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Espín S, Andersson T, Haapoja M, Hyvönen R, Kluen E, Kolunen H, Laaksonen T, Lakka J, Leino L, Merimaa K, Nurmi J, Rainio M, Ruuskanen S, Rönkä K, Sánchez-Virosta P, Suhonen J, Suorsa P, Eeva T. Fecal calcium levels of bird nestlings as a potential indicator of species-specific metal sensitivity. Environ Pollut 2024; 345:123181. [PMID: 38237850 DOI: 10.1016/j.envpol.2023.123181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/14/2023] [Accepted: 12/14/2023] [Indexed: 02/20/2024]
Abstract
Sensitivity of bird species to environmental metal pollution varies but there is currently no general framework to predict species-specific sensitivity. Such information would be valuable from a conservation point-of-view. Calcium (Ca) has antagonistic effects on metal toxicity and studies with some common model species show that low dietary and circulating calcium (Ca) levels indicate higher sensitivity to harmful effects of toxic metals. Here we measured fecal Ca and five other macroelement (potassium K, magnesium Mg, sodium Na, phosphorus P, sulphur S) concentrations as proxies for dietary levels in 66 bird species to better understand their interspecific variation and potential use as an indicator of metal sensitivity in a wider range of species (the main analyses include 39 species). We found marked interspecific differences in fecal Ca concentration, which correlated positively with Mg and negatively with Na, P and S levels. Lowest Ca concentrations were found in insectivorous species and especially aerial foragers, such as swifts (Apodidae) and swallows (Hirundinidae). Instead, ground foraging species like starlings (Sturnidae), sparrows (Passeridae), cranes (Gruidae) and larks (Alaudidae) showed relatively high fecal Ca levels. Independent of phylogeny, insectivorous diet and aerial foraging seem to indicate low Ca levels and potential sensitivity to toxic metals. Our results, together with information published on fecal Ca levels and toxic metal impacts, suggest that fecal Ca levels are a promising new tool to evaluate potential metal-sensitivity of birds, and we encourage gathering such information in other bird species. Information on the effects of metals on breeding parameters in a wider range of bird species would also help in ranking species by their sensitivity to metal pollution.
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Affiliation(s)
- S Espín
- Area of Toxicology, Department of Socio-sanitary Sciences, University of Murcia, Spain
| | - T Andersson
- Kevo Subarctic Research Institute, University of Turku, Finland
| | | | | | - E Kluen
- Helsinki Institute of Life Science HiLIFE, University of Helsinki, Finland
| | | | - T Laaksonen
- Department of Biology, University of Turku, Finland
| | | | - L Leino
- Department of Biology, University of Turku, Finland
| | - K Merimaa
- Department of Biology, University of Turku, Finland
| | - J Nurmi
- Department of Biology, University of Turku, Finland
| | - M Rainio
- Department of Biology, University of Turku, Finland
| | - S Ruuskanen
- Department of Biological and Environmental Science, University of Jyväskylä, Finland
| | - K Rönkä
- Helsinki Institute of Life Science HiLIFE, University of Helsinki, Finland
| | - P Sánchez-Virosta
- Area of Toxicology, Department of Socio-sanitary Sciences, University of Murcia, Spain
| | - J Suhonen
- Department of Biology, University of Turku, Finland
| | | | - T Eeva
- Department of Biology, University of Turku, Finland.
