Synergistic effect of independent risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis: a multicenter retrospective study in Japan

Background/Aims

This study aimed to examine the synergistic effect of independent risk factors on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

Methods

This multicenter retrospective study included 1,273 patients with native papillae who underwent ERCP for bile dust stones in Japan. Independent PEP risk factors were identified using univariate and multivariate analyses. Significant risk factors for PEP in the multivariate analysis were included in the final analysis to examine the synergistic effect of independent risk factors for PEP.

Results

PEP occurred in 45 of 1,273 patients (3.5%). Three factors including difficult cannulation ≥10 minutes, pancreatic injection, and normal serum bilirubin level were included in the final analysis. The incidences of PEP in patients with zero, one, two, and three factors were 0.5% (2/388), 1.9% (9/465), 6.0% (17/285), and 12.6% (17/135), respectively. With increasing risk factors for PEP, the incidence of PEP significantly increased (1 factor vs. 2 factors, p=0.006; 2 factors vs. 3 factors, p=0.033).

Conclusions

As the number of risk factors for PEP increases, the risk of PEP may not be additive; however, it may multiply. Thus, aggressive prophylaxis for PEP is strongly recommended in patients with multiple risk factors.

Comparison of Outcomes between a Basket Catheter and a Balloon Catheter for Endoscopic Common Bile Duct Stone Removal

INTRODUCTION

Evidence for the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) between a basket catheter and a balloon catheter for endoscopic common bile duct stone (CBDS) removal is lacking. This study aimed to compare ERCP outcomes using a basket catheter and a balloon catheter for endoscopic CBDS removal.

METHODS

This multicenter retrospective study included 904 consecutive patients with native papilla who underwent endoscopic stone removal for CBDS ≤10 mm using a basket catheter and/or a balloon catheter at three institutions in Japan. ERCP outcomes between the basket and balloon groups were compared using inverse probability of treatment weighting (IPTW) method.

RESULTS

ERCP-related adverse events occurred in 6.5% (29/449) and 7.7% (35/455) of patients in the basket and balloon groups, respectively (IPTW-adjusted p = 0.52). The incidences of post-ERCP pancreatitis, cholangitis, and perforation were similar in the basket and balloon groups (3.8% vs. 2.9%, 1.3% vs. 0.9%, and 0.7% vs. 0.7%, respectively). However, bleeding incidences were significantly higher in the balloon group than in the basket group (3.3% vs. 0.7%, IPTW-adjusted p = 0.012). Successful complete stone removal at one ERCP session using a single catheter was achieved in 17.8% (80/449) in the basket group and in 81.3% (370/455) in the balloon group (IPTW-adjusted p < 0.001).

DISCUSSION

A balloon catheter is more likely to complete stone extraction for CBDS ≤10 mm with a single catheter at one endoscopic stone removal session. However, the risk for post-ERCP bleeding is higher in the balloon group than in the basket group.

Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis after Conservative Treatment for Symptomatic Bile Duct Stones

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) for asymptomatic common bile duct stones (CBDS) has been associated with an increased risk of post-ERCP pancreatitis (PEP). Patients with asymptomatic CBDS at the time of ERCP include those with incidentally discovered CBDS (group A) and previously symptomatic patients with CBDS who became asymptomatic after conservative treatment for symptomatic CBDS, including obstructive jaundice or acute cholangitis (group B). In this study, we aimed to examine PEP risk in group B by comparing PEP risks between groups A, B, and currently symptomatic patients (group C).

Methods

In this multicenter retrospective study, we examined 77 patients in group A, 41 patients in group B, and 1225 patients in group C who had native papillae. PEP incidence rates between asymptomatic patients at the time of ERCP (groups A and B) and symptomatic patients (group C) were compared using one-to-one propensity score matching. Bonferroni's correction analysis was also performed to compare PEP incidence rates among the three groups.

Results

As per our findings, PEP incidence rate in propensity score-matched groups A and B was significantly higher than that of propensity score-matched group C (13.2% [15/114] versus 4.4% [5/114], respectively, P = 0.033). In groups A and B, PEP incidence rates were 11.7% (9/77) and 14.6% (6/41), respectively. PEP risk in group B was similar to that in group A (P = 1.0). PEP incidence in group B was significantly higher than PEP incidence in group C (14.6% (6/41)) vs. 2.9% (35/1225)) (P = 0.005)).

