Feasibility of endoscopic retrograde cholangiopancreatography-related procedures in hemodialysis patients

Delayed bleeding after endoscopic sphincterotomy in patients receiving anticoagulants

Delayed bleeding after endoscopic sphincterotomy (EST) constitutes a significant adverse event, occurring in ~0.5-5% of patients. The number of patients receiving anticoagulants to prevent cardiovascular and cerebrovascular disease has increased with the aging society worldwide; however, anticoagulants (direct oral anticoagulants [DOACs] and warfarin) are one of the most major risk factors for postprocedure bleeding. This review investigated post-EST bleeding in anticoagulant users, focusing on risk factors, clinical guidelines, pharmacological characteristics, and the future of post-EST bleeding. Several clinical guidelines for antithrombotic drug users have been established to prevent postprocedure bleeding; nevertheless, the risk of bleeding is believed to be several times higher than for nondrug users, regardless of clinical guideline compliance. The major problem in this field is that patients who experience delayed bleeding are often receiving multiple antithrombotic drugs, and no parameters that can accurately monitor the anticoagulant effect of DOACs have been identified. Therefore, identifying patients with a generally high-risk of postprocedure bleeding is crucial. Recently, the plasma level and antifactor Xa activity of factor Xa inhibitors have been investigated in relation to the risk of major bleeding in users. Similar to the prothrombin time-international normalized ratio for warfarin, plasma levels, and antifactor Xa activity may be useful parameters for monitoring the anticoagulant effect and identifying DOAC users at higher risk of postprocedure bleeding, including post-EST bleeding. Future studies should stratify the risk of post-EST delayed bleeding based on a scoring system to prevent this complication.

Outcomes of Endoscopic Retrograde Cholangiopancreatography in End-Stage Renal Disease Patients Undergoing Hemodialysis: A Systematic Review and Pooled Analysis

Background/Aims: The adverse events associated with endoscopic retrograde cholangiopancreatography (ERCP) in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD) have not been sufficiently evaluated. This study aimed to review the morbidity and mortality associated with ERCP in ESRD patients on HD using a systematic review and pooled analysis. Methods: A systematic review and pooled analysis were conducted on studies that evaluated the clinical outcomes of ERCP in patients on HD. Random-effect model meta-analyses with subgroup analyses were conducted. The methodological quality of the included publications was evaluated using the risk of bias assessment tool for nonrandomized studies. The publication bias was assessed. Results: A total of 239 studies were identified, and 12 studies comprising 7921 HD patients were included in the analysis. The pooled estimated frequency of bleeding associated with ERCP in HD patients was 5.8% (460/7921). In the subgroup analysis of seven comparative studies, the ERCP-related bleeding rate was significantly higher in HD patients than in non-HD patients (5.5% (414/7544) vs. 1.5% (6734/456,833), OR 3.84; 95% CI 4.26−25.5; p < 0.001). The pooled frequency of post-ERCP pancreatitis was 8.3%. The pooled frequency of bowel perforation was 0.3%. The pooled estimated mortality associated with ERCP was 7.1% The publication bias was minimal. Conclusion: This pooled analysis showed that ERCP-related morbidity and mortality are higher in HD patients than in non-dialysis patients.

Comparison of Different Endoscopic Methods Used for Managing Choledocholithiasis in Patients with End-Stage Renal Disease Undergoing Hemodialysis

BACKGROUND AND AIM

Endoscopic sphincterotomy (EST), endoscopic papillary balloon dilation (EPBD), and endoscopic sphincterotomy plus balloon dilation (ESBD) are all techniques used to manage choledocholithiasis. We aim to analyze the efficacy and safety of these techniques for treating choledocholithiasis in patients undergoing hemodialysis (HD).

METHODS

We performed a retrospective study of 80 patients with end-stage renal disease (ESRD) on HD who underwent endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis management between August 1st, 2012, and December 31st, 2020, at a medical center in southern Taiwan. These patients were divided into three groups: EST (n = 21), EPBD (n = 28), and ESBD (n = 31). Post-ERCP complications, including pancreatitis, bleeding, cholangitis, and perforation, were reviewed for analysis.