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Archibugi L, Ciarfaglia G, Cárdenas-Jaén K, Poropat G, Korpela T, Maisonneuve P, Aparicio JR, Casellas JA, Arcidiacono PG, Mariani A, Stimac D, Hauser G, Udd M, Kylänpää L, Rainio M, Di Giulio E, Vanella G, Lohr JM, Valente R, Arnelo U, Fagerstrom N, De Pretis N, Gabbrielli A, Brozzi L, Capurso G, de-Madaria E. Machine learning for the prediction of post-ERCP pancreatitis risk: A proof-of-concept study. Dig Liver Dis 2023; 55:387-393. [PMID: 36344369 DOI: 10.1016/j.dld.2022.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Predicting Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) pancreatitis (PEP) risk can be determinant in reducing its incidence and managing patients appropriately, however studies conducted thus far have identified single-risk factors with standard statistical approaches and limited accuracy. AIM To build and evaluate performances of machine learning (ML) models to predict PEP probability and identify relevant features. METHODS A proof-of-concept study was performed on ML application on an international, multicenter, prospective cohort of ERCP patients. Data were split in training and test set, models used were gradient boosting (GB) and logistic regression (LR). A 10-split random cross-validation (CV) was applied on the training set to optimize parameters to obtain the best mean Area Under Curve (AUC). The model was re-trained on the whole training set with the best parameters and applied on test set. Shapley-Additive-exPlanation (SHAP) approach was applied to break down the model and clarify features impact. RESULTS One thousand one hundred and fifty patients were included, 6.1% developed PEP. GB model outperformed LR with AUC in CV of 0.7 vs 0.585 (p-value=0.012). GB AUC in test was 0.671. Most relevant features for PEP prediction were: bilirubin, age, body mass index, procedure time, previous sphincterotomy, alcohol units/day, cannulation attempts, gender, gallstones, use of Ringer's solution and periprocedural NSAIDs. CONCLUSION In PEP prediction, GB significantly outperformed LR model and identified new clinical features relevant for the risk, most being pre-procedural.
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Affiliation(s)
- Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy.
| | - Gianmarco Ciarfaglia
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Karina Cárdenas-Jaén
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Goran Poropat
- University Hospital of Rijeka, Department of Gastroenterology, Rijeka, Croatia
| | - Taija Korpela
- Helsinki University Hospital and University of Helsinki, Gastroenterological Surgery, Abdominal Center, Helsinki, Finland
| | - Patrick Maisonneuve
- Unit of Clinical Epidemiology, Division of Epidemiology and Biostatistics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - José R Aparicio
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Juan Antonio Casellas
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Mariani
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Davor Stimac
- University Hospital of Rijeka, Department of Gastroenterology, Rijeka, Croatia
| | - Goran Hauser
- University Hospital of Rijeka, Department of Gastroenterology, Rijeka, Croatia
| | - Marianne Udd
- Helsinki University Hospital and University of Helsinki, Gastroenterological Surgery, Abdominal Center, Helsinki, Finland
| | - Leena Kylänpää
- Helsinki University Hospital and University of Helsinki, Gastroenterological Surgery, Abdominal Center, Helsinki, Finland
| | - Mia Rainio
- Helsinki University Hospital and University of Helsinki, Gastroenterological Surgery, Abdominal Center, Helsinki, Finland
| | - Emilio Di Giulio
- Department of Gastroenterology, Sant'Andrea Hospital, University Sapienza, Rome, Italy
| | - Giuseppe Vanella
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy; Department of Gastroenterology, Sant'Andrea Hospital, University Sapienza, Rome, Italy
| | - Johannes Matthias Lohr
- HPD Disease Unit, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Roberto Valente
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgical Oncology, Anschutz Medical Campus, University of Colorado, Denver, USA
| | - Urban Arnelo
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | | | - Nicolò De Pretis
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Armando Gabbrielli
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Lorenzo Brozzi
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
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Kaasalainen T, Pekkarinen A, Kylänpää L, Rainio M, Tenca A, Jokelainen K, Barner-Rasmussen N, Puustinen L, Udd M, Lindström O. Occupational radiation dose from gastrointestinal endoscopy procedures with special emphasis on eye lens doses in endoscopic retrograde cholangiopancreatography. Endosc Int Open 2023; 11:E237-E246. [PMID: 36910845 PMCID: PMC9995179 DOI: 10.1055/a-2022-2663] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/25/2023] [Indexed: 03/14/2023] Open
Abstract
Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) procedures may result in remarkable radiation doses to patients and staff. The aim of this prospective study was to determine occupational exposures in gastrointestinal endoscopy procedures, with a special emphasis on eye lens dose in ERCP. Methods Altogether 604 fluoroscopy-guided procedures, of which 560 were ERCPs belonging to four American Society for Gastrointestinal Endoscopy procedural complexity levels, were performed using two fluoroscopy systems. Personal deep-dose equivalent H p (10), shallow-dose equivalent H p (0.07), and eye lens dose equivalent H p (3) of eight interventionists and H p (3) for two nurse dosimeters were measured. Thereafter, conversion coefficients from kerma-area product (KAP) for H p (10), H p (0.07), and H p (3) were determined and dose equivalents per procedure to an operator and assisting staff were estimated. Further, mean conversion factors from H p (10) and H p (0.07) to H p (3) were calculated. Results The median KAP in ERCP was 1.0 Gy·cm 2 , with mobile c-arm yielding higher doses than a floor-mounted device ( P < 0.001). The median H p (3) per ERCP was estimated to be 0.6 µSv (max. 12.5 µSv) and 0.4 µSv (max. 12.2 µSv) for operators and assisting staff, respectively. The median H p (10) and H p (0.07) per procedure ranged from 0.6 to 1.8 µSv. ERCP procedural complexity level ( P ≤ 0.002) and interventionist ( P < 0.001) affected dose equivalents. Conclusions Occupational dose limits are unlikely to be exceeded in gastrointestinal endoscopy practice when following radiation-hygienic working methods and focusing on dose optimization. The eye lens dose equivalent H p (3) may be estimated with sufficient agreement from the H p (10) and H p (0.07).