Conclusions

ERCP for previously symptomatic patients with CBDS who became asymptomatic after conservative treatment for symptomatic CBDS may increase the risk of PEP compared with ERCP for currently symptomatic patients. Thus, ERCP should be performed before patients become asymptomatic using conservative treatments if patients can tolerate ERCP procedures.

Unnecessary endoscopic retrograde cholangiopancreatography associated with the spontaneous passage of common bile duct stones into the duodenum: a multicenter retrospective study

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.

Low Detection Rates of Bile Duct Stones During Endoscopic Treatment for Highly Suspected Bile Duct Stones with No Imaging Evidence of Stones

BACKGROUND

The revised American Society for Gastrointestinal Endoscopy (ASGE) guideline 2019 provides the high-risk criteria for suspected common bile duct stones (CBDSs).

AIMS

To evaluate CBDS detection rates during endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients with suspected CBDSs based on the ASGE guideline 2019.

METHODS

This multicenter retrospective study included 1100 consecutive patients who underwent ERCP for suspected CBDSs with any high-risk criteria based on the revised ASGE guideline 2019: Criterion 1, CBDSs on imaging; Criterion 2, clinical ascending cholangitis; and Criterion 3, total bilirubin exceeding 4 mg/dL and dilated common bile duct on imaging. We compared CBDS detection rates during ERCP based on individual and combined high-risk criteria.

RESULTS

The CBDS detection rates of patients who met any of the criteria, only Criterion 1, and Criteria 2 or 3 were 86.0% (946/1100), 93.4% (113/121), and 50.0% (106/212), respectively. In patients who met Criteria 1 and 2, 1 and 3, 2 and 3, and all criteria, CBDSs were confirmed during ERCP in 95.1% (490/515), 96.2% (25/26), 55.3% (26/47), and 98.4% (186/189), respectively. The CBDS detection rate during ERCP of patients with at least Criterion 1 significantly exceeded that of patients without at least Criterion 1 [95.7% (814/851) vs. 51.0% (132/259), respectively, P < 0.001].

CONCLUSIONS

Patients with CBDS visualization on imaging have very high CBDS detection rates during ERCP. However, performing ERCP on patients with only clinical predictors, such as cholangitis and dilated CBD with total bilirubin exceeding 4 mg/dL, often results in unnecessary ERCP.

Endoscopic retrograde cholangiopancreatography for bile duct stones in patients with a performance status score of 3 or 4

BACKGROUND

As the aging population grows worldwide, the rates of endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct stones (CBDS) in older patients with a poor performance status (PS) have been increasing. However, the data on the safety and efficacy of ERCP for CBDS in patients with a PS score of 3 or 4 are lacking, with only a few studies having investigated this issue among patients with poor PS.

AIM

To examine the safety and efficacy of ERCP for CBDS in patients with a PS score of 3 or 4.

METHODS

This study utilized a retrospective multi-centered design of three institutions in Japan for 8 years to identify a total of 1343 patients with CBDS having native papillae who underwent therapeutic ERCP. As a result, 1113 patients with a PS 0-2 and 230 patients with a PS 3-4 were included. One-to-one propensity-score matching was performed to compare the safety and efficacy of ERCP for CBDS between patients with a PS 0-2 and those with a PS 3-4.

RESULTS

The overall ERCP-related complication rates in all patients and propensity score-matched patients with a PS 0-2 and 3-4 were 9.0% (100/1113) and 7.0% (16/230; P = 0.37), and 4.6% (9/196) and 6.6% (13/196; P = 0.51), respectively. In the propensity score-matched patients, complications were significantly more severe in the group with a PS 3-4 than in the group with a PS 0-2 group (P = 0.042). Risk factors for complications were indications of ERCP and absence of antibiotics in the multivariate analysis. Therapeutic success rates, including complete CBDS removal and permanent biliary stent placement, in propensity score-matched patients with a PS 0-2 and 3-4 were 97.4% (191/196) and 97.4% (191/196), respectively (P = 1.0).

CONCLUSION

ERCP for CBDS can be effectively performed in patients with a PS 3 or 4. Nevertheless, the indication for ERCP in such patients should be carefully considered with prophylactic antibiotics.

