Same-day discharge after endoscopic biliary sphincterotomy: observations from a prospective multicenter complication study. The Multicenter Endoscopic Sphincterotomy (MESH) Study Group

BACKGROUND

Same-day discharge after endoscopic biliary sphincterotomy (ES) is a common clinical practice, but there have been few data to guide appropriate selection of patients. Using a prospective, multicenter database of complications, we examined outcomes after same-day discharge as it was practiced by a variety of endoscopists and evaluated the ability of a multivariate risk factor analysis to predict which patients would require readmission for complications.

METHODS

A 150-variable database was prospectively collected at time of ES, before discharge and again at 30 days in consecutive patients undergoing ES at 17 centers. Complications were defined by consensus criteria and included all specific adverse events directly or indirectly related to ES requiring more than 1 night of hospitalization.

RESULTS

Six hundred fourteen (26%) of 2347 patients undergoing ES were discharged on the same day as the procedure, ranging from none at 6 centers to about 50% at 2 centers. After initial observation and release, readmission to the hospital for complications occurred in 35 (5.7%) of 614 same-day discharge patients (20 pancreatitis and 15 other complications, 3 severe). Of the same-day discharge patients, readmission was required for 14 (12.2%) of 115 who had at least one independently significant multivariate risk factor for overall complications (suspected sphincter of Oddi dysfunction, cirrhosis, difficult bile duct cannulation, precut sphincterotomy, or combined percutaneous-endoscopic procedure) versus 21 (4.2%) of 499 without a risk factor (odds ratio 3.1: 95% confidence interval [1.6, 6.3], p < 0.001). Of complications presenting within 24 hours after ES, only 44% presented within the first 2 hours, but 79% presented within 6 hours.

CONCLUSIONS

Same-day discharge is widely utilized and relatively safe but results in a significant number of readmissions for complications. For patients at higher risk of complications, as indicated by the presence of at least one of five independent predictors, observation for 6 hours or overnight may reduce the need for readmission.

Complications of endoscopic biliary sphincterotomy

BACKGROUND

Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes.

METHODS

We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994.

RESULTS

Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure). The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01).

CONCLUSIONS

The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.

Cystic duct anatomy: an endoscopic perspective

Knowledge of the junction of the cystic and common hepatic duct is essential for endoscopic management of biliary tract disease. The cystic and common hepatic ducts were evaluated retrospectively in cholangiograms obtained for a variety of indications in 524 persons. The cysticohepatic junction was adequately visualized in 70%. Medial junctions were noted in 18% and a spiral configuration in 32%, both more common than reported. An 11% occurrence of parallel duct systems was less frequent than expected. In 10% of patients, the cystic duct entered the hepatic duct in the distal third of the extrahepatic biliary tree. The importance of understanding this anatomy is illustrated with selected cases of therapeutic biliary endoscopy and laparoscopic cholecystectomy complications. Suggestions are made for improving performance in this area.

Results of a multicenter trial using a mechanical lithotripter for the treatment of large bile duct stones

A prospective, uncontrolled trial of the use of a prototype mechanical lithotripter was performed in 116 patients at nine centers. Standard endoscopic approaches had failed to remove all stones, primarily because of large size (80% of patients). For 92% of patients, common bile duct stones were successfully captured and fragmented following the use of this lithotripter. The frequency of pancreatitis and hemorrhage was no greater than with standard endoscopic retrograde sphincterotomy, and complications unique to lithotripter use were not noted. For endoscopists skilled in therapeutic duodenoscopy, this modality should be considered in management of common bile duct stones refractory to standard techniques.

A new mechanical lithotripter for the treatment of large common bile duct stones

A prospective uncontrolled multi-center trial of a prototype mechanical lithotripter was performed in 30 patients with common bile duct calculi. Standard endoscopic sphincterotomy had failed to remove all stones, primarily because of large size (26 patients). Stone size ranged from 13 to 35 mm. Forty-three of 45 stones (97%) were successfully captured, fragmented, and extracted with this newly designed mechanical lithotripter. The overall success rate of 93% using this simple and inexpensive modality compares favorably with other methods under investigation for the treatment of common bile duct stones not amenable to routine endoscopic measures.