Retrospective analysis of complications related to endoscopic retrograde cholangio-pancreatography in patients with cirrhosis vs patients without cirrhosis

Applicability of Child-Turcotte-Pugh Score in Anticipating Post-ERCP Adverse Events in Patients With Cirrhosis: A Systematic Review and Meta-analysis

Limited objective data exist on the comparison of post-endoscopic retrograde cholangiopancreatography (ERCP) complications in patients with cirrhosis based on the severity of the disease. We evaluated the effectiveness of the Child-Turcotte-Pugh (CTP) score system in anticipating the risk of post-ERCP complications in patients with cirrhosis. The PubMed, Scopus, Embase, and Cochrane databases were searched from inception through September 2022 to identify studies comparing post-ERCP complications in patients with cirrhosis based on CTP score. Odds ratios (ORs) and their associated 95% CIs were pooled using a random-effect model to calculate effect size. The reference group for analysis was the CTP class C patient group. Seven studies comprising 821 patients who underwent 1068 ERCP procedures were included. The CTP class C patient population exhibited a higher risk of overall post-ERCP adverse events compared with those with class A or B (OR: 2.87, 95% CI: 1.77-4.65, P = 0.00 and OR: 2.02, 95% CI: 1.17-3.51, P = 0.01, respectively). Moreover, CTP class B patients had a significantly higher complication rate than CTP class A patients (OR: 1.62, 95% CI: 1.04-2.53, P = 0.03). However, no statistically significant differences were found in the occurrence of specific types of complications, including bleeding, pancreatitis, cholangitis, perforation, or mortality across the three CTP groups. We demonstrated that the CTP classification system is a reliable predictor of ERCP complications in patients with cirrhosis. Consequently, caution should be exercised when performing ERCP in patients classified as CTP class C.

Safety of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhosis compared to non-cirrhosis and effect of Child-Pugh score on post-ERCP complications: a systematic review and meta-analysis

BACKGROUND/AIMS

The safety of endoscopic retrograde cholangiopancreatography (ERCP) in hepatic cirrhosis and the impact of Child-Pugh class on post-ERCP complications need to be better studied. We investigated the post-ERCP complication rates in patients with cirrhosis compared with those without cirrhosis.

METHODS

We conducted a literature search of relevant databases to identify studies that reported post-ERCP complications in patients with hepatic cirrhosis.

RESULTS

Twenty-four studies comprising 28,201 patients were included. The pooled incidence of post-ERCP complications in cirrhosis was 15.5% (95% confidence interval [CI], 11.8%-19.2%; I2=96.2%), with an individual pooled incidence of pancreatitis 5.1% (95% CI, 3.1%-7.2%; I2=91.5%), bleeding 3.6% (95% CI, 2.8%-4.5%; I2=67.5%), cholangitis 2.9% (95% CI, 1.9%-3.8%; I2=83.4%), and perforation 0.3% (95% CI, 0.1%-0.5%; I2=3.7%). Patients with cirrhosis had a greater risk of post-ERCP complications (risk ratio [RR], 1.41; 95% CI, 1.16-1.71; I2=56.3%). The risk of individual odds of adverse events between cirrhosis and non-cirrhosis was as follows: pancreatitis (RR, 1.25; 95% CI, 1.06-1.48; I2=24.8%), bleeding (RR, 1.94; 95% CI, 1.59-2.37; I2=0%), cholangitis (RR, 1.15; 95% CI, 0.77-1.70; I2=12%), and perforation (RR, 1.20; 95% CI, 0.59-2.43; I2=0%).

CONCLUSION

Cirrhosis is associated with an increased risk of post-ERCP pancreatitis, bleeding, and cholangitis.

Incidence and Cross-Continents Differences in Endoscopic Retrograde Cholangiopancreatography Outcomes Among Patients With Cirrhosis: A Systematic Review and Meta-Analysis

Background

There are conflicting data on the frequency and variability of endoscopic retrograde cholangiopancreatography (ERCP) outcomes in patients with cirrhosis. Our aim was to systematically review the literature on the incidence of post-ERCP adverse events in cirrhotic patients and to examine the differences across continents.

Methods

We searched PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases to identify studies reporting adverse events after ERCP in patients with cirrhosis from conception to September 30, 2022. The random effects model was used to calculate odds ratios (ORs), mean differences (MDs), and confidence intervals (CIs). A P value < 0.05 was considered statistically significant. Heterogeneity was assessed using the Cochrane Q-statistic (I²).

