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Su1624 Early Precut Sphincterotomy for Patients With Difficult Biliary Access: a Meta-Analysis of Randomized Controlled Trials.
Abstracts Summary Of Studies Used For The Analysis Name of study
Country of Study
Years of Study
Operator Type
Type of Operator
Total Number of Patients
Patients with PAD
Incidence of PAD
Mean Age of PAD Patients
Mean of on Non PAD Patients
% Cannulation for PAD
% Cannulation for Non PAD
OR Failed Cannulation
PValue
Kirk et al
UK
R
M
755
38
5.0
64
51
60
80
2.6
0.005
Vicente et al ChangChien Vaira et al
Spain
19731977 19771980 19801985 19831988 19911996 19911996 19972007 20012002 20012006 20082010
R
M
520
50
9.8
67
55
74
82
1.7
0.129
P
S
1243
153
12.3
58.5
NA
91.5
91.0
0.8
0.582
P
M
2458
308
12.5
75
75
94.2
96.7
1.8
0.031
P
M
626
72
11.5
60.6
54.7
88.9
95.3
2.5
0.029
R
M
2925
350
12
NA
NA
95.4
98.9
4.1
0.012
R
M
601
65
10.8
NA
NA
88.1
83.1
1.3
0.484
P
S
400
131
32.8
74.7
64.4
90.1
88.1
0.7
0.291
P
S
637
132
20.7
72.7
67
94.9
94.8
1.9
0.025
P
M
1159
59
19.6
69.7
49.9
89.8
96.5
3.1
0.015
P
S
428
107
25
77.4
68.1
97.2
99.7
9.2
0.055
P
S
780
44
5.6
65
57
64.5
88.5
4.4
0.001
P
M
417
83
19.9
73
72
94
94
1.0
0.972
P
M
1211
308
9.9
76
65
61
92.7
7.7
0.012
14160
1900
13.1
China UK
Rajnakova et al. Zoepf et al
Singapore
Straja et al
Romania
Biox et al
Spain
Panteris et al GuitronCantu et al Katsinelos et al Alizadeh et al Tham and Kelly Lobo et al
Greece
POOLED
Germany
Mexico
Greece Iran UK UK
20082010 20092010 NA 8 year review
2.2
S-Single endoscopist, M-Multiple endoscopist, P-Prospective study, R-Retrospective study. PAD-Periampullary Diverticulum NA-Not available
methods that can be used to cannulate difficult intradiverticular papilla. Studies need to be done to find out which method will decrease cannulation failure rate. This could then be incorporated into the curriculum of trainees. This will also go a long way to reduce operator and patient exposure to radiation during difficult cannulation.
Su1624 Early Precut Sphincterotomy for Patients With Difficult Biliary Access: a Meta-Analysis of Randomized Controlled Trials. Praka Sundaralingam*1, Michael J. Bourke1,2 1 Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; 2Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
associated with increased risk of post ERCP pancreatitis. However, early use of precut sphincterotomy may reduce this risk by reducing papillary trauma caused by persistent attempts using standard cannulation techniques. We performed a metaanalysis of randomized controlled trials (RCT) to determine how use of early precut sphincterotomy affects the risk of pancreatitis and cannulation success when compared to persistent standard cannulation in patients with difficult biliary access. Methods: We searched for RCT that compared early use of precut sphincterotomy to persistent standard therapy (+/- salvage precut if required) in patients with difficult biliary access. We used MEDLINE, EMBASE and CENTRAL (inception to August 2014). Reference lists and abstracts of conference proceedings (American Gastroenterology Association Digestive Disease Week 2014) were searched by hand. Study selection, data extraction and quality assessment were conducted by two reviewers. Data was extracted for key clinical outcomes including overall cannulation