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Ishiwatari H, Sakamoto H, Doi T, Yamamura M. Prevention of Adverse Events in Endoscopic Ultrasound-Guided Biliary Drainage. DEN OPEN 2026; 6:e70145. [PMID: 40416588 PMCID: PMC12098953 DOI: 10.1002/deo2.70145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2025] [Revised: 04/30/2025] [Accepted: 05/04/2025] [Indexed: 05/27/2025]
Abstract
Endoscopic ultrasound-guided biliary drainage (EUS-BD) is used when biliary drainage using endoscopic retrograde cholangiopancreatography fails. Recently, it has been adopted as a primary biliary drainage method, and its indications have expanded. Since EUS-BD can cause adverse events (AEs), such as bile leakage and stent migration, which do not occur in endoscopic retrograde cholangiopancreatography, endoscopists need to be well-versed in its management and preventive techniques. EUS-BD includes several procedures, such as EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided antegrade stenting (EUS-AS), and EUS-guided rendezvous (EUS-RV). A recent meta-analysis reported that the overall AE rate of EUS-BD was 13.7% (EUS-CDS, 11.9%; EUS-HGS, 15.5%; EUS-AS, 9.9%; and EUS-RV, 8.8%). Among various EUS-BD techniques, EUS-CDS and EUS-HGS are the most frequently reported. Tubular self-expandable metal stents have been traditionally used in EUS-CDS; however, lumen-apposing metal stents have recently gained popularity. A systematic review showed that the rates of early AEs were similar between self-expandable metal stents and lumen-apposing metal stents; however, stent maldeployment was more problematic with lumen-apposing metal stents. Although tubular self-expandable metal stents are used in EUS-HGS, stent maldeployment remains a serious issue, and available devices and technical tips for preventing this AE should be well understood. Furthermore, AEs, such as sepsis, cholangitis, and bleeding, can occur, and strategies to mitigate these risks are essential. In this narrative review, we discussed AEs related to EUS-BD with a focus on management options and strategies for prevention.
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Affiliation(s)
| | | | - Takuya Doi
- Division of EndoscopyShizuoka Cancer CenterShizuokaJapan
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Damonti L, Huttner A, Buetti N. The relationship between diagnostic and antimicrobial stewardship: trusting blood cultures alone in diagnosis of cholangitis. Clin Microbiol Infect 2025; 31:890-892. [PMID: 40024527 DOI: 10.1016/j.cmi.2025.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2025] [Revised: 02/18/2025] [Accepted: 02/25/2025] [Indexed: 03/04/2025]
Affiliation(s)
- Lauro Damonti
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Angela Huttner
- Infectious Diseases Division, Geneva University Hospitals, Geneva, Switzerland
| | - Niccolò Buetti
- Infection Control Program and WHO Collaborating Centre, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland; Infection Antimicrobials Modeling Evolution, INSERM, Université Paris-Cité, Paris, France.
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Atarere JO, Mensah B, Kunkle B, Nwaneki C, Annor E, Vasireddy R, Orhurhu V, Weisman D, Thompson C. Factors Associated With Delayed Endoscopic Retrograde Cholangiopancreatography Among Patients With Acute Cholangitis. J Clin Gastroenterol 2025:00004836-990000000-00453. [PMID: 40434819 DOI: 10.1097/mcg.0000000000002203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2025] [Accepted: 04/28/2025] [Indexed: 05/29/2025]
Abstract
BACKGROUND AND GOALS Delayed ERCP is associated with increased morbidity and mortality from acute cholangitis (AC). We aimed to identify the factors associated with delayed receipt of early or urgent ERCP among patients with AC. STUDY For this retrospective cohort study, we analyzed data from the 2016 to 2020 iterations of the Nationwide Inpatient Sample. We stratified the study population as severe versus nonsevere AC and timing of ERCP as urgent (within 24 h of admission), early (between 24 and 48 h of admission), and late (after 48 h of admission). Using multivariable logistic regression, we examined for the factors associated with delay in urgent or early ERCP overall and delay in urgent ERCP among patients with severe AC. RESULTS Of the 12,613 participants included in this study, 3032 (24.0%) had severe AC. Blacks [aOR 1.53; 95% CI (1.27, 1.85)], Asians/Pacific Islanders [aOR 1.22; 95% CI (1.02, 1.46)], those with a history of bariatric surgery [aOR 2.10; 95% CI (1.40, 3.17)] and those with one [aOR 1.33; 95% CI (1.13, 1.58)] or more comorbidities were more likely to have a delay in receiving ERCP within 48 hours of admission when compared with non-Hispanic Whites and those with no comorbidities respectively. Racial disparities were not observed among patients with severe AC. CONCLUSION Black/AA and API's presenting with AC are more likely to have a delay in the receipt of ERCP within 48 hours of admission. Assessing the impact of medical comorbidities on procedural risk is important when deciding timing of ERCP.
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Affiliation(s)
- Joseph O Atarere
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
| | - Boniface Mensah
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
| | - Bryce Kunkle
- Department of Medicine, Georgetown University Hospital, Washington, DC
| | - Chisom Nwaneki
- Department of Medicine, Saint Peter's University Hospital, New Brunswick, NJ
| | - Eugene Annor
- Department of Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL
| | - Ramya Vasireddy
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
| | - Vwaire Orhurhu
- Department of Anesthesiology, University of Pittsburgh Medical Center, Williamsport, PA
| | - David Weisman
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
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Barakat M, Saumoy M, Forbes N, Elmunzer BJ. Complications of Endoscopic Retrograde Cholangiopancreatography. Gastroenterology 2025:S0016-5085(25)00527-X. [PMID: 40120770 DOI: 10.1053/j.gastro.2025.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2024] [Revised: 03/13/2025] [Accepted: 03/15/2025] [Indexed: 03/25/2025]
Abstract
Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.
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Affiliation(s)
- Monique Barakat
- Divisions of Pediatric and Adult Gastroenterology & Hepatology, Departments of Pediatrics and Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Monica Saumoy
- Center for Digestive Health, Penn Medicine Princeton Health, Princeton, New Jersey
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
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Yadlapati S, Gutta A, Fogel EL. Determining the value of endoscopic retrograde cholangiopancreatography in the management of patients with acute pancreatitis and related complications. Expert Rev Gastroenterol Hepatol 2025:1-19. [PMID: 39921919 DOI: 10.1080/17474124.2025.2464057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2024] [Revised: 02/02/2025] [Accepted: 02/04/2025] [Indexed: 02/10/2025]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic to a therapeutic tool in acute pancreatitis management, largely due to the availability of less invasive diagnostic modalities such as endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP). AREAS COVERED This review explores the therapeutic applications of ERCP across various acute pancreatitis etiologies and its role in managing complications such as bile duct obstructions, pancreatic duct disruptions, and infected necrosis. The discussion highlights the procedure's expanding indications and its critical role in addressing complex cases. EXPERT OPINION ERCP remains central to the management of acute pancreatitis complications. As endoscopic techniques and devices continue to advance, its therapeutic scope is likely to grow. Performing ERCP for appropriate indications and optimizing its use is essential for minimizing risks and improving outcomes.
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Affiliation(s)
- Sujani Yadlapati
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indiana University Hospital, Indianapolis, IN, USA
| | - Aditya Gutta
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indiana University Hospital, Indianapolis, IN, USA
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Chen W, Huang P, Gu X, Liu X, Ying X, Yang J. Efficacy and safety of sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage for the treatment of hilar malignant biliary stricture: a retrospective cohort study. Therap Adv Gastroenterol 2025; 18:17562848251319809. [PMID: 39963248 PMCID: PMC11831652 DOI: 10.1177/17562848251319809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2024] [Accepted: 01/24/2025] [Indexed: 02/20/2025] Open
Abstract
Background The rising incidence of hilar malignant bile duct strictures poses challenges for diagnosis and treatment. While endoscopic treatment is essential for relieving obstruction, it carries a high risk of postoperative cholangitis. Sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage may emerge as an effective strategy to mitigate these complications. Objectives This study aimed to evaluate the efficacy and safety of nasobiliary tube cutting after nasobiliary drainage versus conventional stent placement in reducing postoperative cholangitis in patients with hilar malignant biliary strictures. Design A retrospective cohort study. Methods From 2015 to 2023, 208 patients were divided into two groups: nasobiliary tube cutting group (n = 103) and conventional stent group (n = 105). The primary outcome was postoperative cholangitis, with secondary outcomes including drainage success, bilirubin reduction, re-interventions, complications, and hospital stay. Results Cholangitis occurred in 11.7% of the nasobiliary tube cutting group and 26.7% of the conventional stent group (p = 0.006). Successful drainage was achieved in 84 patients (81.6%) in the nasobiliary tube cutting group and 78 patients (74.3%) in the conventional stent group, with no statistically significant difference (p = 0.207). Patients whose total bilirubin reduction >50% within 7 days were significantly higher in the nasobiliary tube cutting group (48.5% vs 27.6%, p = 0.002). There were no significant differences between the groups in the number of endoscopic retrograde cholangiopancreatography procedures or re-interventions required (p > 0.05). Except for postoperative cholangitis, other postoperative complications were comparable between the groups (p > 0.05). The postoperative hospital stay was significantly longer in the nasobiliary tube cutting group, with a median duration of 10.0 (7.0, 14.0) days compared to 7.0 (5.5, 12.5) days in the conventional stent group (p = 0.024). Bismuth-Corlette Type IV was identified as an independent risk factor for cholangitis (OR = 3.207, 95%CI: 1.253-8.210, p = 0.015). Conclusion For patients with hilar malignant biliary stricture, sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage may reduce the incidence of postoperative cholangitis and achieve early successful drainage, but it may result in a prolonged postoperative hospital stay. Bismuth-Corlette Type IV is an independent risk factor for the development of postoperative cholangitis.