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Affiliation(s)
- Touko Kaasalainen
- HUS Diagnostic Center, Radiology, University of Helsinki and Helsinki University Hospital, Finland
| | - Antti Pekkarinen
- Radiation and Nuclear Safety Authority - STUK, Helsinki, Finland.,Department of Physics, University of Helsinki, Helsinki, Finland.,Department of Medical Physics, Kymsote, Kymenlaakso Central Hospital, Helsinki, Finland
| | - Leena Kylänpää
- HUS Abdominal Center, Endoscopy Department, University of Helsinki and Helsinki University Hospital, Finland
| | - Mia Rainio
- HUS Abdominal Center, Endoscopy Department, University of Helsinki and Helsinki University Hospital, Finland
| | - Andrea Tenca
- HUS Abdominal Center, Endoscopy Department, University of Helsinki and Helsinki University Hospital, Finland
| | - Kalle Jokelainen
- HUS Abdominal Center, Endoscopy Department, University of Helsinki and Helsinki University Hospital, Finland
| | - Nina Barner-Rasmussen
- HUS Abdominal Center, Endoscopy Department, University of Helsinki and Helsinki University Hospital, Finland
| | - Lauri Puustinen
- HUS Abdominal Center, Endoscopy Department, University of Helsinki and Helsinki University Hospital, Finland
| | - Marianne Udd
- HUS Abdominal Center, Endoscopy Department, University of Helsinki and Helsinki University Hospital, Finland
| | - Outi Lindström
- HUS Abdominal Center, Endoscopy Department, University of Helsinki and Helsinki University Hospital, Finland
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Abstract
INTRODUCTION Although sporadic non-ampullary duodenal adenomas (SNADA) are rare, with the risk of progression to cancer, they deserve therapy. Endoscopic therapy of SNADA is effective, but with the increased risk of complications, endotherapy should be performed in high-volume units. The results of endotherapy of SNADA in our unit are presented. PATIENTS AND METHODS A total of 97 patients with SNADA had endoscopic resection in 2005-2021 and control endoscopies between 3 and 24 months. Snare polypectomy, endoscopic mucosal resection (EMR), endoscopic band ligation (EBL) and endoloop were used (en bloc 37% and piecemeal 63%). In cases of residual/recurrent adenomas, endotherapy was repeated. RESULTS The median size of the adenoma was 12 (5-60) mm and most polyps were sessile (25%) or flat (65%). Primary endotherapy eradicated adenomas in 57 (59%) cases. Residual and recurrence rates were 24% (n = 23) and 17% (n = 16) with successful endotherapy in 16 (70%) and 13 (81%) patients. Endotherapy was successful in 86 (89%) patients after a median (range) follow-up of 23 (1-166) months. Four out of 11 patients with failed endotherapy had surgery; seven patients were not fit for surgery. There were no disease-specific deaths or carcinoma. Eleven patients (11%) suffered from complications: perforation requiring surgery (n = 1), sepsis (n = 1), postprocedure bleeding (n = 7), cardiac arrest (n = 1) and coronary infarct (n = 1). The thirty-day mortality was zero. Colonoscopy was performed on 67 (69%) patients with neoplastic lesions in 33% patients during follow-up. CONCLUSIONS Endotherapy of SNADA is effective and safe. Repeat endotherapy in residual and recurrent adenomas is successful. Careful patient selection is mandatory. Abbreviations: ASA: American Society of Anesthesiologist classification; BMI: body mass index; CT: computed tomography; EBL: endoscopic band ligation; EMR: endoscopic mucosal resection; ESD: endoscopic submucosal dissection; ET: endotherapy; FAP: familial adenomatous polyposis; F: female; LST: laterally spreading tumours; M: male; SD: standard deviation; SNADA: sporadic nonampullary duodenal adenoma.