success, incidence of post ERCP pancreatitis, primary cannulation success (success with randomized technique alone) and overall complication rate. Data synthesis was expressed as pooled risk ratios (RR) with 95% confidence intervals using a random effects model. Results: 5 RCT (523 participants) compared early use of precut sphincterotomy (of any technique) to persistent standard therapy (+/- salvage precut if required) in patients with difficult biliary access. The incidence of post ERCP pancreatitis (RR 0.62, 95% CI 0.28 to 1.36) and success of overall cannulation (RR 1.01,95 % CI 0.93 to 1.09) did not vary between the early precut groups compared to persistent standard therapy group. There was no significant increase in overall complications between the two study arms. The early use of precut was associated with a significantly higher primary cannulation success (RR 1.32, 95% CI 1.04 to1.68) though there was statically significant heterogeneity in this analysis. Subgroup analysis of studies involving only fully qualified endoscopists found a significant reduction in pancreatitis rate with early precut compared to standard technique (RR 0.29,95% CI 0.10 to 0.86) (Figure 1). Conclusion: When compared to standard therapy, the early use of precut sphincterotomy does not increase the risk of post ERCP pancreatitis. In experienced hands the risk of post ERCP pancreatitis may be reduced with the early precut strategy compared to the standard technique. Overall cannulation rates are the same between both strategies though primary cannulation rates are improved with early precut. Further studies are needed to confirm these findings.
Background and Objectives: The use of precut sphincterotomy as a late salvage technique in difficult endoscopic retrograde cholangiopancreatography (ERCP) has been
AB356 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
www.giejournal.org
Abstracts
were recorded in both groups. Results: In the bile aspiration group, 349 patients were included, while 295 patients had ERCP performed without bile aspiration. There was no difference in the age, gender, or trainee participation between the 2 groups. There were more patients with PSC in the bile aspiration group compared to the non-bile aspiration group (47 vs. 14, pZ0.0001). There was no difference in patients with underlying sphincter of oddi dysfunction (17 vs. 20, pZ0.86) or choledocholithiasis (74 vs. 61, pZ0.86) respectively. More patients in the non-bile aspiration group required pre-cut sphincterotomy for biliary access (24.5% vs. 5.1%, p !0 .0001). Post-ERCP adverse events were observed in 12 patients (3.4%) in the bile aspiration group vs. 25 patients (8.5%) in the non-bile aspiration group. (p Z 0.006) More patients in the non-bile aspiration group developed pancreatitis, [16 (5.4%) vs. 6 (1.7%), p Z 0.009] and cholangitis [7 (2.3%) vs. 1(0.2%), p Z0.04]. There was no difference in the risk of bleeding [2 (0.7%) vs. 4 (1.1%), pZ0.31]. Conclusion: In spite of higher number of PSC patients in the bile aspiration group, cholangitis risk was lower. Bile aspiration should be considered routinely to decrease cholangitis risk in patients undergoing ERCPs.
Figure 1. Subgroup analysis. Comparison of post ERCP pancreatitis rates between Early precut sphincterotomy and persistent standard therapy by fellow involvement.
