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Ru N, Chai N, Zhang B, Li L, Bi Y, Linghu E. Impact of pancreatic and biliary stent on post-endoscopic papillectomy complications: A single-center retrospective study. Chin Med J (Engl) 2024:00029330-990000000-01081. [PMID: 38809090 DOI: 10.1097/cm9.0000000000002893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Endoscopic papillectomy (EP) is recommended as the first-line therapy for ampullary tumors, despite a relatively high incidence of complications. Pancreatic and/or biliary stents are placed at the endoscopist's discretion to prevent post-EP complications. The present study aimed to evaluate the efficacy of different stents. METHODS A total of 117 patients who underwent EP and met the criteria between June 2006 and October 2022 were enrolled in the study. These patients were divided into a pancreatic stent group (PS group, n = 47), a biliary stent group (BS group, n = 38), and a two-stent group (PBS [PS and BS] group, n = 32). Relevant clinical data were collected and compared among the three groups. Multivariate logistic analyses were performed to explore risk factors for post-EP complications. RESULTS The incidence of all complications was 37.6% (44/117). Pancreatitis and hemorrhage were the two most common complications with incidence rates of 14.5% (17/117) and 17.9% (21/117). The incidence rates of post-EP pancreatitis were 10.6% (5/47), 23.7% (9/38), and 9.4% (3/32) in the PS group, BS group, and PBS group, respectively, with no significant differences. There were also no significant differences in other complications among the three groups. Age (odds ratio [OR]: 0.95; 95% confidence interval [CI]: 0.91-0.99; P = 0.022) was independently associated with post-EP pancreatitis while tumor size (OR: 1.66; 95% CI: 1.06-2.60; P = 0.028) was independently associated with post-EP hemorrhage. CONCLUSIONS While pancreatic stenting is the first choice to prevent post-EP pancreatitis, biliary stenting could also be considered as a substitute for patients with difficulties in pancreatic cannulation. Two-stent (biliary and pancreatic stent) placement is unnecessary unless it is required due to other concerns.
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Affiliation(s)
- Nan Ru
- Department of Gastroenterology, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Ningli Chai
- Digestive Endoscopy Center, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Bo Zhang
- Digestive Endoscopy Center, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Longsong Li
- Department of Gastroenterology, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Yawei Bi
- Digestive Endoscopy Center, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Enqiang Linghu
- Department of Gastroenterology, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100853, China
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Salama HZ, Alnajjar YA, Owais TA, Jobran AWM, Safi R, Bahar M, Al-Ashhab H. Endoscopic retrograde cholangiopancreatography utilisation and outcomes in the first advanced endoscopy centre in Palestine at Al-Ahli Hospital: a retrospective cohort study. BMJ Open 2023; 13:e077806. [PMID: 38154896 PMCID: PMC10759078 DOI: 10.1136/bmjopen-2023-077806] [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: 07/18/2023] [Accepted: 12/11/2023] [Indexed: 12/30/2023] Open
Abstract
OBJECTIVE To evaluate the utilisation and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) procedures, success rates, incidence and risk factors for procedural-related complications in a single centre-based study. STUDY DESIGN Retrospective cohort study. SETTING First advanced tertiary endoscopy centre in Palestine. PARTICIPANTS A total of 1909 procedures on 1303 patients were included in the analysis: females were 57.9% of the cases (n=755), 1225 patients (94%) were from West Bank and Jerusalem and 78 (6%) were from Gaza Strip. All patients who underwent ERCP throughout the period from December 2017 to September 2022 were selected to participate in the study. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcomes of interest in our analysis were success rates, procedural outcomes and post- procedural complications including pancreatitis, bleeding and others. Two multivariate logistic regression models were performed to calculate the risk of post-ERCP complications and post-ERCP pancreatitis (PEP) in patients with certain risk factors like demographic factors, procedural techniques' variation, pancreatic duct manipulations and others. We also discussed the management of the failed procedures. RESULTS The overall complication rate was 5%, including PEP (n=43, 2.3%), infection/cholangitis (n=20, 1%), bleeding (n=9, 0.5%) and perforation (n=7, 0.4%). The mortality rate was 0.6% (n=11). Risk factors for adverse events included pancreatic duct cannulation and PEP (p<0.001, OR=3.64). Additionally, younger patients (≤45) were found to carry a higher risk for PEP when compared with older patients (≥65) (p=0.023, OR=2.84). In comparison with sphincterotomy, the double-wire technique was associated with a higher risk of complications (p=0.033, OR=2.29). CONCLUSIONS We summarised the utilisation and outcomes of ERCP among the Palestinian population in the first advanced centre in Palestine. Cannulation success rates are similar to the established standards and are acceptable compared with other centres worldwide. Perioperative complication rates of ERCP remain infrequent, and death is quite unusual and thus considered a safe procedure.