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Affiliation(s)
- Marianne Udd
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Outi Lindström
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andrea Tenca
- Gastroenterology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mia Rainio
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Leena Kylänpää
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Kylänpää L, Koskensalo V, Saarela A, Ejstrud P, Udd M, Lindström O, Rainio M, Tenca A, Halttunen J, Qvigstad G, Arnelo U, Fagerström N, Hauge T, Aabakken L, Grönroos J. Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation: a randomized controlled trial. Endoscopy 2021; 53:1011-1019. [PMID: 33440441 DOI: 10.1055/a-1327-2025] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) increases the risk of post-ERCP pancreatitis (PEP). The purpose of this prospective, randomized, multicenter study was to compare two advanced rescue methods, transpancreatic biliary sphincterotomy (TPBS) and a double-guidewire (DGW) technique, in difficult common bile duct (CBD) cannulation. METHODS Patients with native papilla and planned CBD cannulation were recruited at eight Scandinavian hospitals. An experienced endoscopist attempted CBD cannulation with wire-guided cannulation. If the procedure fulfilled the definition of difficult cannulation and a guidewire entered the pancreatic duct, randomization to either TPBS or to DGW was performed. If the randomized method failed, any method available was performed. The primary end point was the frequency of PEP and the secondary end points included successful cannulation with the randomized method. RESULTS In total, 1190 patients were recruited and 203 (17.1 %) were randomized according to the study protocol (TPBS 104 and DGW 99). PEP developed in 14/104 patients (13.5 %) in the TPBS group and 16/99 patients (16.2 %) in the DGW group (P = 0.69). No difference existed in PEP severity between the groups. The rate of successful deep biliary cannulation was significantly higher with TPBS (84.6 % [88/104]) than with DGW (69.7 % [69/99]; P = 0.01). CONCLUSIONS In difficult biliary cannulation, there was no difference in PEP rate between TPBS and DGW techniques. TPBS is a good alternative in cases of difficult cannulation when the guidewire is in the pancreatic duct.
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Affiliation(s)
- Leena Kylänpää
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Vilja Koskensalo
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Arto Saarela
- Department of Gastrointestinal Surgery, Oulu University Hospital, Oulu, Finland
| | - Per Ejstrud
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Marianne Udd
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Outi Lindström
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mia Rainio
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Tenca
- Abdominal Center, Gastroenterology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jorma Halttunen
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Gunnar Qvigstad
- Department of Gastroenterology and Hepatology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Urban Arnelo
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Niklas Fagerström
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Lars Aabakken
- Department of Medical Gastroenterology, Rikshospitalet University Hospital, Oslo, Norway
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Turku, Finland
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Koskensalo V, Aronen P, Färkkilä M, Kylänpää L, Lindström O, Rainio M, Udd M, Jokelainen K, Tenca A. Use of thiopurines is not a risk factor for post-ERC pancreatitis in patients with primary sclerosing cholangitis. Dig Liver Dis 2021; 53:1020-1027. [PMID: 34116970 DOI: 10.1016/j.dld.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/04/2021] [Accepted: 05/11/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Risk of post-ERC pancreatitis (PEP) in patients with primary sclerosing cholangitis (PSC) is 1-7.8%. PSC is often associated with inflammatory bowel disease and autoimmune hepatitis, which are usually treated with thiopurines. The role of thiopurines in PEP risk is still unclear. AIMS AND METHODS We evaluated the thiopurine use in PEP. The data of 354 PSC patients who underwent 985 ERCs between 2009 and 2018 were collected. 177 patients treated with thiopurines (study group, SG) and 177 controls (CG) were matched with a propensity score (PSM). Odds ratios (ORs) with 95% confidence interval (95% CI) were calculated. Multivariable logistic regression analysis and generalized linear mixed model were performed. The P-value <0.05 was significant. RESULTS In matched data, 472 ERCs were performed in SG and 513 in CG. Thiopurines were used in 373/472 (79.0%) ERCs in SG. The PEP rate was 5.3% in SG and 5.7% in CG (p = 0.889). Unintentional pancreatic duct cannulation (OR 1.28, 95%CI 1.07-1.51, p = 0.004), and periampullary diverticulum (OR 4.87, 95%CI 1.72-11.98, p = 0.001) increased the risk of PEP. CONCLUSION Prior or present thiopurine use did not increase the risk of PEP.
