AIM:To investigate the prognostic usefulness of several existing scoring systems in predicting the severity of acute pancreatitis(AP).METHODS:We retrospectively analyzed the prospectively collected ...clinical database from consecutive patients with AP in our institution between January 2011 and December 2012.Ranson,Acute Physiology and Chronic Health Evaluation(APACHE)-Ⅱ,and bedside index for severity in acute pancreatitis(BISAP)scores,and computed tomography severity index(CTSI)of all patients were calculated.Serum C-reactive protein(CRP)levels were measured at admission(CRPi)and after 24h(CRP24).Severe AP was defined as persistent organ failure for more than 48 h.The predictive accuracy of each scoring system was measured by the area under the receiver-operating curve(AUC).RESULTS:Of 161 patients,21(13%)were classified as severe AP,and 3(1.9%)died.Statistically significant cutoff values for prediction of severe AP were Ranson≥3,BISAP≥2,APACHE-Ⅱ≥8,CTSI≥3,and CRP24≥21.4.AUCs for Ranson,BISAP,APACHE-Ⅱ,CTSI,and CRP24 in predicting severe AP were 0.69(95%CI:0.62-0.76),0.74(95%CI:0.66-0.80),0.78(95%CI:0.70-0.84),0.69(95%CI:0.61-0.76),and0.68(95%CI:0.57-0.78),respectively.APACHE-Ⅱdemonstrated the highest accuracy for prediction of severe AP,however,no statistically significant pairwise differences were observed between APACHE-Ⅱand the other scoring systems,including CRP24.CONCLUSION:Various scoring systems showed similar predictive accuracy for severity of AP.Unique models are needed in order to achieve further improvement of prognostic accuracy.
AIM To evaluate complications and management outcomes of retained long-term plastic biliary stents.METHODS Endoscopic plastic biliary stent placement was performed in 802 patients at Yeungnam ...University Hospital between January 2000 and December 2014. Follow-up loss with a subsequently forgotten stent for more than 12 mo occurred in 38 patients. We retrospectively examined the cause of biliary stent insertion, status of stents, complications associated with biliary stents and management outcomes of longterm plastic biliary stents. Continuous variables were analyzed using the t test. Observed frequencies in subsets of the study population were compared using Fisher’s exact test and χ~2 tests. Statistical significance was defined as P < 0.05(two-tailed).RESULTS Mean age of patients was 73.7 ± 12 years and maleto-female ratio was 2.2:1. Indications of plastic biliary stent insertion were bile duct stones(63.2%, 24/38) and benign bile duct stricture(52.6%, 20/38). Mean duration of retained plastic stent was 22.6 ± 12.2 mo, and in 10 cases(26.3%), stents were retained for more than 24 mo. Common bile duct(CBD) stones or sludgewere found in most cases(92.1%, 35/38). The most common complication was acute cholangitis(94.7%, 36/38). Stent removal by endoscopic approach was successfully performed in 92.1%(35/38) of the cases. In 3 cases, an additional plastic stent was inserted alongside the previous stent due to failure of the stent removal. Endoscopic removal of bile duct stones was successful in 73.7%(28/38) of the cases. When patients were divided into two groups by duration of stent placement(12 to 24 mo vs over 24 mo), there were no differences in the development of cholangitis, presence of biliary stones, and success rate of endoscopic removal of stones and biliary stents. CONCLUSION The most common complication of retained long-term plastic biliary stents was acute cholangitis associated with CBD stones. Endoscopic management was successfully performed in most cases.
There have been no previous studies that directly compared outcomes between cap-fitted forward-viewing and side viewing endoscopes (SE). This study aimed to compare the technical success rate and ...occurrence of adverse events between the side viewing and cap-fitted forward-viewing endoscope (CE) groups among patients with Billroth II anatomy who underwent ERCP.
The medical records of patients with a previous history of subtotal gastrectomy using Billroth II reconstruction who underwent ERCP at Yeungnam University Hospital between January 2004 and December 2020 were reviewed retrospectively. The patients were divided into CE and SE group. Propensity score matching analysis was performed to minimize selection bias.