Su1625 Technical Evolution for Safe Biliary Cannulation by Pancreatic Guidewire Placement in Difficult Cases During ERCP Kei Ito*, Shinsuke Koshita, Yoshihide Kanno, Takahisa Ogawa, Kaori Masu, Yutaka Noda Gastroenterology, Sendai City Medical Center, Sendai, Japan Background and Aim: Pancreatic guidewire placement (P-GW) has been reported to be useful for difficult biliary cannulation. This technique may pose a risk of postERCP pancreatitis (PEP) due to papillary edema or pancreatic parenchyma injury by the guidewire. Patients and Methods: Between 2004 and 2013, biliary cannulation was attempted in 5540 patients with biliary diseases. Among them, 270 patients who had undergone P-GW with a contrast injection method using a cannula/sphincterotome (single guidewire technique: SGT) for difficult biliary cannulation were enrolled in this study. Wire-guided cannulation under P-GW (double guidewire technique: DGT) or precut sphincterotomy was performed if SGT was unsuccessful. The successful cannulation rate and the frequency of PEP were investigated. PEP was defined according to the consensus criteria. Results: Biliary cannulation with SGT was achieved in 70% (188 patients). Of 41 patients with unsuccessful SGT, DGT was performed, biliary cannulation being successful in 83% (34 patients). Of the 24 patients who underwent precut sphincterotomy, biliary cannulation was achieved in 42% (10 patients). The incidence of PEP in SGT, DGT, and precut sphincterotomy was 11% (29: mild, 25; moderate, 3; severe, 1), 7% (mild, 3), and 0%, respectively. Pancreatic duct (PD) stenting was performed to prevent PEP in 75% (202 patients) of the patients. The incidence of PEP in the no PD stenting group was significantly higher than that in the PD stenting group (24% vs 6%, OR 4.5, 95% CI 2.0-9.9). In subgroup analysis in which a prospective randomized controlled trial (PD stenting (n Z35) vs. no stenting (n Z35)) had been carried out, multivariate analysis revealed no PD stenting to be the only significant risk factor for PEP (P Z 0.0071, RR 16, 95% CI 1.3-193). Of 160 patients in whom PD stenting was attempted to prevent PEP, the incidence of PEP in patients with failed stent placement was significantly higher than that in patients with successful stent placement (23% vs. 7%, OR 3.7, 95% CI 1.2-11). Conclusions: DGT rather than precut sphincterotomy should be considered as a salvage procedure in cases of unsuccessful SGT due to its relatively high success rate with an acceptable incidence of PEP. Although PD stenting can prevent the incidence of PEP after P-GW, failed PD stenting was frequently associated with PEP.
Su1626 Bile Aspiration During ERCP Is Associated With Lower Risk of Post-ERCP Cholangitis: a Single Center Prospective Study Udayakumar Navaneethan*1,2, Vennisvasanth Lourdusamy1, Ramprasad Jegadeesan1, Madhusudhan R. Sanaka1, John J. Vargo1, Mansour A. Parsi1 1 Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH; 2Center for Interventional Endoscopy, Florida Hospital Institute for Minimally Invasive Therapy, Orlando, FL Background: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with adverse events. Pancreatitis and cholangitis are the most common adverse events. Bile aspiration is performed to obtain bio-markers and theoretically should reduce biliary pressure and may decrease post-ERCP adverse events in particular cholangitis. Aim: Our aim was to compare adverse events with ERCP and bile aspiration versus ERCP performed without bile aspiration. Methods: This was a prospective study of ERCPs from 2012-2014 in which bile aspiration was performed. Once biliary cannulation was achieved, 2-5 ml of bile was obtained with a sphincterotome. This was compared to ERCPs performed during the same time period in which bile aspiration was not performed and contrast was injected once biliary cannulation was achieved with wire guided cannulation. The 30-day adverse events
www.giejournal.org