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Affiliation(s)
- Wangyang Chen
- Department of Gastroenterology, Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang Province, China
| | - Peiyao Huang
- Department of Gastroenterology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang Province, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang Province, China
| | - Xinyi Gu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang Province, China
| | - Xiaodie Liu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang Province, China
| | - Xiuzhiye Ying
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang Province, China
| | - Jianfeng Yang
- Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, #261 Huansha Road, Hangzhou, Zhejiang Province 310006, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research, Hangzhou, Zhejiang Province, China
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Lodato F, Landi S, Bassi M, Ghersi S, Cennamo V. Urgent Endoscopic Biliary Procedures: "Run Like the Wind"? J Clin Med 2025; 14:1017. [PMID: 39941686 PMCID: PMC11818415 DOI: 10.3390/jcm14031017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2025] [Revised: 02/01/2025] [Accepted: 02/04/2025] [Indexed: 02/16/2025] Open
Abstract
Emergency endoscopy is an activity that must be guaranteed 7 days a week and 24 h a day. The pathologies of endoscopic interest that require emergency intervention are mainly hemorrhages of the upper digestive tract, the removal of foreign bodies, and the ingestion of caustics. The emergency endoscopist must therefore be experienced in the management of these pathologies. Nowadays, however, we know that even some biliary tract pathologies must be managed within a variable period between 12 and 72 h, in particular acute cholangitis (Ach), acute biliary pancreatitis (ABP), biliary duct leaks (BDLs), and acute cholecystitis (AC). If, on one hand, there is little awareness among doctors about which pathologies of the biliary tract really deserve urgent treatment, on the other, the international guidelines, although not uniformly, have acquired the results of the studies and have clarified that only severe Ach should be treated within 12 h; in other cases, endoscopic treatment can be delayed up to 72 h according to the specific condition. This obviously has a significant organizational implication, as not all endoscopists have training in biliary tract endoscopy, and guaranteeing the availability of a biliary endoscopist 24/7 may be incompatible with respecting the working hours of individual professionals. This review aims to evaluate which pathologies of the biliary tract really require an endoscopic approach in emergency or urgency and the organizational consequences that this can determine. Based on the guidelines, we can conclude that a daytime availability for urgent biliary tract procedures 7 days a week should be provided for the management of severe ACh. Patients with ABP, AC unfit for surgery, and not responsive to medical therapy or BDLs can be treated over a longer period, allowing its scheduling on the first available day of the week.
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Affiliation(s)
- Francesca Lodato
- Department of Gastroenterology and Interventional Endoscopy, AUSL Bologna Bellaria, Maggiore Hospital, 40133 Bologna, Italy; (S.L.); (M.B.); (S.G.); (V.C.)
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Chen G, Sha Y, Wang K, Tang R, Zhai Z, Wang Z, Chen Y. Advancements in Managing Choledocholithiasis and Acute Cholangitis in the Elderly: A Comprehensive Review. Cureus 2025; 17:e78492. [PMID: 40051943 PMCID: PMC11884421 DOI: 10.7759/cureus.78492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2025] [Indexed: 03/09/2025] Open
Abstract
The increasing elderly population has led to a rising prevalence of choledocholithiasis and acute cholangitis, presenting unique diagnostic and therapeutic challenges owing to age-related physiological changes and multiple comorbidities. This comprehensive review synthesizes current evidence and recent advances in managing these conditions in elderly patients, with a particular focus on diagnostic innovations, therapeutic strategies, and perioperative optimization. Recent advances in diagnostic modalities, including enhanced imaging techniques and AI-assisted systems, have improved early detection accuracy, whereas minimally invasive interventions, particularly endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration (LCBDE), have demonstrated superior outcomes when combined with comprehensive perioperative care. The implementation of multidisciplinary approaches and personalized treatment strategies has significantly improved patient outcomes, with evidence supporting the critical role of early antibiotic intervention, careful surgical selection, and enhanced recovery protocols in reducing morbidity and mortality. The optimal management of elderly patients with choledocholithiasis and acute cholangitis requires a systematic, individualized approach incorporating advanced diagnostic techniques, minimally invasive interventions, and comprehensive perioperative care, while future research should focus on developing age-specific treatment algorithms and validating novel therapeutic approaches.
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Affiliation(s)
- Guangbin Chen
- Hepatobiliary Surgery, The Second People's Hospital of Wuhu, Wuhu Hospital Affiliated to East China Normal University, Wuhu, CHN
- Hepatobiliary Surgery, Wannan Medical College, Wuhu, CHN
| | - Yanguang Sha
- Hepatobiliary Surgery, Wannan Medical College, Wuhu, CHN
| | - Ke Wang
- Hepatobiliary Surgery, Wannan Medical College, Wuhu, CHN
| | - Rongmei Tang
- Hepatobiliary Surgery, The Second People's Hospital of Wuhu, Wuhu Hospital Affiliated to East China Normal University, Wuhu, CHN
| | - Zhengqun Zhai
- Hepatobiliary Surgery, The Second People's Hospital of Wuhu, Wuhu Hospital Affiliated to East China Normal University, Wuhu, CHN
| | - Zhilin Wang
- Hepatobiliary Surgery, Wannan Medical College, Wuhu, CHN
| | - Yisheng Chen
- General Surgery, Wuhu Guangji Hospital, Wuhu, CHN
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Cooper KM, Winkie M, Achebe I, Devuni D, Mehta S. Endoscopic transpapillary gallbladder drainage is associated with favorable long-term outcomes in patients with advanced liver disease. Endosc Int Open 2025; 13:a24724256. [PMID: 40012578 PMCID: PMC11863550 DOI: 10.1055/a-2472-4256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 11/15/2024] [Indexed: 02/28/2025] Open
Abstract
Background and study aims Endoscopic gallbladder therapy is increasingly used in high-risk surgical patients, but data in advanced liver disease are lacking. Patients and methods We performed a single-center retrospective analysis of patients with cirrhosis undergoing endoscopic transpapillary gallbladder drainage (ET-GBD) with cystic duct stenting (n = 55). Short-term outcomes were assessed at Day 30. Long-term outcomes were assessed at 6 months and 1 and 3 years or last known follow-up. Subgroup analyses were completed by location (inpatient vs. outpatient). Results A total of 52 patients, mean MELD-Na 16, underwent successful ET-GBD (38 inpatient, 14 outpatient). Most patients (n = 48) experienced immediate symptomatic relief. Short-term adverse event rate was 7.7% and 30-day mortality was 1.9%. At 6 months, 86.5% of patients had a favorable outcome; unfavorable outcomes included death (n = 2), recurrent cholecystitis and/or need for urgent cholecystectomy (n = 5). At the end of the study, 80% of patients experienced a favorable outcome including five patients bridged to liver transplant and 20 who had their stent in place with adequate symptom control. Of those with imaging, 65% of patients experienced resolution of cholelithiasis. Recurrent cholecystitis ( P = 1.00) and stone resolution ( P = 0.35) did not differ in patients with one or two cystic duct stents in place. Conclusions Transpapillary gallbladder stenting is technically feasible and associated with high rates of clinical success in patients with decompensated liver disease. Stone resolution is common after transpapillary gallbladder stenting and may portend favorable patient outcomes.
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Affiliation(s)
| | - Mason Winkie
- Medicine, UMass Chan Medical School, Worcester, United States
| | - Ikechukwu Achebe
- Medicine, Division of Gastroenterology and Hepatology, UMass Chan Medical School, Worcester, United States
| | - Deepika Devuni
- Medicine, Division of Gastroenterology and Hepatology, UMass Chan Medical School, Worcester, United States
| | - Savant Mehta
- Medicine, Division of Gastroenterology and Hepatology, UMass Chan Medical School, Worcester, United States
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Jagtap N, Chavan D, Rughwani H, Memon SF, Lakhtakia S, Asif S, Kalapala R, Ramchandani M, Reddy DN. Impact of timing of ERCP on long term outcomes of ERCP for acute cholangitis - A single center retrospective study. Dig Liver Dis 2024; 56:2149-2153. [PMID: 39245601 DOI: 10.1016/j.dld.2024.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/29/2024] [Accepted: 08/11/2024] [Indexed: 09/10/2024]
Abstract
INTRODUCTION Acute cholangitis is a critical medical emergency. The association between the timing of ERCP and clinical outcomes of acute cholangitis is still debated. The current study aims to evaluate whether ERCP within 48 h (urgent) is associated with improved long term clinical outcomes. METHODS This study is a single-center retrospective analysis of a prospectively maintained database. All patients admitted with acute cholangitis as per Tokyo guidelines at AIG Hospitals, Hyderabad between January 2022 to December 2022 were included. We evaluated the association between urgent ERCP and length of hospital stay, need for reintervention and readmissions, and mortality. RESULTS A total of consecutive 301 patients underwent ERCP for acute cholangitis; of which 217 patients (31.3 % females; mean age 54.02 ± 14.9 years) underwent urgent ERCP. The remaining 84 (32.1 % females; mean age 56.56 ± 13.9 years) underwent routine ERCP. Fifty-eight (26.7 %) and 22 (26.2 %) patients with Grade III underwent urgent and routine ERCP respectively. The median (IQR) hospital stay for urgent ERCP was 8.00 (6.00 - 11.00) days and for routine ERCP was 11.00(8.00 - 15.00; p value 0.0001), with similar hospital stay post ERCP (p 0.26). There was no significant difference in mortality upto one year between patients who underwent urgent (22.1 %;48/217) or routine ERCP (31.0 %;26/84, p 0.135). The cox proportional hazard model showed that mortality is independently associated with older age (HR 1.034;95 %CI: 1.013 - 1.054; p 0.001) and malignancy (HR 8.64;95 %CI:4.728 - 15.790; p 0.0001). There was no significant difference between two groups in terms of need for reinterventions and readmissions. CONCLUSIONS Urgent ERCP for acute cholangitis is associated comparable overall mortality, need for reinterventions, and readmissions with decreased total length of hospital stay. There is an unmet need to confirm these findings by randomized controlled studies.
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Affiliation(s)
- Nitin Jagtap
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Digvijay Chavan
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Hardik Rughwani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sana Fathima Memon
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Shujaath Asif
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rakesh Kalapala
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.
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Wang DHE, Chang P, Tintara S, Chang F, Phan J. Comparative Analysis of ERCP and PTBD for Biliary Interventions for Readmission Rates and Patient Outcomes. J Clin Gastroenterol 2024:00004836-990000000-00347. [PMID: 39312533 DOI: 10.1097/mcg.0000000000002074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 08/09/2024] [Indexed: 09/25/2024]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are interventions used to relieve biliary obstruction. The utility of ERCP compared with PTBD is not fully understood from a utilization outcome standpoint. Our study compares readmission rates and hospitalization outcomes in ERCP and PTBD. METHODS Using the National Readmission Database (NRD) 2016 to 2020, we identified all patients with an ERCP or PTBD completed during admission. The study cohort was first analyzed by 3 weighted study arms including those admitted with cholangitis, biliary/pancreatic malignancy, and choledocholithiasis. Second, we analyzed the cohort by a 1:1, unweighted propensity match. The primary outcome was 30 day, 90 day, and 6 month readmission. Secondary outcomes were readmission/overall mortality, cost, and length of stay. Outcomes were analyzed using multivariate analysis. RESULTS A total of 621,735 admissions were identified associated with 589,796 ERCP and 31,939 PTBD. In the propensity matched cohort, PTBD had a higher readmission rate at 30 days (20.38% vs. 13.71% P<0.0001), 90 days (14.63% vs. 13.14%, P<0.0001) but lower rate at 6 months (8.50% vs. 9.67%, P=0.0003). Secondary outcomes included increased PTBD-associated hospital length of stay (9.01 d vs. 6.74 d, P<0.0001), hospitalization cost ($106,947.97 vs. $97,602.25, P<0.0001), and overall mortality (6.86% vs. 4.35%, P<0.0001). No major differences were found for mortality among readmissions at 30 days (7.19% vs. 6.88%, P=0.5382), 90 day (6.82% vs. 6.51%, P=0.5612), and 6 months (5.08% vs. 5.91%, P=0.1744). CONCLUSIONS ERCP demonstrated superior results compared with PTBD for readmission rates, length of stay and overall mortality. For failed ERCP cases, emerging data for Endoscopic ultrasound guided-biliary drainage (EUS-BD) offers potential over PTBD and may provide additional options for the future in tertiary referral centers with experience.