Propensity score matching resulted in 55 matched pairs for further analysis. Patients' characteristics were comparable in the matched cohorts. Final success rate of selective bile duct cannulation was not significantly different between the SE and CE groups (98.2% vs. 94.5%, p = 0.308). The complete CBD stone removal rate in CBD stone and successful biliary drainage rate in malignant biliary obstruction were not significantly different between the two groups. The rate of total ERCP-related adverse events was higher in the CE group than in the SE group, but the difference was not statistically significant (10.9% vs. 7.3%, p = 0.507). Among adverse events, the rate of post-ERCP pancreatitis showed higher tendency in the CE group than in the SE group (10.9% vs. 5.5%, p = 0.297).
In conclusion, CE seems to be equally effective as SE for ERCP in patients with Billroth II anatomy. However, attention should be paid to development of post ERCP complications, especially pancreatitis, when performed by CE.
Introduction
Endoscopic retrograde cholangiopancreatography (ERCP) is generally recommended for removal of CBD stones. There were no studies focusing on the role of symptoms related to CBD stone in ...performing endoscopic stone removal. The aim of our study was to compare outcomes and complications of ERCP between asymptomatic and symptomatic CBD stones.
Methods
The medical records of 568 patients with naïve papilla who underwent ERCP for treatment of CBD stone from Jan 2009 to Aug 2014 were reviewed and analyzed retrospectively. Patients were divided as asymptomatic group (
n
= 32) and symptomatic group (
n
= 536).
Results
Age and gender were not significantly different between the two groups (
p
> 0.005). Mean sizes of CBD and CBD stones were not significantly different between asymptomatic and symptomatic group (
p
> 0.05). No differences in performance of needle knife fistulotomy, endoscopic sphincterotomy, and endoscopic papillary balloon dilatation were observed between the two groups (
p
> 0.05). Unintentional injection into the pancreatic duct was not significantly different between the two groups (
p
> 0.05). The overall complete stone removal rate was 96.9 % in the asymptomatic group and 94.4 % in the symptomatic group (
p
= 0.295). Requirement of mechanical lithotripsy was not significantly different between asymptomatic and symptomatic group (18.8 vs 8.4 %,
p
= 0.057). Significantly higher incidence of post-ERCP pancreatitis was observed in the asymptomatic group than in the symptomatic group (12.5 vs 3.9 %,
p
= 0.045).
Conclusion
The overall success rates of CBD stone removal were comparable between asymptomatic and symptomatic patients. However, risk of post-ERCP pancreatitis appears to be increased in patients with asymptomatic CBD stones.
Recently, the European Society of Gastrointestinal Endoscopy (ESGE) proposed criteria for "difficult biliary cannulation" during endoscopic retrograde cholangiopancreatography (ERCP). This study ...aimed to investigate the clinical relevance of the ESGE criteria from the perspective of post-ERCP pancreatitis (PEP).
An ERCP database was prospectively maintained between November 2014 and December 2015 across six teaching hospitals in South Korea. The ESGE criteria (biliary cannulation time, the number of cannulation attempts, and inadvertent pancreatic duct PD manipulation) were recorded in this database as well as other technical factors. Logistic regression analysis was used to identify risk factors for PEP. Then, the PEP prediction model was investigated using decision tree analysis.
We analyzed 1,067 consecutive patients with naïve papilla. The overall rate of PEP was 6.6%. Multivariate analysis revealed that female sex (odds ratio OR, 1.860; 95% confidence interval CI, 1.124 to 3.078), a selective biliary cannulation duration >5 minutes (OR, 3.282; 95% CI, 1.641 to 6.566), and inadvertent PD manipulation (OR, 2.614; 95% CI, 1.480 to 4.617) were significant factors affecting PEP. Decision tree analysis revealed that biliary cannulation time (χ
=49.857, p<0.001) and inadvertent PD manipulation (χ
=8.556, p=0.010) were decisive factors. PEP occurred in 3.9%, 11.8%, and 16.2% of patients with biliary cannulation duration lasting 3 to 5 minutes, >5 minutes, and >5 minutes with inadvertent PD manipulation, respectively.
Biliary cannulation time and inadvertent PD manipulation could be relevant indicators of PEP, and 5 minutes might be used as a cutoff value for the implementation of the rescue cannulation technique.