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Affiliation(s)
- Vilja Koskensalo
- Department of Gastrointestinal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Pasi Aronen
- Biostatistics Consulting Unit, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Martti Färkkilä
- Department of Gastroenterology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Leena Kylänpää
- Department of Gastrointestinal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Outi Lindström
- Department of Gastrointestinal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mia Rainio
- Department of Gastrointestinal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marianne Udd
- Department of Gastrointestinal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kalle Jokelainen
- Department of Gastroenterology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Tenca
- Department of Gastroenterology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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7
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Cárdenas-Jaén K, Archibugi L, Poropat G, Korpela T, Maisonneuve P, Aparicio JR, Udd M, Stimac D, Arcidiacono PG, De Pretis N, Valente R, Di Giulio E, Casellas JA, Kylänpää L, Hauser G, Mariani A, Gabbrielli A, Löhr M, Vanella G, Rainio M, Brozzi L, Arnelo U, Fagerström N, Capurso G, de-Madaria E. Chronic use of statins and acetylsalicylic acid and incidence of post-endoscopic retrograde cholangiopancreatography acute pancreatitis: A multicenter, prospective, cohort study. Dig Endosc 2021; 33:639-647. [PMID: 32713065 DOI: 10.1111/den.13801] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Post-endoscopic retrograde cholangiopancreatography (ERCP) acute pancreatitis (PEP) is a frequent complication of this endoscopic procedure. Chronic statin intake has been linked to lower incidence and severity of acute pancreatitis (AP). Periprocedural rectal administration of non-steroidal anti-inflammatory drugs is protective against PEP, but the role of chronic acetylsalicylic acid (ASA) treatment is unclear. We aimed to investigate whether statins and chronic ASA intake are associated with lower risk of PEP. METHODS An international, multicenter, prospective cohort study. Consecutive patients undergoing ERCP in seven European centers were included. Patients were followed-up to detect those with PEP. Multivariate analysis by means of binary logistic regression was performed, and adjusted odds ratios (aORs) were calculated. RESULTS A total of 1150 patients were included, and 70 (6.1%) patients developed PEP. Among statins users, 8.1% developed PEP vs. 5.4% among non-users (P = 0.09). Multivariate analysis showed no association between statin use and PEP incidence (aOR 1.68 (95% CI 0.94-2.99, P = 0.08)). Statin use had no effect on severity of PEP, being mild in 92.0% of statin users vs. 82.2% in non-statin users (P = 0.31). Chronic ASA use was not associated with PEP either (aOR 1.02 (95% CI 0.49-2.13), P = 0.96). Abuse of alcohol and previous endoscopic biliary sphincterotomy were protective factors against PEP, while >1 pancreatic guidewire passage, normal bilirubin values, and duration of the procedure >20 minutes, were risk factors. CONCLUSIONS The use of statins or ASA is not associated with a lower risk or a milder course of PEP.