Increased post-endoscopic retrograde cholangiopancreatography pancreatitis for choledocholithiasis without acute cholangitis

BACKGROUND AND AIM

Choledocholithiasis is the most common indication for endoscopic retrograde cholangiopancreatography (ERCP). Identifying risk factors for post-ERCP pancreatitis (PEP) is important for reducing the risk of developing PEP after common bile duct (CBD) stone removal. However, studies examining the risk factors for PEP for CBD stones are scarce. The aim of this study was to examine whether the presence or absence of acute cholangitis is a clinical risk factor for PEP in patients with CBD stones.

METHODS

In this multicenter retrospective study, 1539 patients with naïve papillae were divided into patients without and with acute cholangitis. We compared the incidence of PEP between the two groups using one-to-one propensity score matching to adjust for the potential confounding factors of PEP.

RESULTS

In the entire cohort, the rates of PEP in patients without and with acute cholangitis were 9.6% (52/542) and 1.8% (18/997), respectively (P < 0.001, odds ratio = 5.8). In the propensity-matched cohort, the rates of PEP in patients without and with acute cholangitis were 8.3% (27/326) and 2.5% (8/326), respectively (P = 0.002, odds ratio = 3.6). The rate of PEP was significantly higher in patients without acute cholangitis than in those with acute cholangitis after adjusting for the confounding factors of PEP.

CONCLUSIONS

The absence of acute cholangitis may be an important clinical risk factor for PEP due to CBD stone removal. In patients without acute cholangitis, endoscopists should explain the specific risk of PEP carefully and actively implement prophylaxis against PEP.

Disease-Based Risk Stratification of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis for Common Bile Duct Stones

BACKGROUND

Risk stratification of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) for common bile duct (CBD) stones is needed for clinicians to adequately explain to patients regarding the risk of PEP in advance of ERCP and to proactively take preventive measures in high-risk patients.

AIMS

To stratify the risk of PEP for CBD stones based on CBD-related diseases.

METHODS

A total of 1551 patients with naïve papilla who underwent ERCP for CBD stones were divided into three groups: Group A: asymptomatic CBD stones, Group B: obstructive jaundice and elevated liver test values without cholangitis, and Group C: mild, moderate, and severe cholangitis. We stratified the risk of PEP by comparing its incidence among the three groups using the Holm's method. Furthermore, we performed one-to-one propensity score matching between Group A and the other groups to examine the risk of PEP in Group A.

RESULTS

The incidence rates in Groups A, B, and C were 13.7%, 7.3%, and 1.8%, respectively. The Holm-adjusted p values between Groups A and B, Groups A and C, and Groups B and C were 0.023, < 0.001, and < 0.001, respectively. Propensity score matching revealed that the incidence of PEP was significantly more in Group A than in the other groups (13.3% vs. 1.5%; p < 0.001).

CONCLUSIONS

The risk of PEP for CBD stones was stratified into low risk (Group C), intermediate risk (Group B), and high risk (Group A). This simple disease-based risk stratification may be useful to predict the risk of PEP in advance of ERCP.

Endoscopic retrograde cholangiopancreatography-related complications for bile duct stones in asymptomatic and symptomatic patients

Background and Aim

Current guidelines recommend the removal of common bile duct (CBD) stones by endoscopic retrograde cholangiopancreatography (ERCP) for both asymptomatic and symptomatic patients. We conducted this study because of the limited research comparing the risks of ERCP-related complications between these two groups.

Methods

This retrospective study involved 1491 patients with native major duodenal papilla diagnosed with choledocholithiasis at three institutions in Japan. The rates of ERCP-related complications, including post-ERCP pancreatitis (PEP), cholangitis, bleeding, and perforation, were compared using one-to-one propensity score matching between the asymptomatic and symptomatic patients.

Results

Complications were observed in 112 (7.5%) of the 1491 patients (asymptomatic group: 31/172 [18.0%] vs symptomatic group: 81/1319 [6.1%], P < 0.001). The rate of severe complications was higher in the asymptomatic group than that in the symptomatic group (asymptomatic group: 5/31 [16.1%] vs symptomatic group: 3/81 [3.7%], P = 0.036). In the propensity-matched asymptomatic and symptomatic patients, the incidences of PEP, cholangitis, bleeding, and perforation were 18/143 (12.6%) vs 4/143 (2.8%) (P = 0.003); 4/107 (3.7%) vs 6/107 (5.6%) (P = 0.75); 1/140 (0.7%) vs 3/140 (2.1%) (P = 0.62); and 2/140 (1.4%) vs 2/140 (1.4%) (P = 1.0).

Conclusions

ERCP for asymptomatic patients with CBD stones is associated with a higher risk of overall and severe complications than that for symptomatic patients with CBD stones; the overall rate is influenced by the high incidence of PEP in the asymptomatic group. Endoscopists should explain the risk of ERCP-related complications for asymptomatic patients before performing the procedure.

Factors Predicting Difficult Biliary Cannulation during Endoscopic Retrograde Cholangiopancreatography for Common Bile Duct Stones

Background/Aims

Difficult biliary cannulation is an important risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Therefore, this study aimed to identify the factors that predict difficult cannulation for common bile duct stones (CBDS) to reduce the risk for PEP.

Methods

This multicenter retrospective study included 1,406 consecutive patients with native papillae who underwent ERCP for CBDS. Factors predicting difficult cannulation for CBDS were identified using univariate and multivariate analyses.

Results

Univariate analysis showed that six factors significantly predicted difficult cannulation: ERCP performed by non-expert endoscopists, low-volume center, absence of acute cholangitis, normal serum bilirubin, intradiverticular papilla, and type of major duodenal papilla. Multivariate analysis identified ERCP performed by non-expert endoscopists (odds ratio [OR], 2.5; p<0.001), low-volume center (OR, 1.6; p<0.001), intradiverticular papilla (OR, 1.3; p=0.007), normal serum bilirubin (OR, 1.3; p=0.038), and absence of acute cholangitis (OR, 1.3; p=0.049) as factors significantly predicting difficult cannulation for CBDS.

Conclusions

Initial cannulation by an experienced endoscopist, early rescue cannulation, or early takeover by an experienced endoscopist should be considered when performing ERCP for CBDS in the presence of factors predicting difficult cannulation.

Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones

Current guidelines for treating asymptomatic common bile duct stones (CBDS) recommend stone removal, with endoscopic retrograde cholangiopancreatography (ERCP) being the first treatment choice. When deciding on ERCP treatment for asymptomatic CBDS, the risk of ERCP-related complications and outcome of natural history of asymptomatic CBDS should be compared. The incidence rate of ERCP-related complications, particularly of post-ERCP pancreatitis for asymptomatic CBDS, was reportedly higher than that of symptomatic CBDS, increasing the risk of ERCP-related complications for asymptomatic CBDS compared with that previously reported for biliopancreatic diseases. Although studies have reported short- to middle-term outcomes of natural history of asymptomatic CBDS, its long-term natural history is not well known. Till date, there are no prospective studies that determined whether ERCP has a better outcome than no treatment in patients with asymptomatic CBDS or not. No randomized controlled trial has evaluated the risk of early and late ERCP-related complications vs the risk of biliary complications in the wait-and-see approach, suggesting that a change is needed in our perspective on endoscopic treatment for asymptomatic CBDS. Further studies examining long-term complication risks of ERCP and wait-and-see groups for asymptomatic CBDS are warranted to discuss whether routine endoscopic treatment for asymptomatic CBDS is justified or not.

Post-endoscopic retrograde cholangiopancreatography pancreatitis in single-stage endoscopic common bile duct stone removal

Background and Aims

Papillary treatment, such as endoscopic sphincterotomy or endoscopic papillary balloon dilation, and subsequent single-stage endoscopic stone removal are often performed for choledocholithiasis; however, the incidence of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) is unclear. This study aimed to compare the overall incidence of PEP between single- and two-stage stone removal groups and the incidence of PEP between these two groups based on cannulation time.

Methods

We included 897 patients with native papilla who underwent papillary treatment and stone removal for choledocholithiasis with no inflammation or mild-to-moderate acute cholangitis at three institutions between April 2012 and March 2018 in Japan. We performed a propensity-matched analysis and regression adjustment by propensity score to adjust for potential confounding factors.

Results

In the propensity-matched analysis with 234 pairs, there was no significant difference in the overall incidence of PEP between single- and two-stage stone removal procedures (15/234, 6.4% vs 6/234, 2.6%, P = 0.072, respectively). Although single-stage stone removal after a cannulation time of ≤15 min was not a significant risk factor of PEP, the procedure after a cannulation time of >15 min was a significant risk factor of PEP as estimated by regression adjustment by propensity score (P = 0.014, 95% CI = 1.4-19.4, odds ratio = 5.2).

Conclusions

Single-stage endoscopic stone removal after a long cannulation time of >15 min increased the incidence of PEP compared with the two-stage stone removal procedure. Thus, single-stage stone removal should be performed in patients with a cannulation time ≤ 15 min.

Safety and Efficacy of Endoscopic Removal of Common Bile Duct Stones in Elderly Patients ≥90 Years of Age

Objective We examined the safety and efficacy of endoscopic stone removal for choledocholithiasis in elderly patients ≥90 years of age with native papilla and compared the outcomes with those in patients 75-89 years of age. Methods This multicenter retrospective study included 569 patients 75-89 years of age and 126 patients ≥90 years of age who had native papilla and underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis at 3 institutions in Japan between April 2012 and March 2018. The main outcomes assessed were the incidence of post-ERCP complications during hospitalization and outcomes of ERCP in patients ≥90 years of age. Results Biliary cannulation and subsequent endoscopic sphincterotomy, endoscopic balloon dilation, and endoscopic large balloon dilation were successful in 97.7% of patients 75-89 years of age and in 98.4% of patients ≥90 years of age. There was no significant difference in the incidence of post-ERCP complications between patients 75-89 years of age and those ≥90 years of age (7.7% vs. 9.5%, respectively; p=0.47). Although the rate of use of mechanical lithotripter was not significantly different, the rate of complete stone removal in patients ≥90 years of age was lower than that in patients 75-89 years of age (81.0% vs. 94.9%, respectively; p<0.001). In all cases with incomplete stone removal in both groups, permanent biliary stent placement was successful. Conclusion ERCP for choledocholithiasis in elderly patients ≥90 years of age is a safe and effective procedure; however, endoscopists should select appropriate strategies after considering each patient's medical condition and background.

Post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with asymptomatic common bile duct stones

BACKGROUND AND AIM

For asymptomatic common bile duct (CBD) stones, removal by endoscopic retrograde cholangiopancreatography (ERCP) is recommended in available guidelines. However, few studies have reported the risk of post-ERCP pancreatitis (PEP), which is the most common and serious ERCP-related complication for asymptomatic CBD stones. We performed a propensity score matching analysis to examine the risk of PEP in therapeutic ERCP for asymptomatic CBD stones.

METHODS

Information from medical databases of three institutions in Japan was collected over 6 years to identify 1113 patients with native papilla who underwent therapeutic ERCP for choledocholithiasis (excluding biliary pancreatitis). We compared the risk of PEP between asymptomatic and symptomatic groups by performing one-to-one propensity score matching.

RESULTS

PEP was present in 52 (4.7%) of the 1113 patients overall. Of the 949 symptomatic patients, 28 (3.0%) had PEP, and of the 164 asymptomatic patients, 24 (14.6%) had PEP. The incidence of PEP was significantly higher in the asymptomatic group than in the symptomatic group (3.0% vs 14.6%; P < 0.001, odds ratio = 5.6). Of the 158 propensity score-matched symptomatic patients, five (3.2%) had PEP. In contrast, of the 158 propensity score-matched asymptomatic patients, 24 (15.2%) had PEP. Propensity score matching analysis revealed that the risk of PEP increased significantly in the asymptomatic group compared with the symptomatic group (3.2% vs 15.2%; P < 0.001, odds ratio = 5.5).

CONCLUSIONS

ERCP for asymptomatic CBD stones had a high risk of PEP. Endoscopists should explain in detail the risk of PEP to patients, especially those with asymptomatic CBD stones.

The Incidence of Complications in Single-stage Endoscopic Stone Removal for Patients with Common Bile Duct Stones: A Propensity Score Analysis

Objective Single-stage endoscopic stone removal for choledocholithiasis is an advantageous approach because it is associated with a shorter hospital stay; however, few studies have reported the incidence of complications related to this procedure in detail. The aim of this study was to examine the incidence of complications and efficacy of this procedure. Methods This retrospective study investigated the incidence of complications in 345 patients with naive papilla who underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis at three institutions between April 2014 and March 2016 by a propensity score analysis. The efficacy of single-stage endoscopic stone removal was assessed based on a hospital stay of within 7 days and the number of ERCP attempts. Results Among 114 patients who underwent single-stage endoscopic stone removal, 15 patients (13.2%) experienced complications. Among the remaining 231 patients in the two-stage endoscopic stone removal group, complications were observed in 17 patients (7.4%). The propensity score analysis, which was adjusted for confounding factors, revealed that single-stage endoscopic stone removal was not a significant risk factor for complications (p=0.52). In patients in whom >10 min was required for deep cannulation, single-stage endoscopic stone removal was not a significant risk factor for complications in the propensity score analysis (p=0.37). In the single-stage group, the proportion of patients with a hospital stay of within 7 days was significantly higher and the number of ERCP attempts was significantly lower in comparison to the two-stage group (p <0.0001 and <0.0001, respectively). Conclusion Single-stage endoscopic stone removal did not increase the incidence of complications associated with ERCP and was effective for reducing the hospital stay and the number of ERCP attempts.

Increased risk and severity of ERCP-related complications associated with asymptomatic common bile duct stones

BACKGROUND AND STUDY AIMS

 Endoscopic removal of asymptomatic common bile duct stones (CBDS) is generally recommended. Although many reports have described the risk of complications in endoscopic retrograde cholangiopancreatography (ERCP), no studies have addressed this problem in the context of asymptomatic CBDS. This study examines the risk of complications arising in ERCP for asymptomatic CBDS.

PATIENTS AND METHODS

 This retrospective study included 425 patients with naive papilla who underwent therapeutic ERCP for choledocholithiasis at 2 institutions in Japan for 2 years. The risk of complications was examined in patients who were divided into the asymptomatic and symptomatic CBDS groups. We used propensity score analysis to adjust for confounding effects.

RESULTS

 Complications were observed in 32 (7.5 %) of the 425 patients. Of the 358 patients with symptomatic CBDS, 14 patients (3.9 %) had complications. In contrast, of the 67 patients with asymptomatic CBDS, 18 patients (26.9 %) had complications. Propensity score analysis revealed that asymptomatic CBDS was a significant risk factor, with a significantly higher incidence of complications compared with symptomatic CBDS (odds ratio, 5.3). Moderate to severe complications were observed in 15 of 18 patients (83.3 %) in the asymptomatic CBDS group, with significantly more moderate to severe complications than those in the symptomatic CBDS (odds ratio, 6.7).

CONCLUSIONS

 Asymptomatic CBDS carried a high risk of ERCP-related complications, and these were often more severe. In asymptomatic CBDS, endoscopic treatment should be carefully performed after considering the patient's background, and detailed explanation of its possible complications should be given to patients in advance.

Magnetic circular dichroism of 3d5/2 --> 2p3/2 resonant inelastic X-ray scattering at the Ho L(III)-edge in Ho3Fe5O12

Magnetic Circular Dichroism (MCD) of Resonant Inelastic X-ray Scattering (RIXS) of 3d(5/2) --> 2p(3/2) decay (Ho Lalpha1) was measured at the Ho L(III)-edge in Ho3Fe5O12. The MCD-RIXS, in which the intermediate state has the 2p4f(n+1) configuration due to the quadrupolar transition of 2p --> 4f, was also observed at the pre-edge region of the Ho L(III)-edge. The obvious superposition of two peaks, which comes from the high-energy off-resonant Raman scattering and the fluorescence, could be found in both the RIXS and the MCD-RIXS when the energy of the incoming X-ray was 7eV higher than the white line. The dependence of the integration of the MCD-RIXS spectra on the incident x-ray energy could roughly reproduce the MCD of X-ray absorption spectra (XAS).

[Prognostic factors in unresectable lung cancer]

Seventy-seven prognostic factors influencing survival time in patients with unresectable lung cancer treated from 1964 to 1983 at Aichi Cancer Center Hospital were analyzed using univariate analysis by log rank test and multivariate analysis by proportional hazard model of Cox. Statistical significance using univariate analysis was identified in 19 factors in small cell lung cancer patients, and in 40 factors in non-small cell lung cancer patients. The string prognostic factors determined by multivariate analysis were, in the order of importance, serum LDH level, chest pain, peripheral lymphocyte count, bone marrow metastasis, brain metastasis, age, and performance status in small cell lung cancer patients. These 7 factors had a p value of less than 0.01. On the other hand, they were the number of metastatic sites, performance status, serum albumin level, serum LDH level, sex, BUN level, N category according to TNM staging system in non-small cell lung cancer patients, with a p value of less than 0.001. The most important prognostic factors were serum LDH level in small cell lung cancer, and the number of metastatic sites and performance status in non-small cell lung cancer. A metastasis to bone marrow or brain was a more important prognostic factor than overall M category in small cell lung cancer patients, and the number of metastatic sites rather than clinical stage classification or TNM staging system in non-small cell lung cancer patients with respect to staging system. Accurate evaluation of the treatment results in unresectable lung cancer patients must take the strong prognostic factors into account.

