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Tu1413 Early Intervention Lowers Morbidity and Mortality in Severe and Moderate Acute Cholangitis
Abstracts
Tu1413 Early Intervention Lowers Morbidity and Mortality in Severe and Moderate Acute Cholangitis Amitasha Sinha*1, Michelle Le1, Anita Sivaraman1, Sayeedul Hasan1, Rakesh Vinayek1, Sudhir Dutta1,2 1 Division of Gastroenterology, Sinai Hospital of Baltimore, Baltimore, MD; 2University of Maryland, Baltimore, MD Background: Urgent biliary intervention is reserved in severe or complicated cases in acute cholangitis. Current practice guidelines in moderate and mild cholangitis recommend biliary drainage in patients refractory to conservative treatment with fluids and antibiotics. Endoscopic drainage is associated with a low morbidity rate and shorter duration of hospitalization, however there has been little data in timing of intervention in improving outcomes based on severity of acute cholangitis. Aim: The aim of our study is to evaluate “time to intervention” from admission as a predictor of outcomes in patients admitted with severe and moderate acute cholangitis. Methods: We used the National Inpatient Sample (NIS) database for year 2011, and identified all patients with the ICD9 discharge diagnosis of acute cholangitis, and biliary intervention with procedure codes for Endoscopic Retrograde Cholangiopancreatography (ERCP), Endoscopic Retrograde Cholangiography (ERC), endoscopic nasobiliary drainage and percutaneous biliary drainage to create our dataset. We evaluated time to intervention, age, gender, race, presence of chronic diseases, and transfer from outside hospital as predictors for mortality. We also evaluated length of stay, and charges of hospitalization as outcomes. Early intervention was defined as any procedure within 24 hours of admission. Severe cholangitis was defined as presence of concurrent persistent organ failure. Univariable and multivariable analysis was performed using logistic regression analysis. Results: A total of 1,999 discharges were identified who had a diagnosis of acute cholangitis and underwent endoscopic or percutaneous biliary intervention, who had a mean age of 67 years (16), with 54% males, and 68.3% white. While a total of 665 (33%) of patients had severe cholangitis, a total of 312 (15.6%) received early intervention. There were 131 deaths (6.6%), and the mean length of stay and mean hospital charges were 10 days and $102,311 respectively. Early biliary intervention was significantly associated with decreased mortality on univariable analysis in both severe (p <0.01), and moderate cholangitis (p 0.02). There was significant difference in time to intervention in patients who died versus those who survived in severe cholangitis (7.8 days vs. 5.4 days, p<0.01). Figure 1 demonstrates that both length of stay (A), and hospitalization charges (B) were directly proportional to the time to intervention. On multivariable analysis, early intervention continued to be an independent predictor of decreased mortality after adjusting for older age, presence of chronic diseases, and transfer from outside hospital (p<0.001). Conclusion: Our study suggests that early biliary intervention is strongly associated with improved mortality in both moderate and severe acute cholangitis.