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Affiliation(s)
- Karina Cárdenas-Jaén
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Goran Poropat
- Department of Gastroenterology, Faculty of Medicine, Clinical Hospital Center of Rijeka, University of Rijeka, Rijeka, Croatia
| | - Taija Korpela
- Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Jose R Aparicio
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Marianne Udd
- Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Davor Stimac
- Department of Gastroenterology, Faculty of Medicine, Clinical Hospital Center of Rijeka, University of Rijeka, Rijeka, Croatia
| | - Paolo G Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Niccolò De Pretis
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Roberto Valente
- Gastrocentrum, Karolinska University Hospital, Stockholm, Sweden
| | - Emilio Di Giulio
- Digestive and Liver Disease Unit, S. Andrea Hospital, Sapienza University, Rome, Italy
| | - Juan A Casellas
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Leena Kylänpää
- Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Goran Hauser
- Department of Gastroenterology, Faculty of Medicine, Clinical Hospital Center of Rijeka, University of Rijeka, Rijeka, Croatia
| | - Alberto Mariani
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Armando Gabbrielli
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Matthias Löhr
- Gastrocentrum, Karolinska University Hospital, Stockholm, Sweden
| | - Giuseppe Vanella
- Digestive and Liver Disease Unit, S. Andrea Hospital, Sapienza University, Rome, Italy
| | - Mia Rainio
- Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Lorenzo Brozzi
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Urban Arnelo
- Gastrocentrum, Karolinska University Hospital, Stockholm, Sweden
| | | | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy.,Digestive and Liver Disease Unit, S. Andrea Hospital, Sapienza University, Rome, Italy
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
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8
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Lindström O, Udd M, Rainio M, Nuutinen H, Jokelainen K, Kylänpää L. Benign biliary strictures treated with biodegradable stents in patients with surgically altered anatomy using double balloon enteroscopy. Scand J Gastroenterol 2020; 55:1225-1233. [PMID: 32794409 DOI: 10.1080/00365521.2020.1806351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Surgically altered anatomy complicates endoscopical procedures of pancreatobiliary tree. Biliary or hepaticojejunal anastomosis strictures have been managed using percutaneous transhepatic or double balloon enteroscopy (DBE) techniques with multiple plastic stents, or fully covered self-expandable metal stents. We report the first seven cases with surgically altered anatomy treated with biodegradable stents with DBE. MATERIALS AND METHODS Seven cases with altered anatomy, all with Roux-en-Y hepaticojejunostomy (HJ), were treated for HJ anastomosis strictures (3 cases) and intrahepatic biliary stricture (4 cases). Fujifilm DB enteroscope with a 200 cm long and 3.2 mm wide working channel was used. Balloon dilatations were first performed and then 1-3 biodegradable stents were deployed with a pusher over a guidewire. RESULTS Two patients had HJ due to liver resections, one due to biliary injury in cholecystectomy and four due to liver transplantation because of primary sclerosing cholangitis (PSC). Median duration of the procedures was 56 min. Deployment of the stents took less than 20 min per patient. There were no stent or cholangiography related adverse events, but one patient required endotracheal intubation for nose bleeding caused by the placement of nasopharyngeal tube. Two PSC patients had recurrent cholangitis in the follow up. There was one stent migration in 90 day follow up. With all the HJ anastomotic strictures resolution of strictures seemed to be achieved. CONCLUSIONS Treatment of biliary or anastomosis strictures in altered anatomy is complex and time consuming. The biodegradable stent, which can be passed through working channel of a long enteroscope, seems promising in the treatment of these strictures. The benefit is that no stent removal is needed.
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Affiliation(s)
- Outi Lindström
- Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marianne Udd
- Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mia Rainio
- Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hannu Nuutinen
- Gastroenterology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kalle Jokelainen
- Gastroenterology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Leena Kylänpää
- Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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9
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Koskensalo V, Tenca A, Udd M, Lindström O, Rainio M, Jokelainen K, Kylänpää L, Färkkilä M. Diclofenac does not reduce the risk of acute pancreatitis in patients with primary sclerosing cholangitis after endoscopic retrograde cholangiography. United European Gastroenterol J 2020; 8:462-471. [PMID: 32213036 DOI: 10.1177/2050640620912608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The European Society of Gastrointestinal Endoscopy recommends rectal indomethacin or diclofenac before endoscopic retrograde cholangiopancreatography (ERCP) to prevent post-ERCP pancreatitis. However, data on the prophylactic effect in patients with primary sclerosing cholangitis (PSC) are lacking. METHODS This was a retrospective case-control study. In 2009-2018, a total of 2000 ERCPs were performed in 931 patients with PSC. Case procedures (N = 1000 after November 2013) were performed after administration of rectal diclofenac. Control procedures (N = 1000 before November 2013) were performed with the same indication but without diclofenac. Acute post-ERCP pancreatitis and other ERCP-related adverse events (AEs) were evaluated. RESULTS Post-ERCP pancreatitis developed in 49 (4.9%) procedures in the diclofenac group and 62 (6.2%) procedures in the control group (p = 0.241). No difference existed between the groups in terms of the severity of pancreatitis or any other acute AEs. The risk of pancreatitis was elevated in patients with native papilla: 11.4% in the diclofenac group and 8.7% in the control group (p = 0.294). In adjusted logistic regression, diclofenac did not reduce the risk of pancreatitis (odds ratio (OR) = 1.074, 95% confidence interval 0.708-1.629, p = 0.737). However, in generalised estimation equations with the advanced model, diclofenac seemed to diminish the risk of pancreatitis (OR = 0.503) but not significantly (p = 0.110). CONCLUSION In this large patient cohort in a low-risk unit, diclofenac does not seem to reduce the risk of post-ERCP pancreatitis in patients with PSC. The trend in the pancreatitis rate after ERCP is decreasing. The evaluation of the benefits of diclofenac among PSC patients warrants a randomised controlled study targeted to high-risk patients and procedures.
