRS with ID/NCT03771547/.
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