Scatter Plot for Length of Stay (days) and Hospitalization Charges ($)
Tu1414 Long-Term Prognosis After Biliary Stenting for Common Bile Duct Stones in Elderly High-Risk Patients Yu Akazawa*, Masahiro Ohtani, Takuto Nosaka, Yasushi Saito, Kazuto Takahashi, Tatsushi Naito, Kazuya Ofuji, Hidetaka Matsuda, Katsushi Hiramatsu, Tomoyuki Nemoto, Yasunari Nakamoto Second Department of Internal Medicine, Faculty of Medical Sciences, Fukui University, Fukui, Japan Background and Aim: While endoscopic stone extraction is currently the first-choice treatment for common bile duct (CBD) stones in patients of any age, biliary stenting is occasionally indicated in elderly patients considered high-risk because of agerelated comorbidities or when the condition is not amenable to endoscopic treatment. Although biliary stenting is considered effective for treating CBD stones, the long-term prognosis in elderly patients remains unclear. We aimed to comparatively assess the long-term outcomes of endoscopic stone removal and biliary stenting in elderly patients with CBD stones. Subjects and Methods: We retrospectively evaluated patients aged 85 years who underwent endoscopic treatment in our depart-
AB616 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
ment (July 2006–March 2016). Patients were stratified according to whether they underwent endoscopic biliary stenting (stenting group) or complete removal of CBD stones using a basket, balloon catheter, and mechanical lithotripsy (duct clearance group). If stented patients developed acute cholangitis, the stent was exchanged for a new one. The recurrence rate of acute cholangitis and the overall survival were compared between the two groups, and predictors of survival were assessed, including sex (male/female), performance status (PS; <3/>3), concomitant disease (yes/no), recurrence of cholangitis (yes/no), endoscopic treatment (duct clearance/ stenting). Results: Of the 105 patients enrolled in the study (43 males, 62 females; mean age, 89.6 years), 65 and 40 patients were included in the duct clearance and stenting groups, respectively. Biliary stenting was most often indicated for poor PS, followed by CBD deformation, multiple stones, and large stone. Over a mean followup of 623 days (range, 34–2748 days), the recurrence rate of acute cholangitis was 4.6% (3/65 cases) and 27.5% (11/40 cases) in the duct clearance and stenting groups, respectively, with significantly higher recurrence rate among stented patients (average recurrence-free period, 1174.7 vs. 433.3 days; log-rank test, p<0.001). Allcause mortality was 35.3% (23/65 cases) and 80.0% (32/40 cases) in the duct clearance and stenting groups, respectively, with significantly shorter survival among stented patients (median survival, 1872 vs. 796 days; rog-rank test, p<0.001). The mortality rate associated with acute cholangitis was 0% (0/23 cases) and 6.3% (2/32 cases) in the duct clearance and stenting groups, respectively. Although univariate analysis indicated poor PS and biliary stenting as predictors of mortality, only poor PS remained associated with mortality on multivariate analysis. Conclusion: Although acute cholangitis recurred less frequently after complete stone removal, endoscopic treatment was not a predictor of long-term prognosis. Biliary stenting for CBD stones is one of the effective treatments in elderly high-risk patients.
Tu1415 An International Multicenter Study on Digital Single Operator Cholangioscopy for the Management of Difficult Bile Duct Stones in 271 Patients Olaya Isabella Brewer Gutierrez*1, Saowonee Ngamruengphong1, Isaac Raijman2, Richard Sturgess3, Divyesh V. Sejpal4, Stuart Sherman5, Raj J. Shah6, Richard Kwon7, James L. Buxbaum8, Claudio Zulli9, Wahid Wassef10, Douglas G. Adler11, Daniel Mullady12, Andrew Y. Wang13, Kumar Krishnan14, Vivek Kaul15, Demetrios Tzimas16, Christopher J. DiMaio17, Sammy Ho18, Bret T. Petersen19, George Webster20, Moon Sung Lee21, Yen-I. Chen1, Laura k. Dwyer3, Sumant Inamdar4, Sheryl Lynch5, Augustin Attwell6, Amy Hosmer7, Amar Manvar18, Christopher Ko8, Attilio Maurano9, Avik Sarkar10, Linda J. Taylor11, Vladimir M. Kushnir12, Jessica P. Harris16, Sanchit Gupta17, John A. Martin19, Noor L. Bekkali20, Yun Nah Lee21, Daniel S. Strand13, Ali Raza14, Majidah A. Bukhari1, Omid Sanaei1, Shivangi Kothari15, Martin H. Gregory12, Asad Ullah15, Truptesh Kothari15, Christopher Gostout19, Mark Topazian19, Dushant Uppal13, Arvind J. Trindade4, Juan Carlos Bucobo16, Nikhil A. Kumta17, Vanessa B. Patrick5, Mouen A. Khashab1 1 Johns Hopkins Hospital, Baltimore, MD; 2Greater Houston Gastroenterology, Houston, TX; 3Aintree University Hospital, Liverpool, United Kingdom; 4Hofstra-Northwell School of Medicine, Manhasset, NY; 5 Indiana University Medical Center, Indianapolis, IN; 6University of Colorado Denver, Denver, CO; 