Studies concerning clinical course and outcome of acute pancreatitis (AP) according to etiologies were rare, especially after year 2000. This study was designed to investigate the difference between ...the clinical course of alcoholic and biliary AP.
Of the 153 patients diagnosed as AP with a first attack between January 2011 and January 2013, extensive clinical data of 50 patients with AP caused by alcohol and 76 patients with AP caused by gallstone were analyzed retrospectively. We compared the severity of AP defined by revised Atlanta classification in 2012, local complications, severity scores, and computed tomography severity index (CTSI) between alcoholic and biliary AP. We also evaluated the length of hospital stay, duration of NPO, and in-hospital mortality in each group.
Hemoglobin, hematocrit, and serum C-reactive protein level measured after admission for 24 h were significantly higher in the alcohol group than in the biliary group. Incidence of pseudocyst formation was significantly higher in the alcohol group than in the biliary group (20.0 % vs. 6.6 %, P = 0.023). Among prognostic scoring systems, only CTSI showed significant difference (P < 0.001) with a mean score of 3.0 ± 0.9 in the alcohol group and 1.7 ± 1.2 in the biliary group. Severe AP with organ failure persisting beyond 48 h was observed in 12 patients (24.0 %) in the alcohol group and one patient (1.3 %) in the biliary group (P < 0.001). There were 4 mortalities in the alcohol group only (P = 0.012).
More severe forms of AP and local complication, such as pseudocyst formation, are associated with alcoholic AP compared with biliary AP.
Background & Aims To assess the risk for the development of hepatocellular carcinoma (HCC) according to the underlying liver status and on-treatment viral response during long-term lamivudine therapy ...in patients with hepatitis B virus-related liver disease. Patients and methods Between March 1997 and February 2005, a total of 872 patients were treated with lamivudine for more than one year. Between 1983 and 1998, a total of 699 patients were enrolled as historical controls. Results For patients with compensated cirrhosis, HCC occurred in 4.9% (5/103) of cases with sustained viral suppression (persistently <141,500 copies/ml), 11.8% (20/170) in cases with viral breakthrough, and 19.4% (7/36) in cases with a suboptimal response (persistently ⩾141,500 copies/ml): the mean follow-up was 5.1 ± 2.7, 5.4 ± 2.3, and 3.7 ± 1.8 years, respectively. For the control group, HCC developed in 25.0% (37/148) of the cases during a mean follow-up of 6.1 ± 4.3 years. Thus, the annual incidence of HCC was 0.95%, 2.18%, 5.26%, and 4.10% in patients with sustained viral suppression, viral breakthrough, suboptimal response, and the control group, respectively. The cumulative incidence of HCC in patients with sustained viral suppression was significantly lower than in patients with a suboptimal response and the controls ( p = 0.002 and p = 0.005, respectively). In patients without cirrhosis and with decompensated cirrhosis, the preventive effects of lamivudine on the development of HCC were not observed ( p = 0.446 and p = 0.123, respectively). Conclusion Lamivudine therapy reduced the incidence of HCC in patients with compensated cirrhosis when the viral suppression was sustained.
Abstract
Objective.
Although endoscopic papillary large balloon dilation (EPLBD) with limited endoscopic sphincterotomy (ES) showed excellent outcomes for treatment of large bile duct stones, ...hemorrhage and recurrence of stones are problematic complications. Recent studies suggest that EPLBD alone is safe and effective for removal of large bile duct stones. This study aimed to determine the therapeutic outcomes and safety of EPLBD, compared with ES, for removal of large bile duct stones.
Material and methods.
Eighty-three patients above 45 years of age with bile duct stones >1 cm in diameter were randomized to EPLBD and ES groups for removal of common bile duct stones from September 2010 to August 2011. Prophylactic gabexate mesilate was given to all patients.
Results.