[Cyclic alternating combination chemotherapy of small cell carcinoma of the lung]

Twenty-six consecutive previously untreated patients with small cell carcinoma of the lung were treated with cyclic alternating combination chemotherapy. COAM consists of cyclophosphamide 140 mg/m2 i.v. day 1 through 5, vincristine 1.3 mg/m2 i.v. day 1 and 15, ACNU 50 mg/m2 i.v. day 1, methotrexate 7 mg/m2 i.v. day 1 through 5 repeated at 4 week intervals. VAP consists of VP-16 100 mg/m2 p.o. day 1 through 5, adriamycin 30 mg/m2 i.v. day 1, procarbazine 100 mg/m2 p.o. day 1 through 14 repeated at 4 week intervals. The order of alternating course was determined by the time of entry into the study. There were 12 complete and partial responses (86%) among 14 patients treated with COAM-VAP including 6 complete responses (43%), whereas there were 12 responses (100%) including 4 complete responses (33%) among 12 patients treated with VAP-COAM. There was no significant difference between patients receiving COAM-VAP and VAP-COAM with respect to response, duration of response, and survival. Overall median survival was 9.8 months. There was no significant difference between patients with and without distant metastasis with respect to response, duration of response and survival. Two patients were alive at 24 months. The addition of second combination chemotherapy did not increase the response rate. Most patients had mild or moderate leukopenia. Four patients developed interstitial pneumonia.

[Current status in the treatment of inoperable non-small cell lung cancer (NSCLC)]

Advances in the treatment of inoperable non-small cell lung cancer (NSCLC) have been falling behind the recent results obtained for small cell lung cancer (SCLC) which had been considered the more malignant type with the shortest survival time. Recently, however, with the introduction of cisplatin, the results of combination chemotherapy for NSCLC have shown a degree of advancement so that an average response rate of 40% and a median survival time (MST) of 8-10 months can be obtained. Our method of combination chemotherapy, PPM (cisplatin, peplomycin, mitomycin C), resulted in an overall response rate of 44% (40% squamous, 29% adeno, 64% large) and an MST of more than 23.3 months in responders. With PFM (cisplatin, 5FU, mitomycin C), response rate was 35% and an MST of 18.7 months was obtained for adenocarcinoma responders. It can therefore be said that we have achieved a new degree of success in the treatment in NSCLC.

Comparison of clinico-epidemiological features of lung cancer patients with and without a history of smoking

In order to study the characteristics of lung cancer in smokers and nonsmokers, clinico-epidemiological features of 943 lung cancer patients treated in the Aichi Cancer Center Hospital from 1964-77 were analyzed according to their smoking histories. About 70% of both male and female patients who smoked fell in Group I (squamous cell, small cell and large cell carcinomas), while of those who did not smoke, 50% of the male and 36% of the female patients fell in Group I. The mean age of the patients who smoked was about 60 yr and that of the nonsmokers was 55 yr in both men and women. It was estimated that about 70% of the Group I tumors originated from main, segmental or subsegmental bronchi, but half of the Group II tumors (adenocarcinoma) originated from peripheral bronchi in both smokers and nonsmokers. One-third of the tumors were seen in the apical and subapical segments of the upper lobes regardless of the smoking history. There was no difference between the survival rates for the patients with and without a history of smoking.