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Affiliation(s)
- Daniel Huai-En Wang
- Department of Internal Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Patrick Chang
- Department of Gastroenterology, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Supisara Tintara
- Department of Gastroenterology, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Frederick Chang
- University of Arizona College of Medicine, Department of Family Medicine, Tucson, AZ, USA
| | - Jennifer Phan
- Department of Gastroenterology, University of Southern California Keck School of Medicine, Los Angeles, CA
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12
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Duijzer R, Bernts LHP, Geerts A, van Hoek B, Coenraad MJ, Rovers C, Alvaro D, Kuijper EJ, Nevens F, Halbritter J, Colmenero J, Kupcinskas J, Salih M, Hogan MC, Ronot M, Vilgrain V, Hanemaaijer NM, Kamath PS, Strnad P, Taubert R, Gansevoort RT, Torra R, Nadalin S, Suwabe T, Gevers TJG, Cardinale V, Drenth JPH, Lantinga MA. Clinical management of liver cyst infections: an international, modified Delphi-based clinical decision framework. Lancet Gastroenterol Hepatol 2024; 9:884-894. [PMID: 38878785 DOI: 10.1016/s2468-1253(24)00094-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/15/2024] [Accepted: 03/21/2024] [Indexed: 08/12/2024]
Abstract
Liver cyst infections often necessitate long-term hospital admission and are associated with considerable morbidity and mortality. We conducted a modified Delphi study to reach expert consensus for a clinical decision framework. The expert panel consisted of 24 medical specialists, including 12 hepatologists, from nine countries across Europe, North America, and Asia. The Delphi had three rounds. The first round (response rate 21/24 [88%]) was an online survey with questions constructed from literature review and expert opinion, in which experts were asked about their management preferences and rated possible management strategies for seven clinical scenarios. Experts also rated 14 clinical decision-making items for relevancy and defined treatment outcomes. During the second round (response rate 13/24 [54%]), items that did not reach consensus and newly suggested themes were discussed in an online panel meeting. In the third round (response rate 16/24 [67%]), experts voted on definitions and management strategies using an online survey based on previous answers. Consensus was predefined as a vote threshold of at least 75%. We identified five subclassifications of liver cyst infection according to cyst phenotypes and patient immune status and consensus on episode definitions (new, persistent, and recurrent) and criteria for treatment success or failure was reached. The experts agreed that fever and elevated C-reactive protein are pivotal decision-making items for initiating and evaluating the management of liver cyst infections. Consensus was reached on 26 management statements for patients with liver cyst infections across multiple clinical scenarios, including two treatment algorithms, which were merged into one after comments. We provide a clinical decision framework for physicians managing patients with liver cyst infections. This framework will facilitate uniformity in the management of liver cyst infections and can constitute the basis for the development of future guidelines.
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Affiliation(s)
- Renée Duijzer
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, Netherlands
| | - Lucas H P Bernts
- Department of Medical Microbiology, Radboudumc, Nijmegen, Netherlands
| | - Anja Geerts
- Department of Hepatology and Gastroenterology, Ghent University, Ghent, Belgium; European Reference Network RARE-LIVER, Hamburg, Germany
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Chantal Rovers
- Department of Internal Medicine, Radboudumc, Nijmegen, Netherlands
| | - Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Ed J Kuijper
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands
| | - Frederik Nevens
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Gastroenterology and Hepatology, UZ Leuven, Leuven, Belgium
| | - Jan Halbritter
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jordi Colmenero
- European Reference Network RARE-LIVER, Hamburg, Germany; Liver Unit, Hospital Clinic Barcelona, IDIBAPS-FRCB, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Juozas Kupcinskas
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Mahdi Salih
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, Rotterdam, Netherlands
| | - Marie C Hogan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Maxime Ronot
- European Reference Network RARE-LIVER, Hamburg, Germany; Service de Radiologie, Hôpital Beaujon, APHP Nord, Clichy & Université Paris Cité, CRI, UMR 1149, Paris, France
| | - Valerie Vilgrain
- European Reference Network RARE-LIVER, Hamburg, Germany; Service de Radiologie, Hôpital Beaujon, APHP Nord, Clichy & Université Paris Cité, CRI, UMR 1149, Paris, France
| | | | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Pavel Strnad
- European Reference Network RARE-LIVER, Hamburg, Germany; Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Richard Taubert
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Roser Torra
- Inherited Kidney Disorders, Department of Nephrology, Fundació Puigvert, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Silvio Nadalin
- Department of General, Visceral, and Transplant Surgery, University of Tübingen, Tübingen, Germany
| | - Tatsuya Suwabe
- Nephrology Center, Okinaka Memorial Institute, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Tom J G Gevers
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, Netherlands; NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
| | - Vincenzo Cardinale
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Joost P H Drenth
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marten A Lantinga
- European Reference Network RARE-LIVER, Hamburg, Germany; Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Netherlands.
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13
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Huang S, Liang Y, Li Y, Pan L, Wang B, Liu Y, Shi R, Feng Y. Digital cholangioscope assisted radiation-free bedside one-stage endoscopic lithotomy and biliary drainage for severe acute cholangitis caused by choledocholithiasis. Sci Rep 2024; 14:18830. [PMID: 39138255 PMCID: PMC11322515 DOI: 10.1038/s41598-024-69943-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 08/12/2024] [Indexed: 08/15/2024] Open
Abstract
Radiation-free one-stage bedside endoscopic stone removal and biliary drainage for severe acute cholangitis (SAC) caused by choledocholithiasis in intensive care unit (ICU) has not been reported. Herein, we introduce our preliminary experience of such intervention. Radiation-free bedside digital cholangioscope-assisted one-stage endoscopic stone removal and biliary drainage was performed in an urgent manner. Data on clinical outcomes and follow-up from thirty patients were retrospectively analyzed. Time interval was 7.6 ± 4.7 (2-18) h between ICU admission and endoscopic intervention, and was 35.5 ± 14.5 (5-48) h between the seizure and endoscopic intervention. A 100% technical success was achieved. Except for one mild pancreatitis, no other complication occurred. Patients showed good responses to endoscopic interventions, which were reflected by ameliorated disease severities and laboratory findings. Time lengths of ICU stay and total in-hospital stay were 8.7 ± 4.9 (2-23) days and 14.5 ± 7.4 (5-39) days, respectively. In-hospital mortality occurred in three patients. According to a 6-month follow-up, two patients died of pneumonia and acute myocardial infarction. No SAC and/or biliary stone residual occurred. The current intervention demonstrated favorable results compared to traditional endoscopic retrograde cholangiopancreatography. Our study provides a novel bedside endoscopic intervention method for SAC caused by choledocholithiasis.
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Affiliation(s)
- Shuaijing Huang
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yan Liang
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yuanyuan Li
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Liang Pan
- Department of Gastroenterology, Changzhou Jintan First People's Hospital Affiliated to Jiangsu University, 500 Jintan Avenue, Jintan, 210036, Jiangsu, China.
| | - Bin Wang
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
- Department of Gastroenterology, The Affiliated Changshu Hospital of Nantong University, Changshu No. 2 People's Hospital, 18 Taishan Road, Changshu, 215500, China
| | - Yang Liu
- Department of Gastroenterology, Nanjing Pukou People's Hospital, 166 Shanghe Road, Nanjing, 210031, Jiangsu, China
| | - Ruihua Shi
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yadong Feng
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China.
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14
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Zhang H, Wang Y, Zhang X, Xu C, Xu D, Shen H, Jin H, Yang J, Zhang X. Carbapenem-resistant Enterobacterales sepsis following endoscopic retrograde cholangiopancreatography: risk factors for 30-day all-cause mortality and the development of a nomogram based on a retrospective cohort. Antimicrob Resist Infect Control 2024; 13:84. [PMID: 39113089 PMCID: PMC11304701 DOI: 10.1186/s13756-024-01441-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 07/25/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) has become a routine endoscopic procedure that is essential for diagnosing and managing various conditions, including gallstone extraction and the treatment of bile duct and pancreatic tumors. Despite its efficacy, post-ERCP infections - particularly those caused by carbapenem-resistant Enterobacterales (CRE) - present significant risks. These risks highlight the need for accurate predictive models to enhance postprocedural care, reduce the mortality risk associated with post-ERCP CRE sepsis, and improve patient outcomes in the context of increasing antibiotic resistance. OBJECTIVE This study aimed to examine the risk factors for 30-day mortality in patients with CRE sepsis following ERCP and to develop a nomogram for accurately predicting 30-day mortality risk. METHODS Data from 195 patients who experienced post-ERCP CRE sepsis between January 2010 and December 2022 were analyzed. Variable selection was optimized via the least absolute shrinkage and selection operator (LASSO) regression model. Multivariate logistic regression analysis was then employed to develop a predictive model, which was evaluated in terms of discrimination, calibration, and clinical utility. Internal validation was achieved through bootstrapping. RESULTS The nomogram included the following predictors: age > 80 years (hazard ratio [HR] 2.61), intensive care unit (ICU) admission within 90 days prior to ERCP (HR 2.64), hypoproteinemia (HR 4.55), quick Pitt bacteremia score ≥ 2 (HR 2.61), post-ERCP pancreatitis (HR 2.52), inappropriate empirical therapy (HR 3.48), delayed definitive therapy (HR 2.64), and short treatment duration (< 10 days) (HR 5.03). The model demonstrated strong discrimination and calibration. CONCLUSIONS This study identified significant risk factors associated with 30-day mortality in patients with post-ERCP CRE sepsis and developed a nomogram to accurately predict this risk. This tool enables healthcare practitioners to provide personalized risk assessments and promptly administer appropriate therapies against CRE, thereby reducing mortality rates.
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Affiliation(s)
- Hongchen Zhang
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Yue Wang
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Xiaochen Zhang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Chenshan Xu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Dongchao Xu
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Hongzhang Shen
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Hangbin Jin
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Jianfeng Yang
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Xiaofeng Zhang
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China.
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China.
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China.
- Hangzhou Institute of Digestive Disease, Zhejiang, China.