Baseline characteristics were not significantly different, except diabetes and gallbladder stones between the EPLBD group (n = 40) and ES group (n = 43). The overall complete stone removal rate in each group was 97.5% (39/40) and 95.3% (41/43), respectively (p = 0.600). Requirement of mechanical lithotripsy was not significantly different between the EPLBD and ES group (10% vs. 21%, p = 0.171). Complete ductal clearance in one session was achieved in 82.4% and 81.4% of cases in each group, respectively (p = 0.577). There were no differences in complication rates between the EPLBD and ES group; pancreatitis, 5.0% vs. 7.0%; hemorrhage, 10.0% vs. 16.3%; acute cholangitis, 5.0% vs. 2.3%, and perforation, 2.5% vs. 0%.
Conclusions.
The therapeutic outcomes and complications of EPLBD for removal of large bile duct stones are comparable to those of ES.
Few studies have addressed the relationship between the occurrence of adverse events (AEs) in endoscopic retrograde cholangiopancreatography (ERCP) and hospital case volume or endoscopist's ...experience with inconsistent results. The aim of our study was to investigate the impact of hospital case volume and endoscopist's experience on the AEs associated with ERCP and to analyze patient- and procedure-related risk factors for post-ERCP AEs.
From January 2015 to December 2015, we prospectively enrolled patients with naïve papilla who underwent ERCP at six centers. Patient- and procedure-related variables were recorded on data collection sheets at the time of and after ERCP.
A total of 1,191 patients (median age, 71 years) were consecutively enrolled. The overall success rate of biliary cannulation was 96.6%. Overall, 244 patients (20.5%) experienced post-ERCP AEs, including pancreatitis (9.0%), bleeding (11.8%), perforation (0.4%), cholangitis (1.2%), and others (0.9%). While post-ERCP pancreatitis (PEP) was more common when the procedure was performed by less experienced endoscopists, bleeding was more common in high-volume centers and by less experienced endoscopists. Multivariate analysis showed that a less experience in ERCP was significantly associated with PEP (odds ratio OR, 1.630; 95% confidence interval CI, 1.050 to 2.531; p=0.030) and post-ERCP bleeding (OR, 1.439; 95% CI, 1.003 to 2.062; p=0.048).
Our study demonstrated that overall AEs following ERCP were associated with the experience of the endoscopist. To minimize post-ERCP AEs, rigorous training with a sufficient case volume is required, and treatment strategies should be modified according to the endoscopist's expertise.
Endoscopic papillectomy (EP) is reported to be a relatively safe and reliable procedure for complete resection of ampullary neoplasms. The aim of this study was to evaluate the therapeutic outcomes ...and complications of EP for ampullary neoplasms.
A retrospective multicenter study was conducted with 5 participating centers from January 2007 to July 2014. A total of 104 patients who underwent EP for ampullary neoplasms were reviewed retrospectively. EP was performed by snare resection with or without submucosal lifting of the lesion.
The mean age of patients was 60.5 ± 12.1 years, and the male-to-female ratio was 2.0:1. En bloc resection was possible in 94 patients (90.3%). A biliary and a pancreatic stent were placed after EP in 42 patients and in 60 patients, respectively. A pathologically incomplete resection was noted in 11 cases (10.6%), and 5 of these patients were treated with additional endoscopic procedure. Histology of resected specimens was as follows: low grade adenoma (43.2%), high grade adenoma (14.4%), adenocarcinoma (16.3%), hyperplastic polyp (7.7%), and others (18.4%). Of the 75 cases with low grade adenoma on biopsy specimen, 21.3% turned out to have high grade adenoma (12%) or adenocarcinoma (9.3%). Procedure-related complications occurred in 33 patients (31.7%); bleeding (18 cases, 17.3%), pancreatitis (16 cases, 15.4%), and perforation (8 cases, 7.7%). Pre-EP ERCP, saline lifting, sphincterotomy, biliary stenting, pancreatic stenting, specimen size, and cauterization were not related to post EP complications. Surgery was performed in 6 cases with pathological incomplete resection and 2 cases with complications after EP, and there were 2 cases of mortality due to complications. During follow-up endoscopy after initial success of EP, remnant tumors were found in 7 patients, one of whom underwent surgery and the others were treated endoscopically. Consequently, the overall endoscopic success rate of EP was 89.4%.
Endoscopic papillectomy appears to be an effective treatment for ampullary neoplasms, and can be considered as an alternative to surgery. However, relatively high risk of procedure related complications is a problem that must be considered.
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