RESULTS

There were no significant among-group differences in the rate of complete stone clearance and hospitalization day after ERCP. Patients in the EST group had a higher post-ERCP complication rate than was the case in the other groups (p = 0.016). ESBD significantly reduced post-ERCP bleeding, compared with that occurring with EST (OR 0.07; 95% CI, 0.01-0.72, p = 0.026). There were no significant among-group differences in the rates of pancreatitis and cholangitis. There were no ERCP-related perforations or deaths in this study.

CONCLUSIONS

EST, EPBD, and ESBD are efficient methods for treating choledocholithiasis in ESRD patients. ESBD was found to lead to a lower risk of bleeding than EST, and the rate of pancreatitis or cholangitis was comparable for EST and EPBD. Our results suggest that ESBD is the best choice of treatment of choledocholithiasis in patients with ESRD undergoing HD.

Safety of Nonagenarians Receiving Therapeutic ERCP, Single Center Experience

(1) Background: The complication rates for nonagenarians receiving therapeutic endoscopic retrograde cholangiopancreatography (ERCP) remain poorly understood. We aimed to determine whether nonagenarians were at an increased risk of ERCP-related complications. (2) Methods: We performed a retrospective study on therapeutic ERCP in nonagenarians from 2011 to 2016 at Taichung Veterans General Hospital. A control group comprising patients aged 65 to 89 years was used to compare demographic data and the outcomes of therapeutic ERCP with the nonagenarians. The risk factors for complications were determined by logistic regression model. (3) Results: There were 35 nonagenarians and 111 patients in the control group. Overall, complication rates were not statistically different between the two groups. However, advanced age was an independent predictor of complications in the multivariate analysis (odds ratio [OR] = 1.06; 95% confidence interval [CI] = 1.01-1.12; p = 0.049). End stage renal disease (ESRD) was another independent predictor of complications (OR = 4.87; 95% CI = 1.11-21.36; p = 0.036). Post-ERCP pancreatitis and bleeding were more common in ESRD patients than patients without ESRD. (4) Conclusions: Although nonagenarians receiving ERCP did not have more complications compared to elderly patients younger than 90 years, advanced age and comorbidity still affect the outcome of therapeutic ERCP in the elderly patients.

Direct oral anticoagulants increase bleeding risk after endoscopic sphincterotomy: a retrospective study

Background

Bleeding can be a serious adverse event of endoscopic sphincterotomy (EST). However, the risk of EST bleeding between direct oral anticoagulant (DOAC) users and those who received no antithrombotic agents has not been clarified. This study analyzed the risk factors for bleeding after EST in patients on DOAC and evaluated the Japan Gastroenterological Endoscopy Society (JGES) guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment.

Methods

We retrospectively analyzed 524 patients treated with EST who received DOAC or no antithrombotic drug from May 2016 to August 2019. We investigated the risk factors for bleeding. DOAC was typically discontinued for ≤ 1-day based on the JGES guideline. Although DOAC therapy recommenced the next morning after EST in principle, the duration of DOAC cessation and heparin replacement were determined by the attending physician based on each patient’s status.

Results

The number of patients on DOAC (DOAC group) and those not on antithrombotic drug (no-drug group) was 42 (8.0%) and 482 (92.0%), respectively. DOAC was discontinued for ≤ 1-day in 17 (40.0%) patients and for > 1-day in 25 (60.0%). Of the 524 patients, 21 (4.0%) had EST bleeding. The bleeding rate was higher in the DOAC group (14.0%) (p = 0.004). Multivariate analysis showed that bleeding occurred more frequently in patients on DOAC (odds ratio [OR] 3.95, 95% confidence interval [CI] 1.37–11.4, p = 0.011), patients with low platelet counts (< 100,000/µl) (OR 6.74, 95% CI 2.1–21.6, p = 0.001), and elderly patients (> 80 years old) (OR 3.36, 95%CI 1.17–9.65, p = 0.024).

Conclusions

DOAC treatment, low platelet count, and old age (> 80 years old) are risk factors for EST bleeding. Although the bleeding incidence increased in patients on DOAC who received antithrombotic therapy according to the JGES guidelines, successful hemostasis was achieved with endoscopy in all cases, and no thrombotic events occurred after cessation of DOAC. Thus, the JGES guidelines are acceptable.

Cerebral Perfusion in Hemodialysis Patients: A Feasibility Study

Background

Patients on hemodialysis (HD) are known to exhibit low values of regional cerebral oxygenation (rSO2) and impaired cognitive functioning. The etiology of both is currently unknown.