Results

Twenty-one studies that included 2,576 cirrhotic patients and 3,729 individual ERCPs were analyzed. The pooled overall rate of adverse events after ERCP in patients with cirrhosis was 16.98% (95% CI: 13.06-21.29%, P < 0.001, I² = 86.55%). ERCPs performed in Asia had the highest ERCP adverse events with an overall complication rate of 19.90%, while the lowest overall adverse events were in North America at 13.04%. The pooled post-ERCP bleeding, pancreatitis, cholangitis and perforation were 5.10% (95% CI: 3.33-7.19%, P < 0.001, I² = 76.79%), 3.21% (95% CI: 2.20-5.36%, P = 0.03, I² = 42.25%), 3.02% (95% CI: 1.19-5.52%, P < 0.001, I² = 87.11%), and 0.12% (95% CI: 0.00 - 0.45, P = 0.26, I² = 15.76%), respectively. The pooled post-ERCP mortality rate was 0.22% (95% CI: 0.00-0.85%, P = 0.01, I² = 51.86%).

Conclusions

This meta-analysis shows that the overall complication rates after ERCP, bleeding, pancreatitis, and cholangitis are high in patients with cirrhosis. Because cirrhotic patients are more likely to have post-ERCP complications, with significant cross-continent variations, the risks and benefits of ERCP in this patient population should be carefully considered.

Analysis of risk factors associated with endoscopic retrograde cholangiopancreatography for patients with liver cirrhosis: a multicenter, retrospective, clinical study

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the endoscopic modality of choice for the treatment of biliary and pancreatic diseases. However, patients with cirrhosis, particularly those with decompensated cirrhosis, are believed to be at increased risk for complications associated with ERCP. There is a paucity of literature describing the outcomes of ERCP for patients with cirrhosis. This study aimed to investigate the outcomes of ERCP for cirrhosis patients, especially adverse events, and evaluated its safety and efficacy.

METHODS

We performed a multicenter, retrospective study of all patients at Beijing Friendship Hospital affiliated to Capital Medical University, Xijing Hospital affiliated to Air Force Military Medical University, Beijing Youan Hospital affiliated to Capital Medical University, and the Fifth Medical Center of the People's Liberation Army General Hospital from June 2003 to August 2019. The adverse events of inpatient ERCP for patients with ( n  = 182) and without liver cirrhosis (controls; n  = 385) were compared.

RESULTS

A total of 567 patients underwent ERCP between January 2003 and December 2019 were enrolled in this study. Compared to patients without cirrhosis, patients with cirrhosis were at higher risk for postoperative complications (odds ratio [OR], 4.172; 95% confidence interval [CI], 1.232-7.031; P  < 0.001) such as postoperative pancreatitis (OR, 2.026; 95% CI, 1.002-4.378; P  = 0.001) and cholangitis (OR, 3.903; 95% CI, 1.001-10.038; P  = 0.036). The main indications for ERCP for patients with cirrhosis in this study included choledocholithiasis (101 cases; 55.5%), benign bile duct strictures (46 cases; 25.3%), and malignant bile duct strictures (28 cases; 15.4%). Among them, 23 patients (12.6%) underwent balloon dilation and 79 patients (43.4%) underwent sphincterotomy. Of the patients with cirrhosis, delayed bleeding occurred in ten patients (5.5%), postoperative pancreatitis occurred in 80 patients (44.0%), and postoperative cholangitis occurred in 25 patients (13.7%). An additional multivariate analysis showed that the total bilirubin (TBIL) level (OR, 4.58; 95% CI, 2.37-6.70) and Child-Pugh score of C (OR, 3.11; 95% CI, 1.04-5.37) were risk factors for postoperative complications in patients with cirrhosis.

CONCLUSIONS

Compared with the general population of patients undergoing ERCP, patients with cirrhosis were more prone to postoperative pancreatitis and cholangitis. TBIL levels and Child-Pugh scores were risk factors for postoperative complications in patients with cirrhosis.

Comparison of Adverse Events of Different Endoscopic Ultrasound-Guided Tissue Acquisition Methods: A Single-Center Retrospective Analysis

The efficacy of new generation endoscopic ultrasound-guided biopsy needles has been promising in recent years. Yet, comparing these needles’ diagnostic yield and safety to conventional needles is not well-known. Our study aims to compare the adverse events of endoscopic ultrasound-guided tissue acquisition (EUS-TA) with different types of needles, including FNA needles, FNB needles with a Franseen tip and FNB needles with a reverse bevel. Furthermore, we will analyze the risk factors, including tumor vascularity, different needle types, and the underlying disease, which may impact the safety of the procedures. From May 2014 to December 2021, 192 consecutive EUS-TAs were performed on pancreatic and peripancreatic lesions in our hospital using different types of FNA and FNB needles. We retrospectively reviewed the data and identified the risk factors for EUS-TA-related complications. As a result, the hypervascular tumor is a significant risk factor for adverse events in our multivariate analysis, with an odds ratio of 4.96 (95% CI 1.33–18.47), while liver cirrhosis is one of the risk factors for adverse events during EUS-TA, with an odds ratio of 5.3 (95% CI 1.1–25.6). However, the risk of adverse events did not increase using Franseen-tip needles, compared to conventional FNA or FNB needles with a reverse bevel. In conclusion, we must be more cautious in patients with liver cirrhosis and hypervascular tumors, such as pancreatic neuroendocrine tumors, when performing EUS-guided tissue acquisition.