7University of Michigan, Ann Arbor, MI; 8 University of Southern California Keck School of Medicine, Los Angeles, CA; 9Hospital of Salerno, G. Fucito Center, Mercato San Severino, Italy; 10 UMassMemorial Health Center, Worcester, MA; 11University of Utah School of Medicine, Salt Lake City, UT; 12Washington University in St. Louis School of Medicine, St. Louis, MO; 13University of Virginia Health System, Charlottesville, VA; 14Houston Methodist Hospital, Houston, TX; 15 University of Rochester Medical Center - Strong Memorial Hospital, Rochester, NY; 16Stony Brook University School of Medicine, Stony Brook, NY; 17Icahn School of Medicine at Mount Sinai, New York, NY; 18 Montefiore Medical Center, New York City, NY; 19Mayo Clinic, Rochester, MN; 20University College London Hospitals, London, United Kingdom; 21SoonChunHyang University School of Medicine, Seoul, Korea (the Republic of) Background: The role of the recently developed digital single-operator cholangioscopy (D-SOC) for the treatment of difficult biliary stones using electrohydraulic (EHL) and laser lithotripsy (LL) is not well known. Aims: (1) To study the technical success (complete ductal clearance) and safety (rate/severity of adverse events (AE) per ASGE lexicon) of D-SOC with EHL/LL in the treatment of difficult biliary stones; (2) To compare the performance of EHL vs. LL. Methods: This is an international, multicenter, retrospective study at 21 tertiary centers between 02/2015 and 10/2016. Difficult bile duct stones were defined as large ( 15mm), multiple (>3), impacted, intrahepatic/cystic duct location, associated with a stricture, difficult anatomic
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Tu1413 Early Intervention Lowers Morbidity and Mortality in Severe and Moderate Acute Cholangitis Amitasha Sinha*1, Michelle Le1, Anita Sivaraman1, Sayeedul Hasan1, Rakesh Vinayek1, Sudhir Dutta1,2 1 Division of Gastroenterology, Sinai Hospital of Baltimore, Baltimore, MD; 2University of Maryland, Baltimore, MD Background: Urgent biliary intervention is reserved in severe or complicated cases in acute cholangitis. Current practice guidelines in moderate and mild cholangitis recommend biliary drainage in patients refractory to conservative treatment with fluids and antibiotics. Endoscopic drainage is associated with a low morbidity rate and shorter duration of hospitalization, however there has been little data in timing of intervention in improving outcomes based on severity of acute cholangitis. Aim: The aim of our study is to evaluate “time to intervention” from admission as a predictor of outcomes in patients admitted with severe and moderate acute cholangitis. Methods: We used the National Inpatient Sample (NIS) database for year 2011, and identified all patients with the ICD9 discharge diagnosis of acute cholangitis, and biliary intervention with procedure codes for Endoscopic Retrograde Cholangiopancreatography (ERCP), Endoscopic Retrograde Cholangiography (ERC), endoscopic nasobiliary drainage and percutaneous biliary drainage to create our dataset. We evaluated time to intervention, age, gender, race, presence of chronic diseases, and transfer from outside hospital as predictors for mortality. We also evaluated length of stay, and charges of hospitalization as outcomes. Early intervention was defined as any procedure within 24 hours of admission. Severe cholangitis was defined as presence of concurrent persistent organ failure. Univariable and multivariable analysis was performed using logistic regression analysis. Results: A total of 1,999 discharges were identified who had a diagnosis of acute cholangitis and underwent endoscopic or percutaneous biliary intervention, who had a mean age of 67 years (16), with 54% males, and 68.3% white. While a total of 665 (33%) of patients had severe cholangitis, a total of 312 (15.6%) received early intervention. There were 131 deaths (6.6%), and the mean length of stay and mean hospital charges were 10 days and $102,311 respectively. Early biliary intervention was significantly associated with decreased mortality on univariable analysis in both severe (p <0.01), and moderate cholangitis (p 0.02). There was significant difference in time to intervention in patients who died versus those who survived in severe cholangitis (7.8 days vs. 5.4 days, p<0.01). Figure 1 demonstrates that both length of stay (A), and hospitalization charges (B) were directly proportional to the time to intervention. On multivariable analysis, early intervention continued to be an independent predictor of decreased mortality after adjusting for older age, presence of chronic diseases, and transfer from outside hospital (p<0.001). Conclusion: Our study suggests that early biliary intervention is strongly associated with improved mortality in both moderate and severe acute cholangitis.
