Background
Risk stratification of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) for common bile duct (CBD) stones is needed for clinicians to adequately explain to ...patients regarding the risk of PEP in advance of ERCP and to proactively take preventive measures in high-risk patients.
Aims
To stratify the risk of PEP for CBD stones based on CBD-related diseases.
Methods
A total of 1551 patients with naïve papilla who underwent ERCP for CBD stones were divided into three groups: Group A: asymptomatic CBD stones, Group B: obstructive jaundice and elevated liver test values without cholangitis, and Group C: mild, moderate, and severe cholangitis. We stratified the risk of PEP by comparing its incidence among the three groups using the Holm’s method. Furthermore, we performed one-to-one propensity score matching between Group A and the other groups to examine the risk of PEP in Group A.
Results
The incidence rates in Groups A, B, and C were 13.7%, 7.3%, and 1.8%, respectively. The Holm-adjusted
p
values between Groups A and B, Groups A and C, and Groups B and C were 0.023, < 0.001, and < 0.001, respectively. Propensity score matching revealed that the incidence of PEP was significantly more in Group A than in the other groups (13.3% vs. 1.5%;
p
< 0.001).
Conclusions
The risk of PEP for CBD stones was stratified into low risk (Group C), intermediate risk (Group B), and high risk (Group A). This simple disease-based risk stratification may be useful to predict the risk of PEP in advance of ERCP.
Objective We examined the safety and efficacy of endoscopic stone removal for choledocholithiasis in elderly patients ≥90 years of age with native papilla and compared the outcomes with those in ...patients 75-89 years of age. Methods This multicenter retrospective study included 569 patients 75-89 years of age and 126 patients ≥90 years of age who had native papilla and underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis at 3 institutions in Japan between April 2012 and March 2018. The main outcomes assessed were the incidence of post-ERCP complications during hospitalization and outcomes of ERCP in patients ≥90 years of age. Results Biliary cannulation and subsequent endoscopic sphincterotomy, endoscopic balloon dilation, and endoscopic large balloon dilation were successful in 97.7% of patients 75-89 years of age and in 98.4% of patients ≥90 years of age. There was no significant difference in the incidence of post-ERCP complications between patients 75-89 years of age and those ≥90 years of age (7.7% vs. 9.5%, respectively; p=0.47). Although the rate of use of mechanical lithotripter was not significantly different, the rate of complete stone removal in patients ≥90 years of age was lower than that in patients 75-89 years of age (81.0% vs. 94.9%, respectively; p<0.001). In all cases with incomplete stone removal in both groups, permanent biliary stent placement was successful. Conclusion ERCP for choledocholithiasis in elderly patients ≥90 years of age is a safe and effective procedure; however, endoscopists should select appropriate strategies after considering each patient's medical condition and background.
Objective Single-stage endoscopic stone removal for choledocholithiasis is an advantageous approach because it is associated with a shorter hospital stay; however, few studies have reported the ...incidence of complications related to this procedure in detail. The aim of this study was to examine the incidence of complications and efficacy of this procedure. Methods This retrospective study investigated the incidence of complications in 345 patients with naive papilla who underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis at three institutions between April 2014 and March 2016 by a propensity score analysis. The efficacy of single-stage endoscopic stone removal was assessed based on a hospital stay of within 7 days and the number of ERCP attempts. Results Among 114 patients who underwent single-stage endoscopic stone removal, 15 patients (13.2%) experienced complications. Among the remaining 231 patients in the two-stage endoscopic stone removal group, complications were observed in 17 patients (7.4%). The propensity score analysis, which was adjusted for confounding factors, revealed that single-stage endoscopic stone removal was not a significant risk factor for complications (p=0.52). In patients in whom >10 min was required for deep cannulation, single-stage endoscopic stone removal was not a significant risk factor for complications in the propensity score analysis (p=0.37). In the single-stage group, the proportion of patients with a hospital stay of within 7 days was significantly higher and the number of ERCP attempts was significantly lower in comparison to the two-stage group (p <0.0001 and <0.0001, respectively). Conclusion Single-stage endoscopic stone removal did not increase the incidence of complications associated with ERCP and was effective for reducing the hospital stay and the number of ERCP attempts.
Difficult biliary cannulation is an important risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Therefore, this study aimed to identify the factors that ...predict difficult cannulation for common bile duct stones (CBDS) to reduce the risk for PEP.
This multicenter retrospective study included 1,406 consecutive patients with native papillae who underwent ERCP for CBDS. Factors predicting difficult cannulation for CBDS were identified using univariate and multivariate analyses.
Univariate analysis showed that six factors significantly predicted difficult cannulation: ERCP performed by non-expert endoscopists, low-volume center, absence of acute cholangitis, normal serum bilirubin, intradiverticular papilla, and type of major duodenal papilla. Multivariate analysis identified ERCP performed by non-expert endoscopists (odds ratio OR, 2.5; p<0.001), low-volume center (OR, 1.6; p<0.001), intradiverticular papilla (OR, 1.3; p=0.007), normal serum bilirubin (OR, 1.3; p=0.038), and absence of acute cholangitis (OR, 1.3; p=0.049) as factors significantly predicting difficult cannulation for CBDS.