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15
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Lee SY, Park SH, Do MY, Lee DK, Jang SI, Cho JH. Increased ERCP-related adverse event from premature urgent ERCP following symptom onset in acute biliary pancreatitis with cholangitis. Sci Rep 2024; 14:13663. [PMID: 38871990 DOI: 10.1038/s41598-024-64644-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 06/11/2024] [Indexed: 06/15/2024] Open
Abstract
Acute biliary pancreatitis (ABP) with cholangitis requires endoscopic retrograde cholangiopancreatography (ERCP) within 24 h to resolve ductal obstruction. However, this recommendation is based on the timing of emergency room (ER) visits. We wanted to determine the optimal timing of ERCP for ABP based on the timing of symptom onset, not the timing of the ER visit. We retrospectively reviewed 162 patients with ABP with cholangitis who underwent urgent ERCP (within 24 h of ER admission). Area under the receiver operating characteristic (ROC) curve (AUC) was analyzed to determine differences in complication rates according to time from symptom onset. A difference in ERCP-related adverse events (AEs) was identified, and Youden's J statistic was used to determine a cutoff time from symptom onset (18 h). We compared mortality and complications based on this cutoff. Based on time to symptom onset, significantly higher rates of aspiration pneumonia (odds ratio [OR] 4.00, 95% confidence interval [CI] 1.15-13.92, P = 0.021) and post-ERCP hypotension (OR 11.9, 95% CI 1.39-101.33, P = 0.005) were observed in the ≤ 18-h group than in the > 18-h group. The study found that patients who underwent ERCP within 18 h of symptom onset is associated with an increased risk of ERCP-related AEs.
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Affiliation(s)
- See Young Lee
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Ho Park
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Min Young Do
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Lee
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Ill Jang
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea.
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Jae Hee Cho
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea.
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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16
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Singh I, Chou JF, Capanu M, Park J, Yu KH, Varghese AM, Park W, Zervoudakis A, Keane F, Rolston VS, Gerdes H, Wei AC, Shah P, Covey A, Schattner M, O'Reilly EM. Morbidity and mortality in patients with stage IV pancreatic adenocarcinoma and acute cholangitis: Outcomes and risk prognostication. Pancreatology 2024; 24:608-615. [PMID: 38749803 PMCID: PMC11164623 DOI: 10.1016/j.pan.2024.05.515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/05/2024] [Accepted: 05/06/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Acute cholangitis (AC) is a common complication of pancreatic ductal adenocarcinoma (PDAC). Herein, we evaluated outcomes after the first AC episode and predictors of mortality and AC recurrence in patients with stage IV PDAC. METHODS We conducted a single-center, retrospective observational study using institutional databases. Clinical data and outcomes for patients with stage IV PDAC and at least one documented episode of AC, were assessed. Overall survival (OS) was estimated using the Kaplan-Meier method, and Cox regression model was employed to identify predictors of AC recurrence and mortality. RESULTS One hundred and twenty-four patients with stage IV PDAC and AC identified between January 01, 2014 and October 31, 2020 were included. Median OS after first episode of AC was 4.1 months (95 % CI, 4.0-5.5), and 30-day, 6, and 12-month survival was 86.2 % (95 % CI, 80.3-92.5), 37 % (95 % CI, 29.3-46.6 %) and 18.9 % (95 % CI, 13.1-27.3 %), respectively. Primary tumor in pancreatic body/tail (HR 2.29, 95 % CI: 1.26 to 4.18, p = 0.011), concomitant metastases to liver and other sites (HR 1.96, 95 % CI: 1.16 to 3.31, p = 0.003) and grade 3 AC (HR 2.26, 95 % CI: 1.45 to 3.52, p < 0.001), predicted worse outcomes. Intensive care unit admission, sepsis, systemic therapy, treatment regimen, and time to intervention did not predict survival or risk of recurrence of AC. CONCLUSIONS AC confers significant morbidity and mortality in advanced PDAC. Worse outcomes are associated with higher grade AC, primary tumor location in pancreatic body/tail, and metastases to liver and other sites.
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Affiliation(s)
- Isha Singh
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, 26505, USA
| | - Joanne F Chou
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Marinela Capanu
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Jennifer Park
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Kenneth H Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Anna M Varghese
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Wungki Park
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Alice Zervoudakis
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Fergus Keane
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Vineet Syan Rolston
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Hans Gerdes
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Pari Shah
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Anne Covey
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Mark Schattner
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Eileen M O'Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; David M. Rubenstein Center for Pancreas Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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17
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İnan B, Akbay A, Güven İE, Ersoy O. Assessment of The Factors Related to The Spontaneous Passage of Common Bile Duct Stones. J Clin Med 2024; 13:2672. [PMID: 38731201 PMCID: PMC11084940 DOI: 10.3390/jcm13092672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/15/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Common bile duct (CBD) stones may pass spontaneously without any intervention. Assessment of the predictors of spontaneous passage can contribute to avoiding unnecessary endoscopic retrograde cholangiopancreatography (ERCP) implementation. This study aimed to investigate the factors related to spontaneous passage of CBD stones. Methods: From January 2021 to August 2023, patients with naïve papilla who had undergone biliary ERCP and with CBD stones detected by MRCP before the procedure were analyzed retrospectively. Subjects were divided into two groups on the basis of the presence of stones during the ERCP procedure: the spontaneous passage group and the non-passage group. Groups were compared in terms of demographic, laboratory, and radiological data. Results: A total of 236 patients, including 26 in the spontaneous passage group and 210 in the non-passage group, were involved. Multivariate logistic regression analyses revealed that only stone size was significantly associated with spontaneous passage. From ROC curve analysis, stone size with a cut-off value of 4.3 mm predicted spontaneous passage with 58% sensitivity and 85% specificity. Conclusions: Stones with a size of less than 4.3 mm are more likely to pass spontaneously without endoscopic intervention. Paying attention to the stone diameter before ERCP procedures can contribute to avoiding unnecessary ERCP implementation.
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Affiliation(s)
- Bayram İnan
- Department of Gastroenterology, Ankara City Hospital, Bilkent, Ankara 06800, Turkey; (B.İ.); (A.A.); (O.E.)
| | - Ahmet Akbay
- Department of Gastroenterology, Ankara City Hospital, Bilkent, Ankara 06800, Turkey; (B.İ.); (A.A.); (O.E.)
| | - İbrahim Ethem Güven
- Department of Gastroenterology, Ankara City Hospital, Bilkent, Ankara 06800, Turkey; (B.İ.); (A.A.); (O.E.)
- Departmant of Gastroenterology, Ankara Yildirim Beyazit University Yenimahalle Training and Research Hospital, Ankara 06370, Turkey
| | - Osman Ersoy
- Department of Gastroenterology, Ankara City Hospital, Bilkent, Ankara 06800, Turkey; (B.İ.); (A.A.); (O.E.)
- Departmant of Gastroenterology, School of Medicine, Ankara Yildirim Beyazit University, Ankara 06800, Turkey
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18
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George JT, Thomas A, Jaleel R, Paul GJS, John A, Kurien RT, Chowdhury SD, Simon EG, Joseph AJ, Dutta AK. Bile Culture May Guide Antibiotic Stewardship in Acute Bacterial Cholangitis. Dig Dis Sci 2024; 69:1872-1879. [PMID: 38457116 DOI: 10.1007/s10620-024-08289-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 01/09/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Bile cultures are often sent with blood cultures in patients with acute bacterial cholangitis. AIMS To assess the yield of blood and bile cultures in patients with cholangitis and the clinical utility of bile cultures in guiding therapy. METHODS All patients diagnosed with cholangitis, based on the Tokyo 2013/2018 guidelines were recruited retrospectively over ten years. The clinical and investigation details were recorded. The results of bile and blood cultures including antibiotic sensitivity patterns were noted. The concordance of microorganisms grown in blood and bile cultures and their sensitivity pattern were assessed. RESULTS A total of 1063 patients with cholangitis were included. Their mean age was 52.7 ± 14 years and 65.4% were males. Blood cultures were positive in 372 (35%) patients. Bile culture was performed in 384 patients with 84.4% being positive, which was significantly higher than the yield of blood culture (p < 0.001). Polymicrobial growth was more in bile (59.3%) than in blood cultures (13.5%, p < 0.001). E.coli, Klebsiella, Enterococcus and Pseudomonas were the four most common organisms isolated from both blood and bile. Extended spectrum betalactamase producing organisms were isolated in 57.7% and 58.8% of positive blood and bile cultures, respectively. Among 127 patients with both blood and bile cultures positive, complete or partial concordance of organisms was noted in about 90%. CONCLUSION Bile and blood cultures have a similar microbial profile in most patients with cholangitis. As bile cultures have a significantly higher yield than blood cultures, they could effectively guide antimicrobial therapy, especially in those with negative blood cultures.
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Affiliation(s)
- John Titus George
- Department of Gastroenterology, Christian Medical College, Vellore, 632002, India.
| | - Ajith Thomas
- Department of Gastroenterology, Christian Medical College, Vellore, 632002, India
| | - Rajeeb Jaleel
- Department of Gastroenterology, Christian Medical College, Vellore, 632002, India
| | - G Jackwin Sam Paul
- Department of Community Medicine, Christian Medical College, Vellore, 632004, India
| | - Anoop John
- Department of Gastroenterology, Christian Medical College, Vellore, 632002, India
| | - Reuben Thomas Kurien
- Department of Gastroenterology, Christian Medical College, Vellore, 632002, India
| | | | - Ebby George Simon
- Department of Gastroenterology, Christian Medical College, Vellore, 632002, India
| | - A J Joseph
- Department of Gastroenterology, Christian Medical College, Vellore, 632002, India
| | - Amit Kumar Dutta
- Department of Gastroenterology, Christian Medical College, Vellore, 632002, India
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Zhou Y, Zhang YQ, Huang SJ, Liang Y, Liang X, Wali M, Feng YD. Urgent one-stage endoscopic treatment for choledocholithiasis related moderate to severe acute cholangitis: A propensity score-matched analysis. World J Gastroenterol 2024; 30:2118-2127. [PMID: 38681983 PMCID: PMC11045478 DOI: 10.3748/wjg.v30.i15.2118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/19/2024] [Accepted: 03/27/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND During emergency endoscopic retrograde cholangiopancreatography (ERCP), the safety and feasibility of performing one-stage endoscopic treatment for patients with acute cholangitis (AC) due to choledocholithiasis are unclear. AIM To investigate the safety and feasibility of one-stage endoscopic treatment for moderate to severe AC. METHODS We enrolled all patients diagnosed with moderate to severe cholangitis due to common bile duct stones from January 2019 to July 2023. The outcomes were compared in this study between patients who underwent ERCP within 24 h and those who underwent ERCP 24 h later, employing a propensity score (PS) framework. Our primary outcomes were intensive care unit (ICU) admission rates, ICU length of stay, and duration of antibiotic use. RESULTS In total, we included 254 patients and categorized them into two groups based on the time elapsed between admission and intervention: The urgent group (≤ 24 h, n = 102) and the elective group (> 24 h, n = 152). Ninety-three pairs of patients with similar characteristics were selected by PS matching. The urgent ERCP group had more ICU admissions (34.4% vs 21.5%, P = 0.05), shorter ICU stays (3 d vs 9 d, P < 0.001), fewer antibiotic use (6 d vs 9 d, P < 0.001), and shorter hospital stays (9 d vs 18.5 d, P < 0.001). There were no significant differences observed in adverse events, in-hospital mortality, recurrent cholangitis occurrence, 30-d readmission rate or 30-d mortality. CONCLUSION Urgent one-stage ERCP provides the advantages of a shorter ICU stay, a shorter duration of antibiotic use, and a shorter hospital stay.