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Affiliation(s)
| | | | - Tarek A Owais
- Faculty of Pharmacy, Beni-Suef University, Beni Suef, Egypt
| | | | - Ruaa Safi
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Mohammad Bahar
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
- Internal Medicine Department, Al-Ahli Hospital, Hebron, Palestine
| | - Hazem Al-Ashhab
- Chief of Internal Medicine Department, Al-Quds University, Jerusalem, Palestine
- Chief of Gastroenterology Department, Al Ahli Hospital, Hebron, Palestine
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Yang Y, Zhou Z, Liu R, Chen L, Xiang H, Chen N. Application of 3D visualization and 3D printing technology on ERCP for patients with hilar cholangiocarcinoma. Exp Ther Med 2018; 15:3259-3264. [PMID: 29545843 PMCID: PMC5840945 DOI: 10.3892/etm.2018.5831] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 01/16/2018] [Indexed: 12/17/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an important treatment for inoperable hilar cholangiocarcinoma (HCC). The aim of the present study as to evaluate the clinical value of three-dimensional visualization (3DV) and 3D printing (3DP) technologies for ERCP in patients with HCC. The clinical data of 15 patients with HCC admitted for ERCP were analyzed retrospectively, including 9 males and 6 females. Thin-sliced data of computed tomography and magnetic resonance cholangiopancreatography (MRCP) were acquired and imported into Mimics Innovation Suite v17.0 software for 3D reconstruction. Standard Template Library files were exported for 3D printing. The target bile duct and Bismuth-Corlette (BC) classification were selected and performed respectively with the aid of Mimics Innovation Suite v17.0 software. The results were compared with the selected ones in ERCP. 3DV and 3DP models were successfully constructed for all patients, which presented the tumor, bile duct and the spatial relationship between them from multiple perspectives. The ERCP of all patients in the present study were performed successfully. The target bile duct screened by them had a high concordance rate of 86.7% with that in ERCP. The diagnostic accuracy of BC type results by 3DV and 3DP models was 93.3%. 3DV and 3DP technologies can accurately show the tumor and its associations with the surrounding bile duct, and it can be used to guide ERCP in HCC patients and improve the success rate of the operation.
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Affiliation(s)
- Yan Yang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Zhongyin Zhou
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Rong Liu
- Department of Orthopaedic Surgery, Puren Hospital of Wuhan, Wuhan University of Science and Technology, Wuhan, Hubei 430060, P.R. China
| | - Lu Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Hongyu Xiang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Na Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
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Chen M, Wang L, Wang Y, Wei W, Yao YL, Ling TS, Shen YH, Zou XP. Risk factor analysis of post-ERCP cholangitis: A single-center experience. Hepatobiliary Pancreat Dis Int 2018; 17:55-58. [PMID: 29428105 DOI: 10.1016/j.hbpd.2018.01.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 11/22/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) may have complications. Our study aimed to investigate the risk factors and prevention of post-ERCP cholangitis. METHODS We retrospectively analyzed 4234 cases undergone ERCP in the Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2008 to December 2013. Patient-related factors and procedure-related factors were analyzed to find the risk factors of post-ERCP cholangitis. The time point of post-ERCP cholangitis was also analyzed. Univariate and multivariate analyses were performed to define the independent risk factors of post-ERCP cholangitis. RESULTS The success rate of ERCP was 96.8% (4099/4234). The overall complication rate was 9.4% (399/4234). Post-ERCP cholangitis occurred in 102 cases (2.4%, 102/4234). The most dangerous time of post-ERCP cholangitis was from 24 h-48 h after ERCP (45.1%, 46/102). Univariate analysis revealed that age, hypertension, diabetes, previous ERCP history, biliary stent insertion, pancreatography, endoscopic sphincterotomy, balloon dilation and hilar obstruction were risk factors of post-ERCP cholangitis (P < 0.05). Multivariate analysis indicated that age, previous ERCP history and hilar obstruction were independent risk factors (P < 0.05). While endoscopic stone extraction was the potential protective factor. CONCLUSIONS Many risk factors are involved in post-ERCP cholangitis. Among them, old age, previous ERCP history and hilar obstruction were independently related to this post-ERCP complication.
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Affiliation(s)
- Min Chen
- Department of Gastroenterology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Lei Wang
- Department of Gastroenterology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Yun Wang
- Department of Gastroenterology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Wei Wei
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China
| | - Yu-Ling Yao
- Department of Gastroenterology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Ting-Sheng Ling
- Department of Gastroenterology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Yong-Hua Shen
- Department of Gastroenterology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Xiao-Ping Zou
- Department of Gastroenterology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China.
