Risk factors for the development of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with asymptomatic common bile duct stones

BACKGROUND Previous studies have revealed that patients with asymptomatic common bile duct(CBD)stones are at a high risk of developing post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP).However,no studies to date have addressed the risk factors for PEP in patients with asymptomatic CBD stones.AIM To examine the risk factors for PEP in patients with asymptomatic CBD stones.METHODS Using medical records of three institutions in Japan for 6 years,we identified a total of 1135 patients with choledocholithiasis including 967 symptomatic patients and 168 asymptomatic patients with native papilla who underwent therapeutic ERCP.We performed univariate and multivariate analyses to examine the risk factors for PEP in the 168 patients with asymptomatic CBD stones.RESULTS The overall incidence rate of PEP in all the patients with during study period was 4.7%(53/1135).Of the 168 patients with asymptomatic CBD stones,24(14.3%)developed PEP.In univariate analysis,precut sphincterotomy(P=0.009)and biliary balloon sphincter dilation(P=0.043)were significant risk factors for PEP.In multivariate analysis,precut sphincterotomy(P=0.002,95%CI:2.2-27.8,odds ratio=7.7),biliary balloon sphincter dilation(P=0.015,95%CI:1.4-17.3,odds ratio=4.9),and trainee endoscopists(P=0.048,95%CI:1.01-8.1,odds ratio=2.9)were significant risk factors for PEP.CONCLUSION ERCP for asymptomatic CBD stones should be performed by experienced endoscopists.When performing precut sphincterotomy or biliary balloon sphincter dilation in patients with asymptomatic CBD stones,the placement of a prophylactic pancreatic stent is strongly recommended to prevent PEP.

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 cholangiopan-creatography(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.

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.