[Randomized controlled study of OK-432 in the treatment of cancerous pleurisy]

A randomized controlled study was performed to evaluate the efficacy of intrapleural and systemic administration of OK-432, streptococcus preparation, in patients with cancerous pleurisy. A total of 53 patients were accessed to the study: 29 patients for the OK-432 group and 24 patients for the control group. Intrapleural instillation of 50 mg of adriamycin and a combination chemotherapy of MFC (mitomycin C 0.08 mg/kg, 5-FU 10 mg/kg, ara-C 0.8 mg/kg iv, weekly) were administered in both groups. In the OK-432 group intrapleural instillation of 2 units of OK-432 was administered daily until disappearance of pleural effusion; thereafter, 2 to 5 units of OK-432 were administered intradermally every other day. Patients with stage III in the OK-432 group survived significantly longer than those in the control group (P less than 0.05), but there was no significance between in patients with stage IV of both treatment groups. Also patients with PPD negative skin reaction at the time of beginning of treatment in the OK-432 group survived significantly longer than those in the control group (P less than 0.001), but there was no significance between both treatment groups in patients with PPD positive skin reaction at the time of beginning of treatment. Eighteen (62%) of 29 patients treated with OK-432 had a fever, but well tolerated.

[Chemotherapy for metastatic lung cancer]

The effects of chemotherapy for lung metastasis in 284 cancer patients using various anti-tumor drugs, including classic ones and modern active agents for the past 18 years, were presented. Lung metastasis for lung cancer was excluded. The response was achieved in cervical carcinoma of the uterus (17/62, 27%), endometrial carcinoma of the uterus (1/7, 14%), colorectal cancer (6/39, 15%), breast cancer (5/28, 18%) and stomach cancer (4/28, 14%). A high response was achieved in myosarcoma (5/12, 42%), testicular cancer (5/11, 45%) and also in ovarian cancer (3/10, 30%). Though there were few cases, a high response was achieved in malignant melanoma (2/3), choriocarcinoma (2/4) and esophageal cancer (1/3). In total patients the response rate was 20%. In these cases a complete response was achieved in 4 cervical cancers; one testicular cancer, ovarian cancer, esophageal cancer and renal cancer, respectively. However, the effect was temporary and no longterm survivor was observed except for one case of renal cancer treated continuously with interferon (3 X 10(6) units daily) and showing complete remission after 7 months of therapy. The effect of chemotherapy for lung metastasis was compared between nodular metastasis (NM) and lymphagiosis carcinomatosa (LC). In cervical carcinoma of the uterus, the response rate in NM (39%) was higher than in LC (11%). However, no difference was observed in breast cancer (NM 15%, LC 13%) nor in stomach cancer (NM 13%, LC 18%).

[Complement components, whole complement activity, and circulating immune complexes in neoplastic diseases]

Serum levels of complement components(cc), whole complement activity (CH 50), and circulating immune complexes (IC) were measured in 41 patients with neoplastic diseases. The level of cc was higher than in healthy controls; the levels of C1q, C1INA, C4, C3c, C3ACT, C5, and C9 were statistically higher. In patients with lung cancer, the levels of cc were correlated with the clinical stage as well as the performance status. Both the IC serum level and the incidence of high serum IC levels in lung cancer were higher in stage III and IV than in stage I and II. Serum CH 50 was higher than in healthy controls, but not correlated with the clinical stage.

[The effect of levamisole on non-resected lung cancer--the results of randomized controlled study]

The effect of levamisole in the treatment of 61 non-resected lung cancer-26 squamous cell ca., 8 adenocarcinoma, 13 large cell ca. and 14 small cell ca- was studied by a randomized controlled trial. Levamisole was given at a daily dose of 150 mg per body weight for 3 consecutive days every 2 weeks. The main therapy, combining polychemotherapy and radiotherapy of standard dose or low dose, was given to both levamisole and control groups. The survival rate of the levamisole group was superior to that of the control group, with median survival time of 52 weeks in the former and 36 weeks in the latter, and with significant difference (p less than 0.05) during 46th to 52nd weeks. Comparing between the selected cases, the levamisole group was significantly superior (p less than 0.05) to the control group in all course examined, with median survival time of 64 weeks in the former and 36 weeks in the latter. Levamisole was more effective in the group of squamous and adenocarcinoma than large and small cell carcinoma. In the group where PPD reaction was negative at the time of initiation of the treatment levamisole was more effective than in the group of PPD positive, and also more effective in non-responders to the main therapy than responders. No side effect such as agranulocytosis was observed. Summarizing the present study, an immunotherapy employing levamisole combined with chemo-radiotherapy for non-resected lung cancer could be said to be effective in prolongation of survival time.