Scatter Plot for Length of Stay (days) and Hospitalization Charges ($)
Tu1414 Long-Term Prognosis After Biliary Stenting for Common Bile Duct Stones in Elderly High-Risk Patients Yu Akazawa*, Masahiro Ohtani, Takuto Nosaka, Yasushi Saito, Kazuto Takahashi, Tatsushi Naito, Kazuya Ofuji, Hidetaka Matsuda, Katsushi Hiramatsu, Tomoyuki Nemoto, Yasunari Nakamoto Second Department of Internal Medicine, Faculty of Medical Sciences, Fukui University, Fukui, Japan Background and Aim: While endoscopic stone extraction is currently the first-choice treatment for common bile duct (CBD) stones in patients of any age, biliary stenting is occasionally indicated in elderly patients considered high-risk because of agerelated comorbidities or when the condition is not amenable to endoscopic treatment. Although biliary stenting is considered effective for treating CBD stones, the long-term prognosis in elderly patients remains unclear. We aimed to comparatively assess the long-term outcomes of endoscopic stone removal and biliary stenting in elderly patients with CBD stones. Subjects and Methods: We retrospectively evaluated patients aged 85 years who underwent endoscopic treatment in our depart-
AB616 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
ment (July 2006–March 2016). Patients were stratified according to whether they underwent endoscopic biliary stenting (stenting group) or complete removal of CBD stones using a basket, balloon catheter, and mechanical lithotripsy (duct clearance group). If stented patients developed acute cholangitis, the stent was exchanged for a new one. The recurrence rate of acute cholangitis and the overall survival were compared between the two groups, and predictors of survival were assessed, including sex (male/female), performance status (PS; <3/>3), concomitant disease (yes/no), recurrence of cholangitis (yes/no), endoscopic treatment (duct clearance/ stenting). Results: Of the 105 patients enrolled in the study (43 males, 62 females; mean age, 89.6 years), 65 and 40 patients were included in the duct clearance and stenting groups, respectively. Biliary stenting was most often indicated for poor PS, followed by CBD deformation, multiple stones, and large stone. Over a mean followup of 623 days (range, 34–2748 days), the recurrence rate of acute cholangitis was 4.6% (3/65 cases) and 27.5% (11/40 cases) in the duct clearance and stenting groups, respectively, with significantly higher recurrence rate among stented patients (average recurrence-free period, 1174.7 vs. 433.3 days; log-rank test, p<0.001). Allcause mortality was 35.3% (23/65 cases) and 80.0% (32/40 cases) in the duct clearance and stenting groups, respectively, with significantly shorter survival among stented patients (median survival, 1872 vs. 796 days; rog-rank test, p<0.001). The mortality rate associated with acute cholangitis was 0% (0/23 cases) and 6.3% (2/32 cases) in the duct clearance and stenting groups, respectively. Although univariate analysis indicated poor PS and biliary stenting as predictors of mortality, only poor PS remained associated with mortality on multivariate analysis. Conclusion: Although acute cholangitis recurred less frequently after complete stone removal, endoscopic treatment was not a predictor of long-term prognosis. Biliary stenting for CBD stones is one of the effective treatments in elderly high-risk patients.