Objective

To determine the feasibility of serially monitoring rSO2 in patients initiating HD. In addition, we sought to investigate how rSO2 is related to hemodynamic and dialysis parameters.

Design

Prospective observational study.

Setting

Single-center tertiary academic teaching hospital in Ontario, Canada.

Participants

Six patients initiating HD were enrolled in the study.

Methods

Feasibility was defined as successful study enrollment (>1 patient/month), successful consent rate (>70%), high data capture rates (>90%), and assessment tolerability. Regional cerebral oxygenation monitoring was performed 1 time/wk for the first year of dialysis. A neuropsychological battery was performed 3 times during the study: before dialysis initiation, 3 months, and 1 year after dialysis initiation. The neuropsychological battery included a traditional screening tool: the Repeatable Battery for the Assessment of Neuropsychological Status, and a robot-based assessment: Kinarm.

Results

Our overall consent rate was 33%, and our enrollment rate was 0.4 patients/mo. In total 243 rSO2 sessions were recorded, with a data capture rate of 91.4% (222/243) across the 6 patients. Throughout the study, no adverse interactions were reported. Correlations between rSO2 with hemodynamic and dialysis parameters showed individual patient variability. However, at the individual level, all patients demonstrated positive correlations between mean arterial pressure and rSO2. Patients who had more than 3 liters of fluid showed significant negative correlations with rSO2. Less cognitive impairment was detected after initiating dialysis.

Limitation

This small cohort limits conclusions that can be made between rSO2 and hemodynamic and dialysis parameters.

Conclusions

Prospectively monitoring rSO2 in patients was unfeasible in a single dialysis unit, due to low consent and enrollment rates. However, rSO2 monitoring may provide unique insights into the effects of HD on cerebral oxygenation that should be further investigated.

Trial Registration

Due to the feasibility nature of this study, no trial registration was performed.

Early Covered Self-Expandable Metal Stent Placement Is Effective for Massive Post-endoscopic Sphincterotomy Bleeding

BACKGROUND

Placement of covered self-expandable metallic stent (CSEMS) for post-endoscopic sphincterotomy (ES) bleeding achieves excellent hemostasis results. Although CSEMS placement is typically performed after failure of conventional endoscopic combination therapy, its excellent outcomes may justify earlier placement.

AIMS

We aimed to examine the efficacy of "early" CSEMS placement for massive post-ES bleeding.

METHODS

The medical records of 2750 patients who underwent ES between 2005 and 2019 were reviewed retrospectively, and 61 patients who developed massive post-ES bleeding were enrolled. These patients were divided into those who underwent early CSEMS placement (E-CSEMS group) and those who underwent conventional endoscopic combination therapy (Conventional group). The outcomes of hemostasis procedures were compared between the groups.

RESULTS

The primary success rates of endoscopic hemostasis were 100% (21/21) and 98% (39/40) in the E-CSEMS group and Conventional group, respectively, without significant differences (P = 1.000). However, in the E-CSEMS group, re-bleeding was significantly less frequent (5% vs. 31%; P = 0.023), the median hemostasis procedure time was significantly shorter (14 min vs. 26 min; P < 0.001), and transfusion after initial hemostasis treatment was less commonly required (10% vs. 38%; P = 0.034). Multivariate analyses showed that hemodialysis was associated with a significantly higher re-bleeding rate (P = 0.029), while CSEMS placement was associated with a significantly lower re-bleeding rate (P = 0.039).

CONCLUSIONS

Early CSEMS placement may be effective for improving the clinical outcomes of massive post-ES bleeding by decreasing re-bleeding and the extent of bleeding.

Predictive model of bleeding following endoscopic sphincterotomy for the treatment of choledocholithiasis in hemodialysis patients: A retrospective multicenter study

BACKGROUND AND AIM

Although hemodialysis (HD) is a strong risk factor for postendoscopic sphincterotomy (ES) bleeding, additional risk factors in HD patients remain unclear. There is no model for predicting post-ES bleeding risk in HD patients. Therefore, we conducted a retrospective multicenter study to reveal these risk factors and develop a predictive model of post-ES bleeding in HD patients.