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Affiliation(s)
- Yang Zhou
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Yin-Qiu Zhang
- Department of Gastroenterology, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing 210019, Jiangsu Province, China
| | - Shuai-Jing Huang
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Yan Liang
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Xiao Liang
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Masoom Wali
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Ya-Dong Feng
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, Jiangsu Province, China
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20
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Maillard A, Micheli G, Lefevre L, Guyonnet C, Poyart C, Canouï E, Belan M, Charlier C. Can Chatbot Artificial Intelligence Replace Infectious Diseases Physicians in the Management of Bloodstream Infections? A Prospective Cohort Study. Clin Infect Dis 2024; 78:825-832. [PMID: 37823416 DOI: 10.1093/cid/ciad632] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/03/2023] [Accepted: 10/09/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND The development of chatbot artificial intelligence (AI) has raised major questions about their use in healthcare. We assessed the quality and safety of the management suggested by Chat Generative Pre-training Transformer 4 (ChatGPT-4) in real-life practice for patients with positive blood cultures. METHODS Over a 4-week period in a tertiary care hospital, data from consecutive infectious diseases (ID) consultations for a first positive blood culture were prospectively provided to ChatGPT-4. Data were requested to propose a comprehensive management plan (suspected/confirmed diagnosis, workup, antibiotic therapy, source control, follow-up). We compared the management plan suggested by ChatGPT-4 with the plan suggested by ID consultants based on literature and guidelines. Comparisons were performed by 2 ID physicians not involved in patient management. RESULTS Forty-four cases with a first episode of positive blood culture were included. ChatGPT-4 provided detailed and well-written responses in all cases. AI's diagnoses were identical to those of the consultant in 26 (59%) cases. Suggested diagnostic workups were satisfactory (ie, no missing important diagnostic tests) in 35 (80%) cases; empirical antimicrobial therapies were adequate in 28 (64%) cases and harmful in 1 (2%). Source control plans were inadequate in 4 (9%) cases. Definitive antibiotic therapies were optimal in 16 (36%) patients and harmful in 2 (5%). Overall, management plans were considered optimal in only 1 patient, as satisfactory in 17 (39%), and as harmful in 7 (16%). CONCLUSIONS The use of ChatGPT-4 without consultant input remains hazardous when seeking expert medical advice in 2023, especially for severe IDs.
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Affiliation(s)
- Alexis Maillard
- Infectious Diseases Stewardship Team, Paris Centre University Hospital, Assistance publique Hôpitaux de Paris (AP-HP), Paris, France
| | - Giulia Micheli
- Infectious Diseases Stewardship Team, Paris Centre University Hospital, Assistance publique Hôpitaux de Paris (AP-HP), Paris, France
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Leila Lefevre
- Infectious Diseases Stewardship Team, Paris Centre University Hospital, Assistance publique Hôpitaux de Paris (AP-HP), Paris, France
| | - Cécile Guyonnet
- Microbiology Department, Paris Centre University Hospital, Assistance publique Hôpitaux de Paris (AP-HP), Paris, France
- Université Paris Cité, Institut Cochin, Institut national de la santé et de la recherche médicale (INSERM), U1016, Centre national de la recherche scientifique (CNRS ), UMR8104, Paris, France
| | - Claire Poyart
- Microbiology Department, Paris Centre University Hospital, Assistance publique Hôpitaux de Paris (AP-HP), Paris, France
- Université Paris Cité, Institut Cochin, Institut national de la santé et de la recherche médicale (INSERM), U1016, Centre national de la recherche scientifique (CNRS ), UMR8104, Paris, France
| | - Etienne Canouï
- Infectious Diseases Stewardship Team, Paris Centre University Hospital, Assistance publique Hôpitaux de Paris (AP-HP), Paris, France
| | - Martin Belan
- Infectious Diseases Stewardship Team, Paris Centre University Hospital, Assistance publique Hôpitaux de Paris (AP-HP), Paris, France
- Faculté de Médecine, Université Paris Cité, Paris, France
| | - Caroline Charlier
- Infectious Diseases Stewardship Team, Paris Centre University Hospital, Assistance publique Hôpitaux de Paris (AP-HP), Paris, France
- Faculté de Médecine, Université Paris Cité, Paris, France
- French National Reference Center and World Health Organization Collaborating Center Listeria, Institut Pasteur, Paris, France
- Biology of Infection Unit, Institut Pasteur, Inserm, Paris, France
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21
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Huang XN, Fang QM, Zhong YF, Liu J. Case report: Rare benign obstructive disease of the biliary tract-a rare case of eosinophilic cholangitis. Front Med (Lausanne) 2024; 10:1340667. [PMID: 38298507 PMCID: PMC10827930 DOI: 10.3389/fmed.2023.1340667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 12/30/2023] [Indexed: 02/02/2024] Open
Abstract
Objective Eosinophilic cholangitis (EC) is an uncommon form of benign biliary obstruction. It frequently eludes accurate clinical diagnosis, leading to inappropriate treatment methods. It is our aspiration that this clinical report will impart comprehensive insights into EC and, specifically, the critical role of tomographic examination. Case summary A 34-year-old man was urgently admitted to the hospital due to excruciating abdominal distress persisting for several hours. Following a six-day course of anti-inflammatory therapy, his symptoms displayed marginal improvement, prompting his discharge. He returned to the hospital a month later for re-examination on doctor's orders. Based on the results of the re-examination, the patient refused steroid hormone shock therapy and subsequently underwent laparoscopic left-lateral hepatic lobectomy in order to confirm the diagnosis. The preoperative absolute counts of eosinophils in the peripheral blood were documented as 2.3 × 109/L, 3.06 × 109/L, and 1.50 × 109/L consecutively; concurrently, the corresponding percentages of eosinophils were quantified at levels of 21.90%, 30.70%, and 19.20%. The subsequent postoperative pathological assessment unveiled EC as the definitive diagnosis. The patient has since remained free from disease recurrence and is presently alive. Conclusion When encountering a patient presenting with persistent elevation in absolute eosinophil count in peripheral blood, coupled with imaging manifestations suggestive of intrahepatic periductal inflammation, diagnosis of EC should be highly suspected. The most optimal diagnostic and therapeutic workflow for EC could entail CT-guided liver lesion biopsy, ensued by glucocorticoid pulse therapy, and finally, short-term monitoring utilizing CT or MRI (including T1WI, T2WI, DWI, CEMRI) techniques.
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Affiliation(s)
- Xiao-Ning Huang
- Department of Radiology, The Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, China
| | - Qi-Min Fang
- Department of Radiology, The Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, China
| | - Yu-Feng Zhong
- Department of Radiology, The Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, China
| | - Jing Liu
- Department of Pathology, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Tsou YK, Su YT, Lin CH, Liu NJ. Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the clinical presentation and outcomes? World J Clin Cases 2023; 11:6984-6994. [PMID: 37946763 PMCID: PMC10631399 DOI: 10.12998/wjcc.v11.i29.6984] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/02/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Whether clinical outcomes of acute cholangitis (AC) vary by etiology is unclear. AIM To compare outcomes in AC caused by malignant biliary obstruction (MBO) and common bile duct stones (CBDS). METHODS This retrospective study included 516 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) due to AC caused by MBO (MBO group, n = 56) and CBDS (CBDS group, n = 460). Clinical and laboratory parameters were compared between the groups. Propensity score matching (PSM) created 55 matched pairs. Confounders used in the PSM analysis were age, sex, time to ERCP, and technical success of ERCP. The primary outcome comparison was 30-d mortality. The secondary outcome comparisons were intensive care unit (ICU) admission rate, length of hospital stay (LOHS), and 30-d readmission rate. RESULTS Compared with the CBDS group, the MBO group had significantly lower body temperature, percentage of abnormal white blood cell counts, and serum levels of aspartate aminotransferase, alanine aminotransferase, and creatinine. Body temperature, percent abnormal white blood cell count, and serum aspartate aminotransferase levels remained significantly lower in the MBO group in the PSM analysis. Platelet count, prothrombin time/international normalized ratio, and serum levels of alkaline phosphatase and total bilirubin were significantly higher in the MBO group. The MBO group had a significantly higher percentage of severe AC (33.9% vs 22.0%, P = 0.045) and received ERCP later (median, 92.5 h vs 47.4 h, P < 0.001). However, the two differences were not found in the PSM analysis. The 30-d mortality (5.4% vs 0.7%, P = 0.019), ICU admission rates (12.5% vs 4.8%, P = 0.028), 30-d readmission rates (23.2% vs 8.0%, P < 0.001), and LOHS (median, 16.5 d vs 7.0 d, P < 0.001) were significantly higher or longer in the MBO group. However, only LOHS remained significant in the PSM analysis. Multivariate analysis revealed that time to ERCP and multiple organ dysfunction were independent factors associated with 30-d mortality. CONCLUSION MBO patients underwent ERCP later and thus had a worse prognosis than CBDS patients. Therefore, clinicians should remain vigilant in MBO patients with clinically suspected AC, and perform ERCP for biliary drainage as soon as possible.
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Affiliation(s)
- Yung-Kuan Tsou
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Yi-Tse Su
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Cheng-Hui Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Nai-Jen Liu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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23
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Li S, Guizzetti L, Ma C, Shaheen AA, Dixon E, Ball C, Wani S, Forbes N. Epidemiology and outcomes of choledocholithiasis and cholangitis in the United States: trends and urban-rural variations. BMC Gastroenterol 2023; 23:254. [PMID: 37501115 PMCID: PMC10373232 DOI: 10.1186/s12876-023-02868-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 06/30/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Gallstone disease poses a significant health burden in the United States. Choledocholithiasis and cholangitis are common complications of gallstone disease for which data on current epidemiological trends are lacking. We aimed to evaluate temporal changes in hospitalization, management, and outcomes for patients with choledocholithiasis and cholangitis. METHODS The National Inpatient Sample was used to identify discharges for choledocholithiasis and cholangitis between 2005 and 2014. Temporal trends were evaluated via annual percent changes (APCs). Joinpoint regression was used to assess inflection points. Multivariable regression models were used to evaluate associations of interest. RESULTS From 189,362 unweighted discharges for choledocholithiasis and/or cholangitis, there was an increase in discharges for choledocholithiasis (APC 2.3%, 95% confidence intervals, CI, 1.9-2.7%) and cholangitis (APC 1.5%, 95% CI 0.7-2.2%). Procedural interventions were more likely at urban hospitals for choledocholithiasis (adjusted odds ratio, aOR, 2.94, 95% CI 2.72 to 3.17) and cholangitis (aOR 2.97, 95% CI 2.50 to 3.54). In-hospital mortality significantly decreased annually for choledocholithiasis (aOR 0.90, 95% CI 0.88 to 0.93) and cholangitis (aOR 0.93, 95% CI 0.89 to 0.97). In-hospital mortality between rural and urban centers was comparable for choledocholithiasis (aOR 1.16, 95% CI 0.89 to 1.52) and cholangitis (aOR 1.12, 95% CI 0.72 to 1.72). CONCLUSIONS Hospitalizations for choledocholithiasis and cholangitis have increased between 2005 and 2014, reflecting a growing burden of gallstone disease. Hospital mortality between urban and rural centers is similar, however urban centers have a higher rate of procedural interventions suggesting limitations to accessing procedural interventions at rural centers.