Tu1415 An International Multicenter Study on Digital Single Operator Cholangioscopy for the Management of Difficult Bile Duct Stones in 271 Patients Olaya Isabella Brewer Gutierrez*1, Saowonee Ngamruengphong1, Isaac Raijman2, Richard Sturgess3, Divyesh V. Sejpal4, Stuart Sherman5, Raj J. Shah6, Richard Kwon7, James L. Buxbaum8, Claudio Zulli9, Wahid Wassef10, Douglas G. Adler11, Daniel Mullady12, Andrew Y. Wang13, Kumar Krishnan14, Vivek Kaul15, Demetrios Tzimas16, Christopher J. DiMaio17, Sammy Ho18, Bret T. Petersen19, George Webster20, Moon Sung Lee21, Yen-I. Chen1, Laura k. Dwyer3, Sumant Inamdar4, Sheryl Lynch5, Augustin Attwell6, Amy Hosmer7, Amar Manvar18, Christopher Ko8, Attilio Maurano9, Avik Sarkar10, Linda J. Taylor11, Vladimir M. Kushnir12, Jessica P. Harris16, Sanchit Gupta17, John A. Martin19, Noor L. Bekkali20, Yun Nah Lee21, Daniel S. Strand13, Ali Raza14, Majidah A. Bukhari1, Omid Sanaei1, Shivangi Kothari15, Martin H. Gregory12, Asad Ullah15, Truptesh Kothari15, Christopher Gostout19, Mark Topazian19, Dushant Uppal13, Arvind J. Trindade4, Juan Carlos Bucobo16, Nikhil A. Kumta17, Vanessa B. Patrick5, Mouen A. Khashab1 1 Johns Hopkins Hospital, Baltimore, MD; 2Greater Houston Gastroenterology, Houston, TX; 3Aintree University Hospital, Liverpool, United Kingdom; 4Hofstra-Northwell School of Medicine, Manhasset, NY; 5 Indiana University Medical Center, Indianapolis, IN; 6University of Colorado Denver, Denver, CO; 7University of Michigan, Ann Arbor, MI; 8 University of Southern California Keck School of Medicine, Los Angeles, CA; 9Hospital of Salerno, G. Fucito Center, Mercato San Severino, Italy; 10 UMassMemorial Health Center, Worcester, MA; 11University of Utah School of Medicine, Salt Lake City, UT; 12Washington University in St. Louis School of Medicine, St. Louis, MO; 13University of Virginia Health System, Charlottesville, VA; 14Houston Methodist Hospital, Houston, TX; 15 University of Rochester Medical Center - Strong Memorial Hospital, Rochester, NY; 16Stony Brook University School of Medicine, Stony Brook, NY; 17Icahn School of Medicine at Mount Sinai, New York, NY; 18 Montefiore Medical Center, New York City, NY; 19Mayo Clinic, Rochester, MN; 20University College London Hospitals, London, United Kingdom; 21SoonChunHyang University School of Medicine, Seoul, Korea (the Republic of) Background: The role of the recently developed digital single-operator cholangioscopy (D-SOC) for the treatment of difficult biliary stones using electrohydraulic (EHL) and laser lithotripsy (LL) is not well known. Aims: (1) To study the technical success (complete ductal clearance) and safety (rate/severity of adverse events (AE) per ASGE lexicon) of D-SOC with EHL/LL in the treatment of difficult biliary stones; (2) To compare the performance of EHL vs. LL. Methods: This is an international, multicenter, retrospective study at 21 tertiary centers between 02/2015 and 10/2016. Difficult bile duct stones were defined as large ( 15mm), multiple (>3), impacted, intrahepatic/cystic duct location, associated with a stricture, difficult anatomic
www.giejournal.org