METHODS

We retrospectively reviewed the medical records of HD patients who underwent ES at eight hospitals between January 2006 and December 2016, with post-ES bleeding as the main outcome measure. Univariate analyses were performed to extract possible risk factors for post-ES bleeding. Factors that were clinically important and statistically significant in our univariate analyses were then included in our logistic regression analysis for the development of a multivariate predictive model of post-ES bleeding. This predictive model was visualized using a predictive nomogram.

RESULTS

Post-ES bleeding occurred in 20 (16.3%) of 123 HD patients. Based on clinically important factors and the results of our univariate analyses, platelet count, prothrombin time (international normalized ratio), and HD duration were included in our predictive model of post-ES bleeding. Receiver operating characteristic analysis found that this model had an area under the curve of 0.715 (95% confidence interval, 0.609-0.822). We developed a predictive nomogram based on these results.

CONCLUSIONS

We demonstrated that post-ES bleeding is more common in HD patients than in the general population and succeeded in constructing a predictive model that can effectively identify HD patients at risk of post-ES bleeding.

Comparison of anticoagulants and risk factors for bleeding following endoscopic sphincterotomy among anticoagulant users: Results from a large multicenter retrospective study

BACKGROUND AND AIM

Bleeding is an inevitable and often severe complication after endoscopic sphincterotomy (EST). We aimed to investigate the factors associated with post-EST bleeding in patients treated with anticoagulants.

METHODS

The data of patients who underwent EST at 15 hospitals between July 2015 and June 2017 were extracted. We investigated the incidence of post-EST bleeding and risk factors for bleeding in patients treated with anticoagulants.

RESULTS

One hundred forty-nine patients undergoing EST who met the inclusion criteria were included in this study. The total-EST bleeding (bleeding occurring during or after EST) rate did not differ between the heparin replacement (8.0%, 6/75) and continuation (16.6%, 2/12; P = 0.37) groups of warfarin users. The total-EST-bleeding rate in the heparin replacement group (12.9%, 4/31) was significantly higher than that in the continuation group (0%, 0/31; P = 0.016) in direct oral anticoagulant (DOAC) users. The rate of total-EST bleeding with continuation of DOAC (0%, 0/31) was significantly lower with continuation of warfarin (16.6%, 2/12; P = 0.021). During-EST bleeding (bleeding occurring during EST) (P = 0.0083) and precut (P = 0.033) were significant risk factors for post-EST bleeding in all 149 patients. Heparin replacement was only a significant risk factor for total-EST bleeding (P = 0.033) in DOAC users.

CONCLUSION

Heparin replacement was a significant risk factor for post-EST bleeding in DOAC users; however, there was no significant difference between the bleeding rate of heparin replacement and that of continuation groups in patients taking warfarin. During EST and precut were significant risk factors for post-EST bleeding in all patients treated with anticoagulants.

Feasibility and safety of duodenal covered self-expandable metallic stent fixation: an experimental study

BACKGROUND AND AIMS

Migration of duodenal covered self-expandable metallic stents (C-SEMS) is the main cause of stent dysfunction in patients with malignant gastric outlet obstruction. However, the ideal method to prevent migration has not been clarified. We aimed to evaluate the feasibility and safety of duodenal C-SEMS fixation in this experimental study.

METHODS

We used the over-the-scope clip (OTSC), suture, and clip methods to fix duodenal C-SEMS and evaluated the gripping force of each device and invasion depth based on pathological findings.

RESULTS

The OTSC and suturing systems had a significantly higher mean gripping force compared with the clipping system (OTSC vs. clip: 13.2 vs. 1.0 Newtons [N], P < 0.001; suture vs. clip: 8.5 vs. 1.0 N, P < 0.001). OTSC compression was stronger compared with suturing (OTSC vs. suture: 13.2 vs. 8.5 N, P = 0.006). The submucosal layer, but not the muscle layer, was compressed more widely and deeply by OTSC compared with clips based on pathological findings by hematoxylin and eosin staining.

CONCLUSION

Both OTSC and suturing methods used for duodenal C-SEMS fixation were feasible compared with the clipping method. The pathological evaluation of invasion depth indicated that OTSC may be safe even for preventive use. This study suggested that these methods can be applied clinically for duodenal C-SEMS fixation.

Risk factor of bleeding after endoscopic sphincterotomy in average risk patients

BACKGROUND

For therapeutic endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (ES) is necessary but it can lead to complications such as bleeding. Thus, we investigated the risk factors of post-ES bleeding in average risk patients.