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Affiliation(s)
- Suqing Li
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, TRW 6D62, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
| | | | - Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, TRW 6D62, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Alimentiv, Inc, London, ON, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Abdel Aziz Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, TRW 6D62, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Chad Ball
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, TRW 6D62, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
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24
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Li K, Hu X, Lu Q, Zhang H, Zhou J, Tian S, Zhou F. Analysis of Pathogenic Bacteria Distribution and Related Factors in Recurrent Acute Cholangitis. Infect Drug Resist 2023; 16:4729-4740. [PMID: 37492797 PMCID: PMC10364819 DOI: 10.2147/idr.s418752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
Background To evaluate the risk factors and prognosis of patients with acute cholangitis recurrence. Methods A total of 503 patients with acute cholangitis admitted to the First Affiliated Hospital of Chongqing Medical University between July 2013 and January 2022 were included in this retrospective observational study, who were followed up for 360 days and divided into relapse group and non-recurrence group according to the recurrence of acute cholangitis. Risk factors and prognosis of patients with acute cholangitis recurrence were analyzed by univariate, multivariate analyses and proportional hazards model. Results A total of 161 patients with recurrent acute cholangitis were identified. Recurrent acute cholangitis usually occurred within 125 days; Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecalis, and Enterococcus faecium was the most common positive record both in blood and bile culture. In the multivariate analysis, abdominal pain (OR = 2.448, 95% CI = 1.196-5.010, P = 0.014), bile stones (OR = 2.429, 95% CI = 1.024-5.762, P = 0.044), diabetes (OR = 1.790, 95% CI = 1.007-3.182, P = 0.047), pathogen (OR = 3.305, 95% CI = 1.932-5.654, P<0.001), and chronic kidney disease (OR = 2.500, 95% CI = 1.197-5.221, P = 0.015) may be ascertained as the risk factors of acute cholangitis recurrence. The recurrence of acute cholangitis was identified as an independent risk factor for patient death (HR = 4.524, 95% CI = 1.426-14.357, P = 0.010) by Cox proportional-hazards regression. Conclusion Abdominal pain, bile stones, diabetes and chronic kidney disease may be risk factors of acute cholangitis recurrence. Patients with recurrent acute cholangitis have poor prognosis and high mortality. Early control of recurrent risk factors and active intervention are beneficial to high-risk patients.
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Affiliation(s)
- Kaili Li
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Xiaoxue Hu
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Quanyi Lu
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Heng Zhang
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Jiayi Zhou
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Shijing Tian
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Fachun Zhou
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
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Silva-Santisteban A, Shah I, Chandnani M, Wadhwa V, Tsai L, Bezuidenhout AF, Berzin TM, Pleskow D, Sawhney M. Prospective assessment of the accuracy of ASGE and ESGE guidelines for choledocholithiasis. Endosc Int Open 2023; 11:E599-E606. [PMID: 37614641 PMCID: PMC10442906 DOI: 10.1055/a-2089-0344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 05/02/2023] [Indexed: 08/25/2023] Open
Abstract
Background and study aims American Society of Gastrointestinal Endoscopy (ASGE) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend categorizing patients by risk for choledocholithiasis to determine management. The goal of our study was to compare the accuracy of criteria proposed in these guidelines. Patients and methods All patients with suspected choledocholithiasis at our institution were prospectively identified. Based upon initial test results, patients were categorized as low, intermediate, and high risk for choledocholithiasis per ASGE 2010 and 2019, and ESGE criteria. Patients were followed until 30 days post-discharge. Results of endoscopic retrograde cholangiography (ERCP), endoscopic ultrasound, and magnetic resonance cholangiopancreatography were used as criteria standard for choledocholithiasis. The accuracy of each criterion for choledocholithiasis was computed. Results During the study period, 359 consecutive patients with suspected choledocholithiasis were identified, of whom 225 had choledocholithiasis. Median patient age was 69 years and 55.3% were women. ESGE criteria categorized 47.9% as high-risk, lower than ASGE 2010 (62.7%, P <0.01), and 2019 criteria (54.6%, P =0.07). In high-risk patients, choledocholithiasis was noted in 83.1% for ESGE criteria, similar for ASGE 2019 (81.6%, P =0.7) and 2010 criteria (79.1%, P =0.3). The percentage of patients who underwent unnecessary ERCP was 8.1% per ESGE criteria, lower than ASGE 2010 (13.1%, P =0.03), but similar to 2019 criteria (10%, P =0.4). No difference in accuracy for choledocholithiasis was noted among the three criteria. No 30-day readmissions for choledocholithiasis were noted in the low-risk category. Conclusions ESGE and ASGE guidelines have similar accuracy for diagnosis of choledocholithiasis. However, ESGE criteria result in more patients needing additional testing, but also a smaller proportion of patients undergoing unnecessary ERCP.
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Affiliation(s)
- Andy Silva-Santisteban
- Div. of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, United States
- Department of Medicine, Harvard Medical School, Boston, United States
| | - Ishani Shah
- Div. of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, United States
- Department of Medicine, Harvard Medical School, Boston, United States
| | - Madhuri Chandnani
- Div. of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, United States
- Department of Medicine, Harvard Medical School, Boston, United States
| | - Vaibhav Wadhwa
- Div. of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, United States
- Department of Medicine, Harvard Medical School, Boston, United States
| | - Leo Tsai
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, United States
- Department of Radiology, Harvard Medical School, Boston, United States
| | - Abraham F. Bezuidenhout
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, United States
- Department of Radiology, Harvard Medical School, Boston, United States
| | - Tyler M. Berzin
- Div. of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, United States
- Department of Medicine, Harvard Medical School, Boston, United States
| | - Douglas Pleskow
- Div. of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, United States
- Department of Medicine, Harvard Medical School, Boston, United States
| | - Mandeep Sawhney
- Div. of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, United States
- Department of Medicine, Harvard Medical School, Boston, United States
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Masuda S, Koizumi K, Shionoya K, Jinushi R, Makazu M, Nishino T, Kimura K, Sumida C, Kubota J, Ichita C, Sasaki A, Kobayashi M, Kako M, Haruki U. Comprehensive review on small common bile duct stones. World J Gastroenterol 2023; 29:1955-1968. [PMID: 37155530 PMCID: PMC10122794 DOI: 10.3748/wjg.v29.i13.1955] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/22/2023] [Accepted: 03/20/2023] [Indexed: 04/06/2023] Open
Abstract
Common bile duct stones are among the most common conditions encountered by endoscopists. Therefore, it is well researched; however, some items, such as indications for endoscopic papillary balloon dilatation (EPBD), safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant, selection strategy for retrieval balloons and baskets, lack adequate evidence. Therefore, the guidelines have been updated with new research, while others remain unchanged due to weak evidence. In this review, we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation, stone retrieval devices, difficult-to-treat cases, troubleshooting during the procedure, and complicated cases of cholangitis, cholecystolithiasis, or distal biliary stricture.
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Affiliation(s)
- Sakue Masuda
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Kazuya Koizumi
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Kento Shionoya
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Ryuhei Jinushi
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Makomo Makazu
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Takashi Nishino
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Karen Kimura
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Chihiro Sumida
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Jun Kubota
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Chikamasa Ichita
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Akiko Sasaki
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Masahiro Kobayashi
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Makoto Kako
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Uojima Haruki
- Department of Gastroenterology, Kitasato University School of Medicine, Kanagawa 252-0375, Japan
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Salaheddine Y, Henry AC, Daamen LA, Derksen WJM, van Lienden KP, Molenaar IQ, van Santvoort HC, Vleggaar FP, Verdonk RC. Risk Factors for Cholangitis After Pancreatoduodenectomy: A Systematic Review. Dig Dis Sci 2023:10.1007/s10620-023-07929-x. [PMID: 37024745 DOI: 10.1007/s10620-023-07929-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 03/14/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Cholangitis is a late complication after pancreatoduodenectomy with considerable clinical impact and is difficult to treat. The aim of this systematic review was to provide an overview of the literature identifying risk factors for postoperative cholangitis. METHODS A systematic search of the databases PUBMED and EMBASE was performed to identify all studies reporting on possible risk factors for cholangitis following pancreatoduodenectomy. Data on patient, peri- and postoperative characteristics were collected. Risk of bias assessment was done according to the methodological index for non-randomized studies (MINORS) criteria. RESULTS In total, 464 studies were identified. Eight studies met the inclusion criteria for this analysis. The definition of postoperative cholangitis was inconsistent, with four studies using the Tokyo Guidelines, whereas other studies used different definitions. Data on 26 potential risk factors concerning the patient, peri- and postoperative characteristics were analyzed. Five factors were significantly associated with cholangitis in two or more studies: high body mass index, duration of surgery, benign disease, postoperative pancreatic fistula, and postoperative serum alkaline phosphatase. CONCLUSION Multiple potential risk factors for postoperative cholangitis were identified, with large discrepancies between studies. Prospective research, with consensus on the definition, is required to determine the true relevance of these risk factors.
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Affiliation(s)
- Youcef Salaheddine
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne Claire Henry
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wouter J M Derksen
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology & Hepatology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
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Kohli DR, Amateau SK, Desai M, Chinnakotla S, Harrison ME, Chalhoub JM, Coelho-Prabhu N, Elhanafi SE, Forbes N, Fujii-Lau LL, Kwon RS, Machicado JD, Marya NB, Pawa S, Ruan W, Sheth SG, Thiruvengadam NR, Thosani NC, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: summary and recommendations. Gastrointest Endosc 2023; 97:607-614. [PMID: 36797162 DOI: 10.1016/j.gie.2022.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 02/18/2023]
Abstract
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of post-transplant strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent for extrahepatic strictures. In patients with unclear diagnoses or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be ensured.
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Affiliation(s)
- Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Heart Medical Center, Spokane, Washington, USA
| | - Stuart K Amateau
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - M Edwyn Harrison
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Jean M Chalhoub
- Department of Gastroenterology and Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | | | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Richard S Kwon
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jorge D Machicado
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Neil B Marya
- Division of Gastroenterology and Hepatology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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Amateau SK, Kohli DR, Desai M, Chinnakotla S, Harrison ME, Chalhoub JM, Coelho-Prabhu N, Elhanafi SE, Forbes N, Fujii-Lau LL, Kwon RS, Machicado JD, Marya NB, Pawa S, Ruan W, Sheth SG, Thiruvengadam NR, Thosani NC, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: methodology and review of evidence. Gastrointest Endosc 2023; 97:615-637.e11. [PMID: 36792483 DOI: 10.1016/j.gie.2022.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 02/17/2023]
Abstract
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent. In patients with unclear diagnosis or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be assured.
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Affiliation(s)
- Stuart K Amateau
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Medical Center, Spokane, Washington, USA
| | - Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - M Edwyn Harrison
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Jean M Chalhoub
- Department of Gastroenterology and Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | | | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Richard S Kwon
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jorge D Machicado
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Neil B Marya
- Division of Gastroenterology and Hepatology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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30
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Saito H, Iwasaki H, Itoshima H, Kadono Y, Shono T, Kamikawa K, Uehara M, Urata A, Nasu J, Matsushita I, Kakuma T, Tada S. Unnecessary endoscopic retrograde cholangiopancreatography associated with the spontaneous passage of common bile duct stones into the duodenum: a multicenter retrospective study. Surg Endosc 2023:10.1007/s00464-023-09954-3. [PMID: 36849567 DOI: 10.1007/s00464-023-09954-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 02/12/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Unnecessary endoscopic retrograde cholangiopancreatography (ERCP) after spontaneous passage of common bile duct stones (CBDSs) should be avoided. This study aimed to examine the cumulative diagnosis rate and the predictive factors of spontaneous CBDS passage during the interval between the imaging diagnosis and ERCP. METHODS This multicenter retrospective study included 1260 consecutive patients with native papilla diagnosed with CBDSs using imaging modalities. Predictive factors and cumulative diagnosis rate of spontaneously passed CBDSs during the interval between imaging diagnosis and ERCP were analyzed. RESULTS The overall cumulative diagnosis rate of spontaneous CBDS passage was 6.2% (78/1260) during a mean interval of 5.0 days. In the multivariate analysis, CBDS sized < 6 mm on diagnostic imaging, solitary CBDS on diagnostic imaging, intervals between the imaging diagnosis and ERCP, and nondilated common bile duct (< 10 mm) were the significant factors associated with spontaneous CBDS passage. Specifically, the cumulative diagnosis rate of spontaneous passage was significantly higher in patients with solitary and CBDSs sized < 6 mm than in those with other CBDSs (14.4% [54/376] vs. 2.7% [24/884], P < 0.001). In both the asymptomatic and symptomatic groups, the cumulative diagnosis rate of the spontaneous passage of CBDSs was significantly higher in patients with solitary and CBDSs sized < 6 mm on diagnostic imaging than in those with multiple and/or CBDSs sized ≥ 6 mm on diagnostic imaging during a mean interval of 20.5 and 2.4 days, respectively (asymptomatic group: 22.4% [15/67] vs. 3.5% [4/113], P < 0.001, symptomatic group: 12.6% [39/309] vs. 2.6% [20/771], P < 0.001). CONCLUSIONS Solitary and CBDSs sized < 6 mm on diagnostic imaging can often lead unnecessary ERCP due to spontaneous passage. Preliminary endoscopic ultrasonography immediately before ERCP is recommended, especially in patients with solitary and small CBDSs on diagnostic imaging.
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Affiliation(s)
- Hirokazu Saito
- Department of Gastroenterology, Kumamoto City Hospital, 4-1-60, Higashimachi, Higashi-Ku, Kumamoto, 862-8505, Japan.
| | - Hajime Iwasaki
- Department of Gastroenterology, Kumamoto Chuo Hospital, 1-5-1, Tainoshima, Minami-Ku, Kumamoto, 862-0965, Japan
| | - Hisashi Itoshima
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-Ku, Kumamoto, 861-4193, Japan
| | - Yoshihiro Kadono
- Department of Gastroenterology, Tsuruta Hospital, 10-112, Hotakubohonmachi, Higashi-Ku, Kumamoto, 862-0925, Japan
| | - Takashi Shono
- Department of Gastroenterology, Kumamoto Chuo Hospital, 1-5-1, Tainoshima, Minami-Ku, Kumamoto, 862-0965, Japan
| | - Kentaro Kamikawa
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-Ku, Kumamoto, 861-4193, Japan
| | - Masayoshi Uehara
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-Ku, Kumamoto, 861-4193, Japan
| | - Atsushi Urata
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-Ku, Kumamoto, 861-4193, Japan
| | - Jiro Nasu
- Department of Gastroenterological Surgery, Kumamoto Chuo Hospital, 1-5-1, Tainoshima, Minami-Ku, Kumamoto, 862-0965, Japan
| | - Ikuo Matsushita
- Department of Gastroenterology, Kumamoto Chuo Hospital, 1-5-1, Tainoshima, Minami-Ku, Kumamoto, 862-0965, Japan
| | - Tatsuyuki Kakuma
- Department of Biostatics Center, Medical School, Kurume University, 67, Asahimachi, Fukuoka, Kurume, 830-0011, Japan
| | - Shuji Tada
- Department of Gastroenterology, Kumamoto City Hospital, 4-1-60, Higashimachi, Higashi-Ku, Kumamoto, 862-8505, Japan
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31
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Yang J, Liu Y, Liu S. Timing of biliary decompression for acute cholangitis. World J Gastroenterol 2023; 29:904-907. [PMID: 36816624 PMCID: PMC9932428 DOI: 10.3748/wjg.v29.i5.904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/03/2023] [Accepted: 01/16/2023] [Indexed: 02/06/2023] Open
Abstract
Severe acute cholangitis (AC) exacerbates the risk of death because of the rapid progression of the disease. The optimal timing of biliary decompression (BD) as a necessary intervention in patients with severe AC is controversial. A recently report titled "Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity" in the World Journal of Gastroenterology that the optimal time of endoscopic retrograde cholangiopancreatography for treating patients with severe AC is ≤ 48 but not ≤ 24 h, providing clinical evidence for selecting the optimal time for implementation of BD. Here, we discuss the controversy over the optimal timing of BD for AC based on guidelines and clinical evidence, and consider that more high-level clinical researches are urgent needed to benefit the management of patients with different severity of AC.
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Affiliation(s)
- Jian Yang
- Central Laboratory, The Third Affiliated Hospital, Qiqihar Medical University, Qiqihar 161000, Heilongjiang Province, China
| | - Ying Liu
- Department of Medical Oncology, The Third Affiliated Hospital, Qiqihar Medical University, Qiqihar 161000, Heilongjiang Province, China
| | - Shi Liu
- Central Laboratory, The Third Affiliated Hospital, Qiqihar Medical University, Qiqihar 161000, Heilongjiang Province, China
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Tokmak S, Cetin MF, Torun S. Feasibility and safety of partial ampullary endoscopic mucosal resection: a novel technique for difficult biliary cannulation (with video). Surg Endosc 2023; 37:471-478. [PMID: 35999314 DOI: 10.1007/s00464-022-09539-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biliary cannulation can be challenging even for expert endoscopists, and rescue techniques are limited. Our objective was to determine the feasibility and safety of partial ampullary endoscopic mucosal resection (PA-EMR), a novel technique for biliary cannulation. METHODS Monocentric, retrospective analysis of a prospectively maintained database in a tertiary referral university hospital. Fourteen patients who required endoscopic retrograde cholangiopancreatography (ERCP) and underwent PA-EMR between January 1, 2020 and January 31, 2021 were included. For biliary cannulation of prominent papillae, PA-EMR was performed using a standard polypectomy snare, alone or in combination with needle-knife sphincterotomy. In patients with non-prominent papilla, the papillary mucosa was elevated with the aid of methylene blue injection before resection and combined with needle-knife fistulotomy when needed. The rate of technical success and adverse events was assessed. RESULTS The bile duct cannulation success was 99% in the first attempt and 100% overall with the PA-EMR technique. Only one patient experienced mild bleeding, which spontaneously stopped. CONCLUSION PA-EMR is an effective technique that may be considered as a rescue technique for difficult biliary cannulation in expert hands. Future studies including larger cohorts and comparisons with other techniques are warranted to further confirm the feasibility and safety of this novel technique.
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Affiliation(s)
- Salih Tokmak
- Department of Gastroenterology, Internal Medicine, Duzce University, Konuralp, 81000, Duzce, Turkey.
| | - Mehmet F Cetin
- General Surgery, Duzce University, Konuralp, 81000, Duzce, Turkey
| | - Serkan Torun
- Department of Gastroenterology, Internal Medicine, Duzce University, Konuralp, 81000, Duzce, Turkey
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Abdominal Pain. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Zejnullahu VA, Zejnullahu VA. Fractured guide wire in the main pancreatic duct during ERCP: A case report. Int J Surg Case Rep 2022; 102:107843. [PMID: 36566740 PMCID: PMC9801095 DOI: 10.1016/j.ijscr.2022.107843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/13/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is an excellent endoscopic method with a wide range of diagnostic and therapeutic utility. The most common complication is post-ERCP pancreatitis with a reported incidence of 3.5 % followed by cholangitis, cholecystitis, gastrointestinal bleeding and duodenal perforation. Uncommon complications of the procedure reported in the literature include contrast allergy, cardio-pulmonary compromise, problems related to instruments such as impaction of a retrieval basket, fractured guidewire in the biliary or pancreatic channel, extravasation of contrast medium into the duodenal wall, splenic hemorrhage, hepatic trauma and complications related to the electrosurgical risk. PRESENTATION OF CASE We present a case of a 37-year old woman referred to the Department of Abdominal Surgery because of severe abdominal pain and jaundice. Medical personal history of the patient was normal and she denied taking any medication. Following radiological and laboratory analysis, ERCP was completed. In our first attempt to selectively cannulate the CBD, unintentionally a guide wire passed in the main pancreatic duct. Attempting to retract the guide wire under fluoroscopy surveillance, the guide wire was fractured and fragments were left in the main pancreatic duct. Removal of the fragments was unsuccessful in several attempts. Consecutively, selective cannulation of the main pancreatic duct with placement of the pancreatic stent 5Fr/5cm was performed and careful cannulation of CBD was achieved. After the sphincterotomy, the biliary sludge and microlites were dispatched into the duodenum. The pancreatic stent was removed seven days later and patient underwent cholecystectomy four months later. No complications related to the procedure were revealed during the 24 months of follow-up. DISCUSSION A fractured guide-wire during the ERCP is an uncommon event that can occur during the selective cannulation of the common bile duct or pancreatic duct as in our presented case. However, data regarding the guidewire fracture during the ERCP are scarce since it is an uncommon occurrence. Our case is an example of rare and unusual complication during the ERCP, which was managed conservatively at our unit. Based on our research successful retrievals of the fractured guidewire from the main pancreatic duct are rarely reported and we found only two cases in the available literature. Concordantly with our case, acute and long-term pancreatico-biliary complications were not reported in previously published case reports with retained guide wire during the ERCP as we found only one case report in which authors report development of cholangitis related to the fracture of the hydrophilic guidewire. However, rare but serious life-threatening complications that can occur during the ERCP procedure should be identified in a timely manner and treated accordingly. CONCLUSION Fractured guide wire during the ERCP is very uncommon complication of the procedure with only few cases reported in the literature. Our experience suggests that no adverse sequels were triggered by the wire pieces left in the main pancreatic duct as the patient remained asymptomatic 2 years after the guide wire fracture.