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Affiliation(s)
- Vilja Koskensalo
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Abdominal Centre, Gastroenterological Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Andrea Tenca
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Abdominal Centre, Gastroenterology, Helsinki University Hospital, Helsinki, Finland
| | - Marianne Udd
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Abdominal Centre, Gastroenterological Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Outi Lindström
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Abdominal Centre, Gastroenterological Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Mia Rainio
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Abdominal Centre, Gastroenterological Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Kalle Jokelainen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Abdominal Centre, Gastroenterology, Helsinki University Hospital, Helsinki, Finland
| | - Leena Kylänpää
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Abdominal Centre, Gastroenterological Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Martti Färkkilä
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Abdominal Centre, Gastroenterology, Helsinki University Hospital, Helsinki, Finland
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10
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Koskensalo V, Udd M, Rainio M, Halttunen J, Sipilä M, Lindström O, Kylänpää L. Transpancreatic biliary sphincterotomy for biliary access is safe also on a long-term scale. Surg Endosc 2020; 35:104-112. [PMID: 31993817 PMCID: PMC7746558 DOI: 10.1007/s00464-019-07364-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 12/24/2019] [Indexed: 02/07/2023]
Abstract
Background Transpancreatic biliary sphincterotomy (TPBS) is an advanced cannulation method for accessing common bile duct (CBD) in endoscopic retrograde cholangiopancreatography (ERCP). If CBD cannulation is difficult, an endoscopist can open the septum between the pancreatic and biliary duct with a sphincterotome to gain access. Long-term results of this procedure are unclear. We wanted to evaluate the short- and long-term complications of TPBS on patients with native papilla and benign indication for ERCP. Patients and Methods ERCPs performed in Helsinki University Hospital between 2007 and 2013 were reviewed. The study group comprised 143 consecutive patients with TPBS and 140 controls (CG). Data were collected from patient records and a phone survey was performed as a follow-up ≥ 4 years after the index ERCP. Results Post-ERCP pancreatitis (PEP) developed in seven patients (4.9%) in TPBS and one patient (0.7%) in CG (p = 0.067). The rates of other acute complications were similar between the groups. ERCP ended with no access to CBD in four cases (2.8%) in TPBS. The median length of follow-up was 6 years in TPBS and 7 years in CG. During this period, three patients (2.1%) in TPBS and six patients (4.3%) in CG suffered from acute pancreatitis (AP) (p = 0.238). One (0.7%) patient in CG and none in TPBS developed chronic pancreatitis (CP). Abdominal pain was suffered by ten patients (6.9%) in TPBS and twelve patients (8.6%) in CG daily, whereas by six patients (4.2%) in TPBS and twelve patients (8.6%) in CG weekly. Conclusion TPBS is a useful procedure, with acceptable complication rates. No significant difference occurred between the groups when evaluating the short-term or long-term complications with a follow-up period of four to 10 years. Additionally, no significant differences occurred in upper abdominal pain, episodes of AP, or development of CP.
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Affiliation(s)
- Vilja Koskensalo
- Abdominal Center, Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland.