METHODS

We retrospectively reviewed the medical records of patients who had been treated for ERCP between April 2006 and March 2013. The length of the ES incision was defined as minimal (up to proximal hooding fold), medium (between minimal and full length), and full (up to superior margin of sphincter opening). Exclusion criteria were as follows: if performed precut sphincterotomy or balloon dilatation, patients having altered anatomy or anticoagulant medications.

RESULTS

A total of 3620 patients underwent ERCP and 1121 patients who underwent biliary ES were enrolled. Post-ES bleeding occurred in 108 of 1121 patients (9.6%) and mostly minor bleeding (94 patients, 87%). Length of ES was the only risk factor for post-ES bleeding in multivariate analysis. Complete hemostasis was achieved by endoscopic modalities and no serious complication developed after hemostasis.

CONCLUSIONS

In average risk patients, length of ES was independent risk factor for post-ES bleeding and endoscopic hemostasis was safe and effective.

End-stage renal disease is associated with increased post endoscopic retrograde cholangiopancreatography adverse events in hospitalized patients

AIM

To determine if end-stage renal disease (ESRD) is a risk factor for post endoscopic retrograde cholangiopancreatography (ERCP) adverse events (AEs).

METHODS

We performed a retrospective cohort study using the Nationwide Inpatient Sample (NIS) 2011-2013. We identified adult patients who underwent ERCP using the International Classification of Diseases 9th Revision (ICD-9-CM). Included patients were divided into three groups: ESRD, chronic kidney disease (CKD), and control. The primary outcome was post-ERCP AEs including pancreatitis, bleeding, and perforation determined based on specific ICD-9-CM codes. Secondary outcomes were length of hospital stay, in-hospital mortality, and admission cost. AEs and mortality were compared using multivariate logistic regression analysis.

RESULTS

There were 492175 discharges that underwent ERCP during the 3 years. The ESRD and CKD groups contained 7347 and 39403 hospitalizations respectively, whereas the control group had 445424 hospitalizations. Post-ERCP pancreatitis (PEP) was significantly higher in the ESRD group (8.3%) compared to the control group (4.6%) with adjusted odd ratio (aOR) = 1.7 (95%CI: 1.4-2.1, a P < 0.001). ESRD was associated with significantly higher ERCP-related bleeding (5.1%) compared to the control group 1.5% (aOR = 1.86, 95%CI: 1.4-2.4, a P < 0.001). ESRD had increased hospital mortality 7.1% vs 1.15% in the control OR = 6.6 (95%CI: 5.3-8.2, a P < 0.001), longer hospital stay with adjusted mean difference (aMD) = 5.9 d (95%CI: 5.0-6.7 d, a P < 0.001) and higher hospitalization charges aMD = $+82064 (95%CI: $68221-$95906, a P < 0.001).

CONCLUSION

ESRD is a risk factor for post-ERCP AEs and is associated with higher hospital mortality. Careful selection and close monitoring is warranted to improve outcomes.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis in Long-Term Dialysis: A Propensity Score Analysis

BACKGROUND AND AIM

Previous studies evaluating the safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients with end-stage renal disease (ESRD) undergoing hemodialysis reported an increased risk of post-procedural bleeding. We investigated the safety and efficacy of ERCP for the treatment of choledocholithiasis in patients with ESRD undergoing long-term dialysis.

METHODS

A total of 3466 patients who underwent ERCP due to choledocholithiasis between January 2000 and Feb 2018 were reviewed and analyzed retrospectively. Patients were divided into dialysis and non-dialysis group, and propensity score matching was used to minimize selection bias.

RESULTS

Patients of dialysis group (n = 39) and non-dialysis group (n = 78) were compared after propensity score matching. Among 39 patients of dialysis group, hemodialysis was used in 28 (71.8%) patients for renal replacement therapy, while 11 (28.2%) patients received peritoneal dialysis. The median duration of dialysis was 8 years (range 1-24 years). Overall success rate of ERCP was not different between two groups. The overall prevalence of post-procedural complications in dialysis group and non-dialysis group was 28.2 and 15.4%, respectively (p = 0.100). Post-procedural bleeding occurred more frequently in dialysis group than non-dialysis group (23.1 vs 5.1%, p = 0.004). All procedure-related bleeding episodes were successfully controlled using endoscopic management. Prevalence of post-ERCP pancreatitis, infection, and perforation were not significantly different between two groups (p > 0.05).