Initial cannulation by an experienced endoscopist, early rescue cannulation, or early takeover by an experienced endoscopist should be considered when performing ERCP for CBDS in the presence of factors predicting difficult cannulation.
This study aimed to examine the synergistic effect of independent risk factors on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).
This multicenter retrospective study ...included 1,273 patients with native papillae who underwent ERCP for bile dust stones in Japan. Independent PEP risk factors were identified using univariate and multivariate analyses. Significant risk factors for PEP in the multivariate analysis were included in the final analysis to examine the synergistic effect of independent risk factors for PEP.
PEP occurred in 45 of 1,273 patients (3.5%). Three factors including difficult cannulation ≥10 minutes, pancreatic injection, and normal serum bilirubin level were included in the final analysis. The incidences of PEP in patients with zero, one, two, and three factors were 0.5% (2/388), 1.9% (9/465), 6.0% (17/285), and 12.6% (17/135), respectively. With increasing risk factors for PEP, the incidence of PEP significantly increased (1 factor vs. 2 factors, p=0.006; 2 factors vs. 3 factors, p=0.033).
As the number of risk factors for PEP increases, the risk of PEP may not be additive; however, it may multiply. Thus, aggressive prophylaxis for PEP is strongly recommended in patients with multiple risk factors.
Background and Aim
Current guidelines recommend the removal of common bile duct (CBD) stones by endoscopic retrograde cholangiopancreatography (ERCP) for both asymptomatic and symptomatic patients. ...We conducted this study because of the limited research comparing the risks of ERCP‐related complications between these two groups.
Methods
This retrospective study involved 1491 patients with native major duodenal papilla diagnosed with choledocholithiasis at three institutions in Japan. The rates of ERCP‐related complications, including post‐ERCP pancreatitis (PEP), cholangitis, bleeding, and perforation, were compared using one‐to‐one propensity score matching between the asymptomatic and symptomatic patients.
Results
Complications were observed in 112 (7.5%) of the 1491 patients (asymptomatic group: 31/172 18.0% vs symptomatic group: 81/1319 6.1%, P < 0.001). The rate of severe complications was higher in the asymptomatic group than that in the symptomatic group (asymptomatic group: 5/31 16.1% vs symptomatic group: 3/81 3.7%, P = 0.036). In the propensity‐matched asymptomatic and symptomatic patients, the incidences of PEP, cholangitis, bleeding, and perforation were 18/143 (12.6%) vs 4/143 (2.8%) (P = 0.003); 4/107 (3.7%) vs 6/107 (5.6%) (P = 0.75); 1/140 (0.7%) vs 3/140 (2.1%) (P = 0.62); and 2/140 (1.4%) vs 2/140 (1.4%) (P = 1.0).
Conclusions
ERCP for asymptomatic patients with CBD stones is associated with a higher risk of overall and severe complications than that for symptomatic patients with CBD stones; the overall rate is influenced by the high incidence of PEP in the asymptomatic group. Endoscopists should explain the risk of ERCP‐related complications for asymptomatic patients before performing the procedure.
Endoscopic retrograde cholangiopancreatography (ERCP) for asymptomatic patients with common bile duct (CBD) stones is associated with a higher risk of overall and severe complications than that for symptomatic patients with CBD stones. However, the two groups have equal risks of post‐ERCP cholangitis, bleeding, and perforation. The overall rate is influenced by the high incidence of post‐ERCP pancreatitis in the asymptomatic group.
Abstract
Background and study aims
Endoscopic removal of asymptomatic common bile duct stones (CBDS) is generally recommended. Although many reports have described the risk of complications in ...endoscopic retrograde cholangiopancreatography (ERCP), no studies have addressed this problem in the context of asymptomatic CBDS. This study examines the risk of complications arising in ERCP for asymptomatic CBDS.
Patients and methods
This retrospective study included 425 patients with naive papilla who underwent therapeutic ERCP for choledocholithiasis at 2 institutions in Japan for 2 years. The risk of complications was examined in patients who were divided into the asymptomatic and symptomatic CBDS groups. We used propensity score analysis to adjust for confounding effects.
Results
Complications were observed in 32 (7.5 %) of the 425 patients. Of the 358 patients with symptomatic CBDS, 14 patients (3.9 %) had complications. In contrast, of the 67 patients with asymptomatic CBDS, 18 patients (26.9 %) had complications. Propensity score analysis revealed that asymptomatic CBDS was a significant risk factor, with a significantly higher incidence of complications compared with symptomatic CBDS (odds ratio, 5.3). Moderate to severe complications were observed in 15 of 18 patients (83.3 %) in the asymptomatic CBDS group, with significantly more moderate to severe complications than those in the symptomatic CBDS (odds ratio, 6.7).
Conclusions
Asymptomatic CBDS carried a high risk of ERCP-related complications, and these were often more severe. In asymptomatic CBDS, endoscopic treatment should be carefully performed after considering the patient’s background, and detailed explanation of its possible complications should be given to patients in advance.
Background and Aims
Papillary treatment, such as endoscopic sphincterotomy or endoscopic papillary balloon dilation, and subsequent single‐stage endoscopic stone removal are often performed for ...choledocholithiasis; however, the incidence of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) is unclear. This study aimed to compare the overall incidence of PEP between single‐ and two‐stage stone removal groups and the incidence of PEP between these two groups based on cannulation time.
Methods
We included 897 patients with native papilla who underwent papillary treatment and stone removal for choledocholithiasis with no inflammation or mild‐to‐moderate acute cholangitis at three institutions between April 2012 and March 2018 in Japan. We performed a propensity‐matched analysis and regression adjustment by propensity score to adjust for potential confounding factors.
Results
In the propensity‐matched analysis with 234 pairs, there was no significant difference in the overall incidence of PEP between single‐ and two‐stage stone removal procedures (15/234, 6.4% vs 6/234, 2.6%, P = 0.072, respectively). Although single‐stage stone removal after a cannulation time of ≤15 min was not a significant risk factor of PEP, the procedure after a cannulation time of >15 min was a significant risk factor of PEP as estimated by regression adjustment by propensity score (P = 0.014, 95% CI = 1.4–19.4, odds ratio = 5.2).
Conclusions
Single‐stage endoscopic stone removal after a long cannulation time of >15 min increased the incidence of PEP compared with the two‐stage stone removal procedure. Thus, single‐stage stone removal should be performed in patients with a cannulation time ≤ 15 min.
Papillary treatment and subsequent single‐stage endoscopic stone removal are often performed for choledocholithiasis. However, the incidence of post‐endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is unclear. This study demonstrated that single‐stage endoscopic stone removal after a long cannulation time of >15 min increased the incidence of PEP compared with the two‐stage stone removal procedure.
Background and Aim
For asymptomatic common bile duct (CBD) stones, removal by endoscopic retrograde cholangiopancreatography (ERCP) is recommended in available guidelines. However, few studies have ...reported the risk of post‐ERCP pancreatitis (PEP), which is the most common and serious ERCP‐related complication for asymptomatic CBD stones. We performed a propensity score matching analysis to examine the risk of PEP in therapeutic ERCP for asymptomatic CBD stones.
Methods
Information from medical databases of three institutions in Japan was collected over 6 years to identify 1113 patients with native papilla who underwent therapeutic ERCP for choledocholithiasis (excluding biliary pancreatitis). We compared the risk of PEP between asymptomatic and symptomatic groups by performing one‐to‐one propensity score matching.
Results
PEP was present in 52 (4.7%) of the 1113 patients overall. Of the 949 symptomatic patients, 28 (3.0%) had PEP, and of the 164 asymptomatic patients, 24 (14.6%) had PEP. The incidence of PEP was significantly higher in the asymptomatic group than in the symptomatic group (3.0% vs 14.6%; P < 0.001, odds ratio = 5.6). Of the 158 propensity score‐matched symptomatic patients, five (3.2%) had PEP. In contrast, of the 158 propensity score‐matched asymptomatic patients, 24 (15.2%) had PEP. Propensity score matching analysis revealed that the risk of PEP increased significantly in the asymptomatic group compared with the symptomatic group (3.2% vs 15.2%; P < 0.001, odds ratio = 5.5).
Conclusions
ERCP for asymptomatic CBD stones had a high risk of PEP. Endoscopists should explain in detail the risk of PEP to patients, especially those with asymptomatic CBD stones.
Background and Aim
Choledocholithiasis is the most common indication for endoscopic retrograde cholangiopancreatography (ERCP). Identifying risk factors for post‐ERCP pancreatitis (PEP) is important ...for reducing the risk of developing PEP after common bile duct (CBD) stone removal. However, studies examining the risk factors for PEP for CBD stones are scarce. The aim of this study was to examine whether the presence or absence of acute cholangitis is a clinical risk factor for PEP in patients with CBD stones.
Methods
In this multicenter retrospective study, 1539 patients with naïve papillae were divided into patients without and with acute cholangitis. We compared the incidence of PEP between the two groups using one‐to‐one propensity score matching to adjust for the potential confounding factors of PEP.
Results
In the entire cohort, the rates of PEP in patients without and with acute cholangitis were 9.6% (52/542) and 1.8% (18/997), respectively (P < 0.001, odds ratio = 5.8). In the propensity‐matched cohort, the rates of PEP in patients without and with acute cholangitis were 8.3% (27/326) and 2.5% (8/326), respectively (P = 0.002, odds ratio = 3.6). The rate of PEP was significantly higher in patients without acute cholangitis than in those with acute cholangitis after adjusting for the confounding factors of PEP.
Conclusions
The absence of acute cholangitis may be an important clinical risk factor for PEP due to CBD stone removal. In patients without acute cholangitis, endoscopists should explain the specific risk of PEP carefully and actively implement prophylaxis against PEP.
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