Su1627 Unplanned Delayed Repeat ERCPs Are Common After ERCP for Benign Biliary Disease: a Population Based Study Dana C. Moffatt*, B. Nancy Yu, Aruni Tennakoon, Charles N. Bernstein Department of Medicine, University of Manitoba, Winnipeg, MB, Canada Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) is the most common therapeutic procedure used to treat benign biliary disease such as choledocholithiasis (CBDS), biliary strictures, ascending cholangitis (AC) and biliary pancreatitis, sphincter of oddi dysfunction (SOD). However, the rates of recurrence of these disorders and the incidence of requiring a repeat ERCP, months or years later is unknown. We set out to establish the incidence of repeat ERCP O6 months after an initial ERCP for benign biliary disease, and asses for patient, physician and procedure factors associated with an increased risk of delayed repeat ERCP. Methods: All ERCPs performed in Manitoba between 1984-2009 were identified using MD billing tariffs and ICD-9 (1984-2004) and ICD-10 (2004-2009) codes. Data were analyzed to define the incidence of delayed repeat ERCP (O6 months after completing an initial ERCP or initial series of ERCPs) for benign biliary indications (CBDS, AC, biliary pancreatitis, biliary miscellaneous (biliary strictures, bile leaks and SOD)). Confirmed or possible malignancies as well as acute and chronic pancreatitis diagnosis (non biliary) were excluded as repeat ERCPs are common in these populations. Patient, procedure and physician variables were evaluated using univariate and multivariate logistic regression to define risk factors for requiring delayed repeat ERCP. Results: 31,607 ERCPs in 21,556 individuals were performed between 19842009 and were included in the analysis. 13,407 underwent their first ERCP for benign biliary indications, and of those 11,791 (88.4%) underwent only one ERCP treatment, while 1,616 (12.1%) had a delayed ERCP O6 months after completion of their initial therapy. The time to delayed ERCP ranged from 180 - 8992 days, median 1204 (interquartile range 576-2333 days). Patient demographics are shown in Table 1. Comparing to initial diagnosis of CBDS, diagnosis at first ERCP of biliary miscellaneous (OR 1.3 95%CI 1.16-1.49), diagnosis of biliary AP (OR 1.58 95% CI 1.36-1.82), diagnosis of non malignant jaundice (OR 1.8 95% CI 1.04-3.12) are the significant risk factors for requiring a delayed repeat ERCP. Other risk factors include living in rural south (vs. urban, OR 1.2, 95% CI 1.06-1.39), or the provider performing the ERCP (GI vs. surgeon, OR 1.21 95% CI 1.06-1.37). Tertiary care vs. community hospital, age, sex and other indications were not predicative. Discussion: About 12% of individuals undergoing ERCP for benign biliary disorders will eventually require a delayed repeat ERCP. No modifiable risk factors were identified to predict the need for repeat ERCP, except for the provider performing the procedure. This information should be used to counsel patients about pre and post procedure risks of ERCP and informed consent should include the significant risk of requiring further ERCPs in the future.
Figure 1. Time to delayed repeat ERCP for benign biliary indications.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB357
Country of Study
Years of Study
Operator Type
Type of Operator
Total Number of Patients
Patients with PAD
Incidence of PAD
Mean Age of PAD Patients
Mean of on Non PAD Patients
% Cannulation for PAD
% Cannulation for Non PAD
OR Failed Cannulation
PValue
Kirk et al
UK
R
M
755
38
5.0
64
51
60
80
2.6
0.005
Vicente et al ChangChien Vaira et al
Spain
19731977 19771980 19801985 19831988 19911996 19911996 19972007 20012002 20012006 20082010
R
M
520
50
9.8
67
55
74
82
1.7
0.129
P
S
1243
153
12.3
58.5
NA
91.5
91.0
0.8
0.582
P
M
2458
308
12.5
75
75
94.2
96.7
1.8
0.031
P
M
626
72
11.5
60.6
54.7
88.9
95.3
2.5
0.029
R
M
2925
350
12
NA
NA
95.4
98.9
4.1
0.012
R
M
601
65
10.8
NA
NA
88.1
83.1
1.3
0.484
P
S
400
131
32.8
74.7
64.4
90.1
88.1
0.7
0.291
P
S
637
132
20.7
72.7
67
94.9
94.8
1.9
0.025
P
M
1159
59
19.6
69.7
49.9
89.8
96.5
3.1
0.015
P
S
428
107
25
77.4
68.1
97.2
99.7
9.2
0.055
P
S
780
44
5.6
65
57
64.5
88.5
4.4
0.001
P
M
417
83
19.9
73
72
94
94
1.0
0.972
P
M
1211
308
9.9
76
65
61
92.7
7.7
0.012
14160
1900
13.1
China UK
Rajnakova et al. Zoepf et al
Singapore
Straja et al
Romania
Biox et al
Spain
Panteris et al GuitronCantu et al Katsinelos et al Alizadeh et al Tham and Kelly Lobo et al
Greece
POOLED
Germany
Mexico
Greece Iran UK UK
20082010 20092010 NA 8 year review
2.2
S-Single endoscopist, M-Multiple endoscopist, P-Prospective study, R-Retrospective study. PAD-Periampullary Diverticulum NA-Not available
methods that can be used to cannulate difficult intradiverticular papilla. Studies need to be done to find out which method will decrease cannulation failure rate. This could then be incorporated into the curriculum of trainees. This will also go a long way to reduce operator and patient exposure to radiation during difficult cannulation.