CONCLUSIONS

Overall success rate of complete ductal clearance was not different between dialysis and non-dialysis groups. The risk of post-procedural bleeding seems to be increased in patients with ESRD undergoing long-term dialysis.

The utility and efficacy of self-expandable metal stents for treating malignant gastric outlet obstructions in patients under best supportive care

PURPOSE

Self-expandable metallic stents (SEMSs) may be used to effectively palliate malignant gastric outlet obstructions (GOOs), but their utility and efficacy in patients under best supportive care (BSC) have not been explored.

METHOD

In this multicenter retrospective study, we reviewed data on patients under BSC who underwent endoscopic SEMS placement to treat malignant GOO without chemotherapy. We evaluated the safety and efficacy of the procedure.

RESULTS

We enrolled a total of 208 patients. SEMS placement was technically successful in 207 (99.5%) and clinically successful in 164 (78.8%). The mean procedure time was 25.6 ± 2.8 min. Stent dysfunction later developed in 30 (14.4%) patients, of whom 90% (27/30) underwent reintervention. The procedure-related mortality rate was 1.44%; all deaths were due to pneumonia. Subgroup analysis by Karnofsky performance status (KPS) revealed that neither technical success, stent dysfunction, reintervention rate, procedure-related pneumonia or death, nor death within 14 days differed between patients with good and poor KPS. However, the clinical success rate and the median survival time were significantly lower and shorter, respectively, in those with poor KPS (p < 0.001).

CONCLUSIONS

Duodenal SEMS placement is an effective palliative treatment for malignant GOO in BSC patients. Although the GOO score did not dramatically improve in patients with poor KPS, the procedure was safe and palliatively feasible. Procedure-related pneumonia was fatal; thus, it is essential to proceed with great caution.

TRIAL REGISTRATION

Clinical trial registration number: UMIN000028367.

Hemodialysis is a strong risk factor for post-endoscopic sphincterotomy bleeding in patients with choledocholithiasis

BACKGROUND AND STUDY AIMS

 Hemodialysis (HD) is considered one of the risk factors for post-endoscopic sphincterotomy (ES) bleeding. Therefore, we conducted a retrospective study to evaluate HD as a risk factor for post-ES bleeding in patients with choledocholithiasis.

PATIENTS AND METHODS

 We used the post-ES bleeding rate as the main outcome measure. To evaluate the influence of HD on the risk of post-ES bleeding, logistic regression and propensity score analyses were conducted. In addition, univariate analysis-based comparisons of various clinical parameters (as secondary outcome measures) were performed between the patients in the HD and non-HD groups that experienced post-ES bleeding.

RESULTS

 A total of 1518 patients were enrolled. In the multivariate analysis, a platelet count of < 50,000, anticoagulant therapy, bleeding during ES, and HD were found to be significantly associated with post-ES bleeding (odds ratio [OR]: 35.30, 95 % confidence interval [CI]: 3.81 - 328.00; OR: 4.39, 95 % CI: 1.53 - 12.60; OR: 4.28, 95 % CI: 2.30 - 7.97; and OR: 13.30, 95 % CI: 5.78 - 30.80, respectively). Propensity score matching created 28 matched pairs. Propensity score analysis showed that the risk difference between the groups was 0.214 (95 % CI: 0.022 - 0.407). In a comparison between the patients in the HD and non-HD groups that suffered post-ES bleeding, it was found that the post-ES bleeding was significantly more severe in the HD group (p = 0.033), and massive blood transfusions and long periods of hospitalization were more frequently required in the HD group (p = 0.008 and p < 0.001, respectively).

CONCLUSION

 HD is an independent risk factor for post-ES bleeding and makes post-ES bleeding more serious.

Covered duodenal self-expandable metal stents prolong biliary stent patency in double stenting: The largest series of bilioduodenal obstruction

BACKGROUND AND AIM

Endoscopic biliary and duodenal stenting (DS; double stenting) is widely accepted as a palliation therapy for malignant bilioduodenal obstruction. The aim of the current study was to investigate the patency and adverse events of duodenal and biliary stents in patients with DS.