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Richards S, Kyle S, White C, El-Haddawi F, Farrant G, Henderson N, Fancourt M, Gilkison W. Outcomes of endoscopic retrograde cholangiopancreatography: a series from a provincial New Zealand hospital. ANZ J Surg 2016; 88:207-211. [PMID: 27599119 DOI: 10.1111/ans.13734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 07/20/2016] [Accepted: 07/20/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is an essential tool in the management of pancreaticobiliary pathology. It is technically demanding and has the potential to cause significant morbidity and mortality. Several trials have identified small centres and lower hospital volume as risk factors for lower success rates and higher complication rates. Taranaki Base Hospital (TBH) is a provincial hospital with a catchment of 100 000, providing its population with an on-site ERCP service. Transporting patients to the nearest tertiary centre would incur significant costs to both the patient and district health board. AIMS To determine the outcomes of performing ERCP at TBH and compare these with published figures. To determine if it is a safe and effective option for patients in this region. METHODS An ambi-directional study of all ERCP procedures at TBH between January 2011 and December 2015 was conducted. Patient demographics, procedure indication and procedural details were captured via ProVation® MD and endoscopist's notes. Complications were identified through patient's notes and recorded if occurring within 30 days of the procedure. All complications were graded mild, moderate or severe based on a grading system described by Cotton et al. RESULTS A total of 445 procedures were performed. Bile duct cannulation rate was 92.3% and therapeutic success rate was 89.9%. Complications occurred in 8.99% of patients and ERCP-specific mortality was 0.22%. Haemorrhage occurred in 1.35% of patients, pancreatitis in 5.2% and perforation in 0.45%. Success and complication rates are similar to other published studies. CONCLUSION ERCP can be safely and successfully performed in a provincial centre.
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Affiliation(s)
- Simon Richards
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Stephen Kyle
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Campbell White
- Department of Gastroenterology, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Falah El-Haddawi
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Glenn Farrant
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Nigel Henderson
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Michael Fancourt
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
| | - William Gilkison
- Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand
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Chang WI, Min YW, Yun HS, Lee KH, Lee JK, Lee KT, Rhee PL. Prophylactic pancreatic stent placement for endoscopic duodenal ampullectomy: a single-center retrospective study. Gut Liver 2014; 8:306-12. [PMID: 24827628 PMCID: PMC4026649 DOI: 10.5009/gnl.2014.8.3.306] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background/Aims We investigated the efficacy of prophylactic pancreatic stent placement for preventing postprocedure pancreatitis in patients undergoing endoscopic papillectomy. Methods This retrospective study included 82 consecutive patients who underwent endoscopic papillectomy for benign ampullary neoplasm at Samsung Medical Center between August 2002 and June 2011. The patients were subdivided into two groups, namely, those who received prophylactic pancreatic stent placement and those who did not. Patient demographics, baseline blood test, tumor characteristics, and endoscopic treatment data were collected. The primary endpoint was postprocedure pancreatitis. Results There was no difference in the development of postprocedure pancreatitis between the stent group and the no stent group (6/54, 10.5% and 2/28, 7.14%, respectively; p=1.00). At baseline, there were no significant differences between the two groups in terms of their risk factors for pancreatitis except pancreatic duct dye injection. The stent group was more likely to have dye injection than the nonstent group (100% vs 42.8%, p<0.001). However, in a logistic regression analysis, no significant difference was observed in the risk factors for pancreatitis including dye injection. Conclusions Our data suggest that routine prophylactic pancreatic duct stent placement in all patients undergoing endoscopic papillectomy may not be necessary and that large-scale prospective studies are required to identify the subgroup of patients who would benefit.
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Affiliation(s)
- Woo Ik Chang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hwan Sic Yun
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Hyuck Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Kyun Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Taek Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Poong Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Lynn AP, Chong G, Thomson A. Endoscopic retrograde cholangiopancreatography in the treatment of intraoperatively demonstrated choledocholithiasis. Ann R Coll Surg Engl 2014; 96:45-8. [PMID: 24417830 PMCID: PMC5137657 DOI: 10.1308/003588414x13824511650290] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The aim of this study was to determine the efficacy and complications of postoperative endoscopic retrograde cholangiopancreatography (ERCP) in confirming and treating choledocholithiasis found at intraoperative cholangiography during laparoscopic cholecystectomy. METHODS Patients who had undergone ERCP following a cholecystectomy between 2008 and 2011 with an indication of intraoperative cholangiography findings consistent with choledocholithiasis were identified from a prospectively collected database of a single endoscopist. Deep biliary access rate, confirmation of choledocholithiasis, clearance rate of bile duct stones, delay between cholecystectomy and postoperative ERCP, and the complication rates following the procedure were analysed. RESULTS The median age of the 41 patients (16 male, 25 female) was 42 years (range: 18–82 years). Sixteen surgeons performed the operations with a median delay of 6 days (range: 1–103 days) between cholecystectomy and postoperative ERCP. Common bile duct access was achieved in 100% of the patients, with ERCP taking a median time of 16 minutes (range: 6–40 minutes). Initial ERCP confirmed the presence of a stone in 30 patients (73%) and successful stone removal occurred in 28 of these 30 patients (93%) during the first ERCP and in the remaining 2 on a subsequent ERCP. Following ERCP, two patients (4.9%) experienced extended hospital stays for four and eight days owing to complications, including one patient (2.4%) with mild acute pancreatitis. CONCLUSIONS This study demonstrates that postoperative ERCP is highly effective in both confirming and treating choledocholithiasis. However, there is a significant risk of short-term complications that must be taken into consideration when deciding management.