Su1624 Early Precut Sphincterotomy for Patients With Difficult Biliary Access: a Meta-Analysis of Randomized Controlled Trials. Praka Sundaralingam*1, Michael J. Bourke1,2 1 Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; 2Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
associated with increased risk of post ERCP pancreatitis. However, early use of precut sphincterotomy may reduce this risk by reducing papillary trauma caused by persistent attempts using standard cannulation techniques. We performed a metaanalysis of randomized controlled trials (RCT) to determine how use of early precut sphincterotomy affects the risk of pancreatitis and cannulation success when compared to persistent standard cannulation in patients with difficult biliary access. Methods: We searched for RCT that compared early use of precut sphincterotomy to persistent standard therapy (+/- salvage precut if required) in patients with difficult biliary access. We used MEDLINE, EMBASE and CENTRAL (inception to August 2014). Reference lists and abstracts of conference proceedings (American Gastroenterology Association Digestive Disease Week 2014) were searched by hand. Study selection, data extraction and quality assessment were conducted by two reviewers. Data was extracted for key clinical outcomes including overall cannulation success, incidence of post ERCP pancreatitis, primary cannulation success (success with randomized technique alone) and overall complication rate. Data synthesis was expressed as pooled risk ratios (RR) with 95% confidence intervals using a random effects model. Results: 5 RCT (523 participants) compared early use of precut sphincterotomy (of any technique) to persistent standard therapy (+/- salvage precut if required) in patients with difficult biliary access. The incidence of post ERCP pancreatitis (RR 0.62, 95% CI 0.28 to 1.36) and success of overall cannulation (RR 1.01,95 % CI 0.93 to 1.09) did not vary between the early precut groups compared to persistent standard therapy group. There was no significant increase in overall complications between the two study arms. The early use of precut was associated with a significantly higher primary cannulation success (RR 1.32, 95% CI 1.04 to1.68) though there was statically significant heterogeneity in this analysis. Subgroup analysis of studies involving only fully qualified endoscopists found a significant reduction in pancreatitis rate with early precut compared to standard technique (RR 0.29,95% CI 0.10 to 0.86) (Figure 1). Conclusion: When compared to standard therapy, the early use of precut sphincterotomy does not increase the risk of post ERCP pancreatitis. In experienced hands the risk of post ERCP pancreatitis may be reduced with the early precut strategy compared to the standard technique. Overall cannulation rates are the same between both strategies though primary cannulation rates are improved with early precut. Further studies are needed to confirm these findings.
Background and Objectives: The use of precut sphincterotomy as a late salvage technique in difficult endoscopic retrograde cholangiopancreatography (ERCP) has been
AB356 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
www.giejournal.org
Abstracts
were recorded in both groups. Results: In the bile aspiration group, 349 patients were included, while 295 patients had ERCP performed without bile aspiration. There was no difference in the age, gender, or trainee participation between the 2 groups. There were more patients with PSC in the bile aspiration group compared to the non-bile aspiration group (47 vs. 14, pZ0.0001). There was no difference in patients with underlying sphincter of oddi dysfunction (17 vs. 20, pZ0.86) or choledocholithiasis (74 vs. 61, pZ0.86) respectively. More patients in the non-bile aspiration group required pre-cut sphincterotomy for biliary access (24.5% vs. 5.1%, p !0 .0001). Post-ERCP adverse events were observed in 12 patients (3.4%) in the bile aspiration group vs. 25 patients (8.5%) in the non-bile aspiration group. (p Z 0.006) More patients in the non-bile aspiration group developed pancreatitis, [16 (5.4%) vs. 6 (1.7%), p Z 0.009] and cholangitis [7 (2.3%) vs. 1(0.2%), p Z0.04]. There was no difference in the risk of bleeding [2 (0.7%) vs. 4 (1.1%), pZ0.31]. Conclusion: In spite of higher number of PSC patients in the bile aspiration group, cholangitis risk was lower. Bile aspiration should be considered routinely to decrease cholangitis risk in patients undergoing ERCPs.