METHODS

Patients who underwent DS from April 2004 to March 2017 were analyzed retrospectively with regard to clinical outcomes and predictive factors of recurrent biliary and duodenal obstruction (recurrent biliary obstruction [RBO] and recurrent duodenal obstruction [RDO]).

RESULTS

A total of 109 consecutive patients was enrolled. Technical success of DS was achieved in 108 patients (99.1%). Symptoms due to biliary and duodenal obstruction were improved in 89 patients (81.7%). RBO occurred in 25 patients (22.9%) and RDO in 13 (11.9%). The median times to RBO and RDO from DS were 87 and 76 days, respectively. Placement of a duodenal uncovered self-expandable metal stent (U-SEMS) was significantly associated with RBO in the multivariable analysis (P = 0.007). Time to RBO was significantly longer in the duodenal covered self-expandable metal stent group than in the U-SEMS group (P = 0.003). No predictive factors of RDO were detected, and duodenal stent type was not associated with the time to RDO (P = 0.724).

CONCLUSIONS

Double stenting was safe and effective for malignant bilioduodenal obstruction. Duodenal U-SEMS is a risk factor for RBO. The covered self-expandable metal stent is the preferred type of duodenal SEMS in patients with DS (Clinical trial registration number: UMIN000027606).

Predictors of outcomes in patients undergoing covered and uncovered self-expandable metal stent placement for malignant gastric outlet obstruction: a multicenter study

BACKGROUND AND AIMS

Uncovered self-expandable metal stents (U-SEMSs) and covered self-expandable metal stents (C-SEMSs) are available for palliative therapy for malignant gastric outlet obstruction (GOO). However, clinical differences and indications between the 2 types of SEMSs have not been elucidated.

METHODS

We retrospectively compared 126 patients with U-SEMS and 126 patients with C-SEMSs with regard to clinical outcome and factors predictive of clinical improvement after SEMSs placement.

RESULTS

No significant difference was observed between the U-SEMS and C-SEMS groups with respect to technical success, clinical success, GOO score, or time to stent dysfunction. Stent migration was significantly more frequent in patients with C-SEMSs (U-SEMSs, .79%; C-SEMSs, 8.73%; P = .005). Karnofsky performance status, chemotherapy, peritoneal dissemination, and stent expansion ≤ 30% were associated significantly with poor GOO score improvement in multivariable analyses, but stent type was not (P = .213). In subgroup analyses, insufficient (≤30%) stent expansion was an independent factor in patients with U-SEMSs (P = .041) but not C-SEMSs. In the insufficient stent expansion subgroup, C-SEMSs was associated significantly with superior clinical improvement compared with U-SEMSs (P = .01). Insufficient stent expansion was observed more frequently in patients with GI obstruction because of anastomotic sites or metastatic cancer (44.8% [13/29], P = .001).

CONCLUSIONS

No clinical difference, apart from stent migration, was observed between patients with U-SEMSs and C-SEMSs. GI obstruction because of an anastomotic site or metastatic cancer may be an indication for C-SEMS use to improve oral intake after SEMSs placement.

Clinical features of gallstone impaction at the ampulla of Vater and the effectiveness of endoscopic biliary drainage without papillotomy

BACKGROUND AND STUDY AIMS

Gallstone impaction at the ampulla of Vater is a critical condition, and the standard treatment is endoscopic papillotomy. However, the clinical features remain largely unclear, and some patients are reluctant to undergo papillotomy because of a bleeding tendency. The aim of this study was to clarify the clinical features of gallstone impaction at the ampulla of Vater and to examine the effectiveness of endoscopic biliary drainage without papillotomy.

PATIENTS AND METHODS

We retrospectively examined 30 patients who had undergone endoscopic treatment for gallstone impaction at the ampulla of Vater between 2010 and 2015.

RESULTS

According to the severity classification for acute cholangitis in the Tokyo Guidelines (TG13), the condition was mild in 8 patients, moderate in 14, and severe in only 8 (27 %), despite the stone impaction at the ampulla of Vater. Hyperamylasemia was observed in 18 patients (60 %); computed tomography (CT) revealed clear pancreatitis in 5 cases (17 %). Patients were classified into Group A (13 patients who received biliary drainage with papillotomy) and Group B (17 patients receiving biliary drainage without papillotomy). All patients in Group B had 1 or more types of hemorrhage risk. There were no differences between the 2 groups in the success rate of biliary drainage, the rate of elevated serum amylase the following day, or procedure-related complications. Serum amylase levels decreased the following day in all patients, even in Group B (including the 10 patients with hyperamylasemia and the 3 patients with clear pancreatitis on CT).