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Affiliation(s)
- Valon A. Zejnullahu
- Department of Abdominal Surgery, University Clinical Center of Kosovo, Pristina, Kosovo
| | - Vjosa A. Zejnullahu
- Faculty of Medicine, University of Prishtina “Hasan Prishtina”, Pristina, Kosovo,Department of Obstetrics and Gynecology, University Clinical Center of Kosovo, Pristina, Kosovo,Corresponding author at: University Clinical Center of Kosovo, Department of Obstetrics and Gynecology, 10000 Pristina, Kosovo.
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35
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Huang YC, Wu CH, Lee MH, Wang SF, Tsou YK, Lin CH, Sung KF, Liu NJ. Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity. World J Gastroenterol 2022; 28:5602-5613. [PMID: 36304084 PMCID: PMC9594008 DOI: 10.3748/wjg.v28.i38.5602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/12/2022] [Accepted: 09/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis (AC) is uncertain, especially in patients with AC of varying severity. AIM To report whether the timing of ERCP is associated with outcomes in AC patients with different severities. METHODS According to the 2018 Tokyo guidelines, 683 patients who met the definite diagnostic criteria for AC were retrospectively identified. The results were first compared between patients receiving ERCP ≤ 24 h and > 24 h and then between patients receiving ERCP ≤ 48 h and > 48 h. Subgroup analyses were performed in patients with grade I, II or III AC. The primary outcome was 30-d mortality. Secondary outcomes were intensive care unit (ICU) admission rate, length of hospital stay (LOHS) and 30-d readmission rate. RESULTS Taking 24 h as the critical value, compared with ERCP > 24 h, malignant biliary obstruction as a cause of AC was significantly less common in the ERCP ≤ 24 h group (5.2% vs 11.5%). The proportion of cardiovascular dysfunction (11.2% vs 2.6%), respiratory dysfunction (14.2% vs 5.3%), and ICU admission (11.2% vs 4%) in the ERCP ≤ 24 h group was significantly higher, while the LOHS was significantly shorter (median, 6 d vs 7 d). Stratified by the severity of AC, higher ICU admission was only observed in grade III AC and shorter LOHS was only observed in grade I and II AC. There were no significant differences in 30-d mortality between groups, either in the overall population or in patients with grade I, II or III AC. With 48 h as the critical value, compared with ERCP > 48 h, the proportion of choledocholithiasis as the cause of AC was significantly higher in the ERCP ≤ 48 h group (81.5% vs 68.3%). The ERCP ≤ 48 h group had significantly lower 30-d mortality (0 vs 1.9%) and shorter LOHS (6 d vs 8 d). Stratified by AC severity, lower 30-d mortality (0 vs 6.1%) and higher ICU admission rates (22.2% vs 10.2%) were only observed in grade III AC, and shorter LOHS was only observed in grade I and II AC. In the multivariate analysis, cardiovascular dysfunction and time to ERCP were two independent factors associated with 30-d mortality. CONCLUSION ERCP ≤ 48 h conferred a survival benefit in patients with grade III AC. Early ERCP shortened the LOHS in patients with grade I and II AC.
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Affiliation(s)
- Yao-Chi Huang
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chi-Huan Wu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Mu Hsien Lee
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Sheng Fu Wang
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Yung-Kuan Tsou
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Cheng-Hui Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Kai-Feng Sung
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Nai-Jen Liu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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Lu ZQ, Zhang HY, Su CF, Xing YY, Wang GX, Li CS. Optimal timing of biliary drainage based on the severity of acute cholangitis: A single-center retrospective cohort study. World J Gastroenterol 2022; 28:3934-3945. [PMID: 36157549 PMCID: PMC9367232 DOI: 10.3748/wjg.v28.i29.3934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/25/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Biliary decompression is well known to greatly decrease the risks of mortality in acute cholangitis (AC). Although early biliary drainage is recommended by the treatment guidelines for AC, the best time for performing this procedure is yet to be established. Furthermore, since the clinical outcomes of patients with severe AC vary dramatically, screening for patients that could benefit the most from early drainage would be more beneficial than the drainage performed based on the severity grade criteria.
AIM To investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction.
METHODS In this retrospective monocenter cohort analysis, we reviewed 1305 patients who were diagnosed with AC according to the Tokyo guidelines 2018 at a Chinese tertiary hospital between July 2016 and December 2020. Demographic characteristics including age and sex, clinical and laboratory characteristics, and imaging findings of each patient were obtained from electronic medical records. We investigated the all-cause in-hospital mortality (IHM), hospital length of stay (LOS), and hospitalization costs associated with the timing of biliary drainage according to the severity grading and different dysfunctioning organs and predictors [age, white blood cell (WBC) count, total bilirubin, albumin, lactate, malignant obstruction, and Charlton comorbidity index (CCI)].
RESULTS Biliary drainage within 24 or 48 h in Grade III AC patients could dramatically decrease IHM (3.9% vs 9.0%, P = 0.041; 4% vs 9.9%, P = 0.018, respectively), while increasing LOS and hospitalization costs. Multivariate logistic analysis revealed that neurological, respiratory, renal, and cardiovascular dysfunctions, hypoalbuminemia, and malignant obstruction were significantly associated with IHM (odds ratio = 5.32, 2.541, 6.356, 4.021, 5.655, and 7.522; P < 0.001, P = 0.016, P < 0.001, P = 0.012, P < 0.001, and P < 0.001; respectively). Biliary decompression performed within 12 h of admission significantly decreased the IHM in AC patients with neurological dysfunction (0% vs 17.3%, P = 0.041) or with serum lactate > 2 mmol/L (0% vs 5.4%, P = 0.016). In the subgroup of AC patients with renal dysfunction, abnormal WBC count, hyperbilirubinemia, or hypoalbuminemia, early drainage (< 24 h) reduced the IHM (3.6% vs 33.3%, P = 0.004; 1.9% vs 5.8%, P = 0.031; 1.7% vs 5.0%, P = 0.019; 0% vs 27%, P = 0.026; respectively). The IHM was lower in patients with AC combined with hepatic dysfunction, malignant obstruction, or a CCI > 3 who had undergone biliary drainage within 48 h (2.6% vs 20.5%, P = 0.016; 3.0% vs 13.5%, P = 0.006; 3.4% vs 9.6%, P = 0.021; respectively).
CONCLUSION Biliary drainage within 12 h is beneficial for AC patients with neurological or cardiovascular dysfunction, while complete biliary decompression within 24 h of admission is recommended for treating patients with Grade III AC.
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Affiliation(s)
- Zhao-Qing Lu
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Han-Yu Zhang
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Chen-Fen Su
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yue-Yan Xing
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Guo-Xing Wang
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Chun-Sheng Li
- Emergency and Critical Care Center, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Percutaneous Biliary Neo-anastomosis or Neo-duct Creation Using Radiofrequency Wires. Cardiovasc Intervent Radiol 2022; 45:337-343. [PMID: 35106635 DOI: 10.1007/s00270-022-03059-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/04/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE This study aims to report a minimally invasive, percutaneous technique to cross complete biliary occlusions using a radiofrequency wire to create a biliary-enteric neo-anastomosis or biliary neo-duct. METHODS All patients who underwent attempted creation of a neo-anastomosis/neo-duct using an RF wire were included in the study. Patients with non-malignant, complete and non-traversable biliary occlusion were considered for the creation of a neo-anastomosis (4 patients)/neo-duct (1 patient). RESULTS Five patients (4 females, 1 male) with a mean age of 40 years (range: 10-69 years) were included in this study. Percutaneous bowel access was obtained in three of five patients and a snare was placed in the jejunal loop to serve as a target for RF wire advancement. In two patients, an enteral target was provided using a peroral endoscope in collaboration with gastroenterology. The procedure was technically successful in all cases and no intra-operative complications occurred. Patency of the neo-anastomosis was maintained in all patients, with follow-up ranging from 4 to 11 months. CONCLUSION The RF wire was successfully used to create a biliary neo-anastomosis with a minimally invasive approach for the treatment of non-malignant complete biliary occlusion. This technique offers patients with complete biliary occlusion a safe, effective and durable treatment option which avoids the need for a permanent biliary drain and ultimately results in an improved quality of life.
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Buxbaum J, Qumseya B, Wani S. Toward an evidence-based approach for cholangitis diagnosis. Gastrointest Endosc 2021; 94:297-302.e2. [PMID: 33905719 DOI: 10.1016/j.gie.2021.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/18/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Despite improvements in imaging and laboratory medicine, consensus criteria for the diagnosis of cholangitis are lacking. Although ERCP is an effective treatment for cholangitis, it should be reserved for those patients with a high probability of the diagnosis, given the morbidity associated with the procedure. METHODS A comprehensive literature search of PubMed (from 1898 to present), Web of Science (1900 to July 15, 2019), Embase (1943 to July 15, 2019), and the Cochrane library (1898 to July 15, 2019) was performed to identify studies that reported on diagnostic paradigms and individual diagnostic parameters of cholangitis. This was used to identify domains associated with high probability of cholangitis. RESULTS We identified 23 observational studies (10,252 patients) that evaluated the performance of individual and combined criteria for the diagnosis of cholangitis. Traditional paradigms including Charcot's criteria and Ranson's criteria have inadequate sensitivity, and complexity has limited the implementation of the contemporary Tokyo criteria. Furthermore, controlled studies to validate diagnostic criteria for cholangitis are lacking. Existing literature suggests that 4 criteria, summarized by the acronym BILE, identifies those at high risk of cholangitis: Biliary imaging abnormalities or recent intervention, Inflammatory test abnormalities, Liver test abnormalities, and Exclusion of cholecystitis and acute pancreatitis. CONCLUSIONS There is a need for cholangitis diagnostic criteria that are supported by controlled validation studies, consistent with contemporary clinical values, and amenable to implementation. The BILE criteria are straightforward but require prospective study of their diagnostic performance and ability to avert unnecessary ERCP.
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Affiliation(s)
- James Buxbaum
- Division of Gastroenterology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Bashar Qumseya
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Sachin Wani
- Division of Gastroenteorlogy and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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