Figure 1. Subgroup analysis. Comparison of post ERCP pancreatitis rates between Early precut sphincterotomy and persistent standard therapy by fellow involvement.
Su1625 Technical Evolution for Safe Biliary Cannulation by Pancreatic Guidewire Placement in Difficult Cases During ERCP Kei Ito*, Shinsuke Koshita, Yoshihide Kanno, Takahisa Ogawa, Kaori Masu, Yutaka Noda Gastroenterology, Sendai City Medical Center, Sendai, Japan Background and Aim: Pancreatic guidewire placement (P-GW) has been reported to be useful for difficult biliary cannulation. This technique may pose a risk of postERCP pancreatitis (PEP) due to papillary edema or pancreatic parenchyma injury by the guidewire. Patients and Methods: Between 2004 and 2013, biliary cannulation was attempted in 5540 patients with biliary diseases. Among them, 270 patients who had undergone P-GW with a contrast injection method using a cannula/sphincterotome (single guidewire technique: SGT) for difficult biliary cannulation were enrolled in this study. Wire-guided cannulation under P-GW (double guidewire technique: DGT) or precut sphincterotomy was performed if SGT was unsuccessful. The successful cannulation rate and the frequency of PEP were investigated. PEP was defined according to the consensus criteria. Results: Biliary cannulation with SGT was achieved in 70% (188 patients). Of 41 patients with unsuccessful SGT, DGT was performed, biliary cannulation being successful in 83% (34 patients). Of the 24 patients who underwent precut sphincterotomy, biliary cannulation was achieved in 42% (10 patients). The incidence of PEP in SGT, DGT, and precut sphincterotomy was 11% (29: mild, 25; moderate, 3; severe, 1), 7% (mild, 3), and 0%, respectively. Pancreatic duct (PD) stenting was performed to prevent PEP in 75% (202 patients) of the patients. The incidence of PEP in the no PD stenting group was significantly higher than that in the PD stenting group (24% vs 6%, OR 4.5, 95% CI 2.0-9.9). In subgroup analysis in which a prospective randomized controlled trial (PD stenting (n Z35) vs. no stenting (n Z35)) had been carried out, multivariate analysis revealed no PD stenting to be the only significant risk factor for PEP (P Z 0.0071, RR 16, 95% CI 1.3-193). Of 160 patients in whom PD stenting was attempted to prevent PEP, the incidence of PEP in patients with failed stent placement was significantly higher than that in patients with successful stent placement (23% vs. 7%, OR 3.7, 95% CI 1.2-11). Conclusions: DGT rather than precut sphincterotomy should be considered as a salvage procedure in cases of unsuccessful SGT due to its relatively high success rate with an acceptable incidence of PEP. Although PD stenting can prevent the incidence of PEP after P-GW, failed PD stenting was frequently associated with PEP.