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Affiliation(s)
- A P Lynn
- Canberra Hospital, The Australian National University, Australia
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A minimally invasive and simple screening test for detection of pancreatic ductal adenocarcinoma using biomarkers in duodenal juice. Pancreas 2013; 42:187-92. [PMID: 23407480 DOI: 10.1097/mpa.0b013e3182649979] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim of this study was to establish a minimally invasive and simple screening test for detection of pancreatic ductal adenocarcinoma (PDAC) using duodenal juice (DJ). METHODS Duodenal juice was collected prospectively before endoscopic retrograde cholangiopancreatography in 46 patients. A protease inhibitor was not added to the samples collected during the initial 2.5 minutes but was added in the latter 2.5 minutes. Thereafter, secretin was administered intravenously, and DJ was subsequently collected for additional 10 minutes. The sensitivities of carcinoembryonic antigen (CEA), S100 calcium-binding protein P (S100P), and interleukin 8 in DJ and pancreatic juice were assessed. RESULTS There were 30 patients with PDAC and 16 with benign lesions. It was possible to collect an adequate amount of DJ without secretin administration. In the PDAC group, CEA concentrations in DJ were significantly higher than those in the benign group, even without the use of a protease inhibitor. S100P levels in DJ in the PDAC group were significantly higher than those in the benign group in the presence of the protease inhibitor. CONCLUSIONS Duodenal juice collection during routine upper endoscopy and assessments of CEA and S100P in DJ might become a useful screening test for detection of PDAC.
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Qin YS, Li QY, Yang FC, Zheng SS. Risk factors and incidence of acute pyogenic cholangitis. Hepatobiliary Pancreat Dis Int 2012; 11:650-4. [PMID: 23232638 DOI: 10.1016/s1499-3872(12)60240-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute cholangitis varies from mild to severe form. Acute suppurative cholangitis (ASC), the severe form of acute cholangitis, is a fatal disease and requires urgent biliary decompression. Which patients are at a high risk of ASC and need emergency drainage is still unclear. The present study aimed to identify the factors for determining early-stage ASC and distinguishing ASC from acute cholangitis. METHODS We analyzed 359 consecutive patients with acute cholangitis who had been admitted to the First Affiliated Hospital, Zhejiang University School of Medicine from January 2004 to May 2011. Emergency endoscopic retrograde cholangiopancreatography (ERCP) was carried out in all patients to decompress or clear the stones by experienced endoscopists. Clinical and therapeutic data were collected, and univariate and multivariate analyses were performed to identify the potential risk factors of ASC. RESULTS Of the 359 patients, 1 was excluded because of failure of ERCP drainage. Of the remaining 358 patients with an average age of 62.7 years (range 17-90), 162 were diagnosed with ASC, and 196 with non-ASC. ENBD catheters were placed in 343 patients (95.8%), of whom 182 patients had stones removed at the same time, and plastic stent was placed in 25 patients (7.0%). Clinical conditions were improved quickly after emergency biliary drainage in all patients. Complications were identified in 11 patients (3.1%): mild pancreatitis occurred in 8 patients and hemorrhage in 3 patients. There was no mortality. Univariate analysis showed that several variables were associated with ASC: age, fever, decreased urine output, hypotension, tachycardia, abnormal white blood cell count (WBC), low platelet, high C reactive protein (CRP), and duration of the disease. Multivariate analysis revealed that advanced age, hypotension, abnormal WBC, high CRP, and duration of the disease were independent risk factors for ASC. CONCLUSIONS This study demonstrates that advanced age, hypotension, abnormal WBC, high CRP, and long duration of antibiotic therapy are significantly associated with ASC. We recommend decompression by ERCP should be carried out in patients as early as possible.
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Affiliation(s)
- Yun-Sheng Qin
- Division of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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