- University of Helsinki, Helsinki, Finland.
| | - Marianne Udd
- Abdominal Center, Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Mia Rainio
- Abdominal Center, Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Jorma Halttunen
- Abdominal Center, Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | | | - Outi Lindström
- Abdominal Center, Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Leena Kylänpää
- Abdominal Center, Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
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11
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Rainio M, Lindström O, Udd M, Haapamäki C, Nordin A, Kylänpää L. Endoscopic Therapy of Biliary Injury After Cholecystectomy. Dig Dis Sci 2018; 63:474-480. [PMID: 28948425 DOI: 10.1007/s10620-017-4768-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 09/16/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Iatrogenic bile duct injury (BDI) is a common complication after cholecystectomy. Patients are mainly treated endoscopically, but the optimal treatment method has remained unclear. AIMS The aim was to analyze endoscopic treatment in BDI after cholecystectomy and to explore endoscopic sphincterotomy (ES), with or without stenting, as the primary treatment for an Amsterdam type A bile leak. METHODS All patients referred to Helsinki University Hospital endoscopy unit due to a suspected BDI between the years 2004 and 2014 were included in this retrospective study. To collect the data, all ERC reports were reviewed. RESULTS Of the 99 BDI patients, 94 (95%) had bile leak of whom 11 had concomitant stricture. Ninety-three percent of all patients were treated endoscopically. Seventy-one patients had native papillae and a leak in the cystic duct or peripheral radicals. They were treated with ES (ES group, n = 50) or with sphincterotomy and stenting (EST group, n = 21). There was no difference between the closure time of the fistula (p = 0.179), in the time of discharge from hospital (p = 0.298), or in the primary healing rate between the ES group and the EST group (45/50 vs 19/21 patients, p = 0.951). CONCLUSION After the right patient selection, the success rate of endoscopic treatment can approach 100% for Amsterdam type A bile leak. ES is an effective and cost-effective single procedure with success rate similar to EST. It may be considered as a first-line therapy for the management of Amsterdam type A leaks.
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Affiliation(s)
- Mia Rainio
- Department of Gastroenterological Surgery, Helsinki University Hospital, Helsinki University, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Outi Lindström
- Department of Gastroenterological Surgery, Helsinki University Hospital, Helsinki University, Haartmaninkatu 4, 00290, Helsinki, Finland
| | - Marianne Udd
- Department of Gastroenterological Surgery, Helsinki University Hospital, Helsinki University, Haartmaninkatu 4, 00290, Helsinki, Finland
| | - Carola Haapamäki
- Department of Gastroenterological Surgery, Helsinki University Hospital, Helsinki University, Haartmaninkatu 4, 00290, Helsinki, Finland
| | - Arno Nordin
- Department of Transplantation and Liver Surgery, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Leena Kylänpää
- Department of Gastroenterological Surgery, Helsinki University Hospital, Helsinki University, Haartmaninkatu 4, 00290, Helsinki, Finland
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12
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Rainio M, Lindström O, Udd M, Louhimo J, Kylänpää L. Diclofenac Does Not Reduce the Risk of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis in Low-Risk Units. J Gastrointest Surg 2017; 21:1270-1277. [PMID: 28374181 DOI: 10.1007/s11605-017-3412-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/26/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs have an inhibitory role in pathogenesis of pancreatitis. Guidelines from the European Society of Gastrointestinal Endoscopy recommend routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP for all patients without contraindications. AIMS Our aim was to evaluate the effect of diclofenac in preventing post-ERCP pancreatitis (PEP) in a high-volume, low-PEP-risk ERCP unit. METHODS The rate and severity of PEP were compared in groups of 1000 historical controls prior to the routine use of diclofenac and in 1000 patients receiving 100 mg diclofenac before ERCP. RESULTS PEP occurred in 56 (2.8%) of the 2000 patients, and the rate of the pancreatitis was 2.8% in control group and 2.8% in diclofenac group (p = 1.000). The PEP rate among the native papilla patients was 3.9% in control group and 3.6% in diclofenac group (p = 0.803). In subgroup analysis of patients with a high risk of PEP, diclofenac neither prevented PEP nor made its course milder. CONCLUSIONS In an unselected patient population in a center with a low incidence of PEP, diclofenac seems to have no beneficial effect.
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Affiliation(s)
- Mia Rainio
- Department of Gastrointestinal Surgery, University of Helsinki, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Outi Lindström
- Department of Gastrointestinal Surgery, University of Helsinki, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland
| | - Marianne Udd
- Department of Gastrointestinal Surgery, University of Helsinki, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland
| | - Johanna Louhimo
- Department of Gastrointestinal Surgery, University of Helsinki, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland
| | - Leena Kylänpää
- Department of Gastrointestinal Surgery, University of Helsinki, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland
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