Su1626 Bile Aspiration During ERCP Is Associated With Lower Risk of Post-ERCP Cholangitis: a Single Center Prospective Study Udayakumar Navaneethan*1,2, Vennisvasanth Lourdusamy1, Ramprasad Jegadeesan1, Madhusudhan R. Sanaka1, John J. Vargo1, Mansour A. Parsi1 1 Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH; 2Center for Interventional Endoscopy, Florida Hospital Institute for Minimally Invasive Therapy, Orlando, FL Background: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with adverse events. Pancreatitis and cholangitis are the most common adverse events. Bile aspiration is performed to obtain bio-markers and theoretically should reduce biliary pressure and may decrease post-ERCP adverse events in particular cholangitis. Aim: Our aim was to compare adverse events with ERCP and bile aspiration versus ERCP performed without bile aspiration. Methods: This was a prospective study of ERCPs from 2012-2014 in which bile aspiration was performed. Once biliary cannulation was achieved, 2-5 ml of bile was obtained with a sphincterotome. This was compared to ERCPs performed during the same time period in which bile aspiration was not performed and contrast was injected once biliary cannulation was achieved with wire guided cannulation. The 30-day adverse events
www.giejournal.org
Su1627 Unplanned Delayed Repeat ERCPs Are Common After ERCP for Benign Biliary Disease: a Population Based Study Dana C. Moffatt*, B. Nancy Yu, Aruni Tennakoon, Charles N. Bernstein Department of Medicine, University of Manitoba, Winnipeg, MB, Canada Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) is the most common therapeutic procedure used to treat benign biliary disease such as choledocholithiasis (CBDS), biliary strictures, ascending cholangitis (AC) and biliary pancreatitis, sphincter of oddi dysfunction (SOD). However, the rates of recurrence of these disorders and the incidence of requiring a repeat ERCP, months or years later is unknown. We set out to establish the incidence of repeat ERCP O6 months after an initial ERCP for benign biliary disease, and asses for patient, physician and procedure factors associated with an increased risk of delayed repeat ERCP. Methods: All ERCPs performed in Manitoba between 1984-2009 were identified using MD billing tariffs and ICD-9 (1984-2004) and ICD-10 (2004-2009) codes. Data were analyzed to define the incidence of delayed repeat ERCP (O6 months after completing an initial ERCP or initial series of ERCPs) for benign biliary indications (CBDS, AC, biliary pancreatitis, biliary miscellaneous (biliary strictures, bile leaks and SOD)). Confirmed or possible malignancies as well as acute and chronic pancreatitis diagnosis (non biliary) were excluded as repeat ERCPs are common in these populations. Patient, procedure and physician variables were evaluated using univariate and multivariate logistic regression to define risk factors for requiring delayed repeat ERCP. Results: 31,607 ERCPs in 21,556 individuals were performed between 19842009 and were included in the analysis. 13,407 underwent their first ERCP for benign biliary indications, and of those 11,791 (88.4%) underwent only one ERCP treatment, while 1,616 (12.1%) had a delayed ERCP O6 months after completion of their initial therapy. The time to delayed ERCP ranged from 180 - 8992 days, median 1204 (interquartile range 576-2333 days). Patient demographics are shown in Table 1. Comparing to initial diagnosis of CBDS, diagnosis at first ERCP of biliary miscellaneous (OR 1.3 95%CI 1.16-1.49), diagnosis of biliary AP (OR 1.58 95% CI 1.36-1.82), diagnosis of non malignant jaundice (OR 1.8 95% CI 1.04-3.12) are the significant risk factors for requiring a delayed repeat ERCP. Other risk factors include living in rural south (vs. urban, OR 1.2, 95% CI 1.06-1.39), or the provider performing the ERCP (GI vs. surgeon, OR 1.21 95% CI 1.06-1.37). Tertiary care vs. community hospital, age, sex and other indications were not predicative. Discussion: About 12% of individuals undergoing ERCP for benign biliary disorders will eventually require a delayed repeat ERCP. No modifiable risk factors were identified to predict the need for repeat ERCP, except for the provider performing the procedure. This information should be used to counsel patients about pre and post procedure risks of ERCP and informed consent should include the significant risk of requiring further ERCPs in the future.
Figure 1. Time to delayed repeat ERCP for benign biliary indications.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB357