Enhancing endoscopic retrograde cholangiopancreatography safety: Predictive insights into gastric retention

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is a vital tool for diagnosing and treating biliary and pancreatic disorders, but its safety and efficacy are marred by preoperative gastric retention. Jia et al retrospectively analyzed 190 patients who underwent ERCP and found that gastrointestinal obstruction, jaundice, opioid use, female sex, and primary diseases were independent predictors and risk factors of preoperative gastric retention. Based on these findings and comprehensive analysis, a proposed predictive model offers clinicians valuable tools to tailor preoperative strategies, improving the procedural safety and efficacy of ERCP. Despite having several limitations, like single-center design and limited generalizability, the study marks a significant advancement in optimizing ERCP outcomes through predictive analytics. Further research with larger populations and prospective designs is warranted to establish these findings.

Key Words: Endoscopic retrograde cholangiopancreatography; Gastric retention; Gastroparesis; Preoperative assessment

Core Tip: This article highlighted the groundbreaking study by Jia et al, which revealed that sex, jaundice, primary disease, opioid use, and gastrointestinal obstruction can exclusively contribute to the occurrence of gastric retention for patients undergoing endoscopic retrograde cholangiopancreatography. Despite several limitations, the study reflects profound clinical implications while suggesting additional research and innovative treatment approaches.

TO THE EDITOR

Endoscopic retrograde cholangiopancreatography (ERCP) is a crucial diagnostic and therapeutic modality widely used to assess and manage biliary and pancreatic disorders. Since its introduction, ERCP has transformed the approach to ascending cholangitis, pancreatitis, choledocholithiasis, and biliary strictures. The use of ERCP in outpatient departments has also expanded dramatically due to its growing popularity and great potential in the surgical field[1]. A study found that in 2016 alone, over 150000 people underwent ERCP for various diseases[2]. By integrating endoscopy and fluoroscopy, ERCP allows for direct visualization and intervention in the biliary and pancreatic ducts, providing the combined benefit of diagnosis and prompt treatment, like stone removal, stent implantation, and tissue biopsy[3].

However, the success and safety of ERCP can be compromised by several factors, one of which is preoperative gastric retention. Gastric retention refers to the abnormal accumulation of gastric contents, leading to the obstruction of the passage of the endoscope through the gastrointestinal (GI) tract, thereby complicating the procedure[4]. This can result in prolonged procedure times, a higher aspiration risk, subpar visibility, and hindered communication with the target ducts. Additionally, it may result in postoperative complications like longer recovery periods, nausea, and vomiting[5]. Thus, it is imperative to address gastric retention and evaluate its risk factors preoperatively to optimize the outcomes of ERCP and ensure patient safety. However, few studies evaluate the various risk factors associated with gastric retention. In this critical context, Jia et al[6] analyzed the factors influencing preoperative gastric retention in ERCP and established a predictive model.

Factors influencing gastric retention

The retrospective study by Jia et al[6] was conducted on 190 individuals who underwent ERCP between January 2020 and February 2024. To ensure the reliability of the result, the study population was split into two groups: A modeling group (n = 152) and a validation group (n = 38). Patients within the modeling group were subdivided into those with preoperative gastric retention (n = 52) and those without it (n = 100). Gastric retention was identified with various clinical findings, including nausea, vomiting with undigested food, dull and colicky abdominal pain, and residual contents observed in the endoscopic visualization. After identifying important predictors of preoperative gastric retention through univariate and multivariate logistic regression analyses, the researchers constructed a predictive model that was rigorously validated using statistical methodologies like calibration curves and receiver operating characteristic analysis.

Jia et al[6] reported that the univariate and multivariate analyses determined five independent preoperative gastric retention predictors, including female sex, primary disease, jaundice, opioid use, and GI obstruction[6]. The probability of developing gastric retention before ERCP was significantly correlated with each of these variables. Moreover, the potential usefulness of the predictive model for these factors in clinical practice was highlighted by its high degree of performance. As reported, the area under the curve for the prediction model was 0.842 in the validation set and 0.901 in the training set, reflecting remarkable accuracy. The fact that the calibrated slope of the model was close to 1 indicated good consistency between the predicted and actual risk of aspiration[6]. Interestingly, Jia et al[6] found that age, body mass index, hypertension, and diabetes were not significantly associated with preoperative gastric retention.

The efforts made by Jia et al[6] in identifying different predicting factors for gastric retention in patients undergoing ERCP are to be congratulated. Implementing univariate and multivariate logistic regression analyses ensured the determination of independent predictors of preoperative gastric retention. This rigorous approach aided in isolating the most substantial factors, providing compact and actionable insights for clinical practice. This thorough analysis strengthened the reliability of the predictive model by ensuring that all pertinent variables were considered. Additionally, the high area under the curve values for the predictive model imply that it has tremendous discriminative ability, making it a reliable tool for predicting preoperative gastric retention. Moreover, including a validation group to confirm the performance of the model increased its clinical applicability.

However, this study had several limitations and shortcomings that should be considered. Firstly, it was a single-center study, which restricts the generalizability of the findings as there are considerable regional and institutional variations in patient demographics, clinical practices, and healthcare settings. Secondly, although Jia et al[6] observed several significant predictors of preoperative gastric retention, it is possible that they missed additional crucial confounding factors that could have affected stomach motility and retention, such as dietary habits, medication adherence, and previous GI surgeries. Thirdly, the study did not evaluate the efficacy of specific preoperative interventions based on the identified predictors. Comprehending the impact of customized interventions, like modifications to opioid consumption or preoperative nutritional support, on outcomes may yield practical recommendations for enhancing patient care. Lastly, the study did not discuss the interesting findings that major factors like age, body mass index, and hypertension were not significantly associated with the increased risk of gastric retention.

The study by Jia et al[6] sheds light on critical factors influencing preoperative gastric retention in patients undergoing ERCP, offering a predictive model with significant clinical implications. Sex-specific variations in the GI anatomy, gastric motility, and hormonal factors may impact GI function differently in males and females. This may account for the finding that female patients are more likely to experience gastric retention[6,7]. Primary diseases of the pancreas and biliary tract, GI obstructions, and jaundice were also found to be significant predictors of gastric retention by Jia et al[6]. This is likely due to the direct impact of these diseases on digestive and hepatic processes, which ultimately result in delayed gastric emptying[8]. Opioids also emerged as a crucial factor due to their well-known side effects on gastrointestinal motility. It is well understood that they can significantly slow digestive processes, leading to prolonged gastric emptying[9]. Jia et al’s model introduced an important tool for pre-procedural risk stratification[6]. Nevertheless, the model could benefit from prospective validation and further refinement, possibly leveraging machine learning algorithms to enhance accuracy. Future research should focus on integrating such tools into pre-ERCP workflows to improve real-time clinical decision-making.

The clinical implications of this study[6] are profound. Due to the close correlation between gastric retention and primary disorders of the biliary system and pancreas, it is crucial to conduct comprehensive preoperative assessments that include an in-depth evaluation of the underlying primary disease, specifically focusing on its impact on gastric motility. High-risk patients identified through the predictive model could benefit from tailored preoperative protocols, such as extended fasting periods or nasogastric decompression, to reduce gastric content volume and improve procedural conditions. Because there is a strong association between jaundice and gastric retention, clinicians should prioritize liver function optimization in jaundiced patients before ERCP. This could entail dietary assistance, biliary drainage techniques, and other focused treatments to enhance digestive function. Furthermore, the link between opioid use and increased gastric retention underscores the need for careful surveillance of opioid therapy and the possible inclusion of prokinetic drugs and integration of opioid stewardship programs, such as dose adjustments or opioid-sparing alternatives, can improve both gastric motility and procedural success. In addition, implementing the predictive model in clinical practice and its incorporation into the electronic medical record systems to automatically flag high-risk patients based on input parameters can allow for real-time clinical decision support and optimization of preoperative strategies.

CONCLUSION

The study by Jia et al[6] highlighted important associations in understanding and predicting preoperative gastric retention in patients undergoing ERCP. By identifying key factors like sex, primary disease, jaundice, opioid use, and GI obstructions, the study offered a comprehensive predictive model with high accuracy. These findings emphasized the significance of targeted preoperative evaluations and interventions adjusted to individual patient risk profiles. The strengths of the study, mainly the thorough statistical analysis and practical clinical implications, make it a valuable tool for improving patient outcomes for future clinical care. However, addressing the limitations through larger studies with a prospective, multicenter design will be essential for validating the generalizability of the findings. Overall, the predictive model proposed in this study holds significant promise for enhancing preoperative care, reducing perioperative complications and increasing the success of ERCP procedures.