CONCLUSIONS

Even with stone impaction at the ampulla of Vater, typical clinical features of cholangitis and pancreatitis are relatively rare. Biliary drainage without papillotomy is acceptable for gallstone impaction at the ampulla of Vater.

Endoscopic Retrograde Cholangiopancreatography in Kidney Transplant Patients: Results From a Single Center

OBJECTIVES

We report the outcomes of endoscopic retrograde cholangiopancreatography procedures performed for diagnostic and therapeutic purposes in patients who had undergone kidney transplant.

MATERIALS AND METHODS

We retrospectively evaluated the records of kidney transplant patients for January 1993 to December 2014. Endoscopic retrograde cholangiopancreatography was carried out using an Olympus JF240 duodenoscope (tip outer diameter 12.6 mm, working channel diameter 3.2 mm). The procedures were performed by Department of Anesthesiology staff while the patients were deeply sedated, given a combination of midazolam plus propofol.

RESULTS

Data from 21 kidney transplant patients (16 men and 5 women; mean age at endoscopic retrograde cholangiopancreatography 42.6 ± 23.4 y) were evaluated. A total of 23 endoscopic retrograde cholangiopancreatography procedures were performed. The indications were choledocholithiasis in 6 patients (28.6%), common bile duct dilatation plus liver enzyme elevations in 4 patients (19%), liver enzyme elevation alone in 4 (19%), biliary necrotizing pancreatitis in 2 (9.6%), and cholangitis in 5 (23.8%). Hepatobiliary ultrasonography findings showed that 3 patients (14.3%) had absence of gallbladder owing to cholecystectomy, 14 (66.7%) had gallstones, 1 (4.7%) had gallstones with cholecystitis findings, and 3 (14.3%) were normal. Endoscopic retrograde cholangiopancreatography findings were normal in 4 patients (19%), showed cholangitis in 2 (9.6%), choledocholithiasis in 10 (47.6%), bile duct wall irregularities in 2 (9.6%), dilated common bile duct in 2 (9.6%), and cholangiocarcinoma in 1 (4.7%). Sphincterotomy was performed in 16 patients. None of the patients who underwent endoscopic retrograde cholangiopancreatography developed any complications, for example, acute pancreatitis, bleeding, duodenal, or bile duct perforation.

CONCLUSIONS

In kidney transplant patients, endoscopic retrograde cholangiopancreatography is safe and able to provide substantial information for managing biliopancreatic diseases.

Risk factors for post-ERCP pancreatitis: a systematic review of clinical trials with a large sample size in the past 10 years

BACKGROUND

Post- endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common and most severe complication associated with diagnostic and therapeutic ERCP. A multivariate analysis of risk factors for PEP is essential for identifying patients at high risk and subsequently choosing other suitable diagnoses.

METHODS

Pertinent publications were identified through systematic searches of MEDLINE, Elsevier, and Springer; we performed a systematic review of 12 clinical studies published in the past ten years, selected out of 451 reviewed articles, in which risk factors for pancreatitis were identified. Seven probable risk factors were evaluated, and outcomes expressed in the case of dichotomous variables, as an odds ratio (OR) (with a 95% confidence interval, 95% CI).

RESULTS

When the risk factors were analyzed, the OR for female gender was 1.40 (95% CI 1.24 to 1.58); the OR for previous PEP was 3.23 (95% CI 2.48 to 4.22); the OR for previous pancreatitis was 2.00 (95% CI 1.72 to 2.33); the OR for endoscopic sphincterotomy was 1.42 (95% CI 1.14 to 1.78); the OR for precut sphincterotomy was 2.11 (95% CI 1.72 to 2.59); the OR for Sphincter of Oddi dysfunction was 4.37 (95% CI 3.75 to 5.09); and the OR for non-prophylactic pancreatic duct stent was 2.10 (95% CI 1.63 to 2.69).

CONCLUSIONS

It appears that female gender, previous PEP, previous pancreatitis, endoscopic sphincterotomy, precut sphincterotomy, Sphincter of Oddi dysfunction, and non-prophylactic pancreatic duct stent are the risk factors for post-ERCP pancreatitis.