Comparison of scoring systems in predicting the severity of acute pancreatitis

AIM:To investigate the prognostic usefulness of several existing scoring systems in predicting the severity of acute pancreatitis(AP).METHODS:We retrospectively analyzed the prospectively collected clinical database from consecutive patients with AP in our institution between January 2011 and December 2012.Ranson,Acute Physiology and Chronic Health Evaluation(APACHE)-Ⅱ,and bedside index for severity in acute pancreatitis(BISAP)scores,and computed tomography severity index(CTSI)of all patients were calculated.Serum C-reactive protein(CRP)levels were measured at admission(CRPi)and after 24h(CRP24).Severe AP was defined as persistent organ failure for more than 48 h.The predictive accuracy of each scoring system was measured by the area under the receiver-operating curve(AUC).RESULTS:Of 161 patients,21(13%)were classified as severe AP,and 3(1.9%)died.Statistically significant cutoff values for prediction of severe AP were Ranson≥3,BISAP≥2,APACHE-Ⅱ≥8,CTSI≥3,and CRP24≥21.4.AUCs for Ranson,BISAP,APACHE-Ⅱ,CTSI,and CRP24 in predicting severe AP were 0.69(95%CI:0.62-0.76),0.74(95%CI:0.66-0.80),0.78(95%CI:0.70-0.84),0.69(95%CI:0.61-0.76),and0.68(95%CI:0.57-0.78),respectively.APACHE-Ⅱdemonstrated the highest accuracy for prediction of severe AP,however,no statistically significant pairwise differences were observed between APACHE-Ⅱand the other scoring systems,including CRP24.CONCLUSION:Various scoring systems showed similar predictive accuracy for severity of AP.Unique models are needed in order to achieve further improvement of prognostic accuracy.

Endoscopic papillary large balloon dilation in patients with periampullary diverticula

AIM:To evaluate the safety and effectiveness of endoscopic papillary large balloon dilation(EPLBD)for bile duct stone extraction in patients with periampullary diverticula.METHODS:The records of 223 patients with large common bile duct stones(≥10 mm)who underwent EPLBD(12-20 mm balloon diameter)with or without limited endoscopic sphincterotomy(ES)from July 2006to April 2011 were retrospectively reviewed.Of these patients,93(41.7%)had periampullary diverticula(PAD),which was categorized into three types.The clinical variables of EPLBD with limited ES(EPLBD+ES)and EPLBD alone were analyzed according to the presence of PAD.RESULTS:Patients with PAD were significantly older than those without(75.2±8.8 years vs 69.7±10.9years,P=0.000).The rates of overall stone removal and complete stone removal in the first session were not significantly different between the PAD and nonPAD groups,however,there was significantly less need for mechanical lithotripsy in the PAD group(3.2%vs 11.5%,P=0.026).Overall stone removal rates,complete stone removal rates in the first session and the use of mechanical lithotripsy were not significantly different between EPLBD+ES and EPLBD alone in patients with PAD(96.6%vs 97.1%;72.9%vs 88.2%;and 5.1%vs 0%,respectively).No significant differences with respect to the rates of pancreatitis,perforation,and bleeding were observed between EPLBD+ES and EPLBD alone in the PAD group(3.4%vs 14.7%,P=0.095;0%vs 0%;and 3.4%vs 8.8%,P=0.351,respectively).CONCLUSION:EPLBD with limited ES and EPLBD alone are safe and effective modalities for common bile duct stone removal in patients with PAD,regardless of PAD subtypes.

Complications and management of forgotten long-term biliary stents

AIM To evaluate complications and management outcomes of retained long-term plastic biliary stents.METHODS Endoscopic plastic biliary stent placement was performed in 802 patients at Yeungnam University Hospital between January 2000 and December 2014. Follow-up loss with a subsequently forgotten stent for more than 12 mo occurred in 38 patients. We retrospectively examined the cause of biliary stent insertion, status of stents, complications associated with biliary stents and management outcomes of longterm plastic biliary stents. Continuous variables were analyzed using the t test. Observed frequencies in subsets of the study population were compared using Fisher's exact test and χ~2 tests. Statistical significance was defined as P < 0.05(two-tailed).RESULTS Mean age of patients was 73.7 ± 12 years and maleto-female ratio was 2.2:1. Indications of plastic biliary stent insertion were bile duct stones(63.2%, 24/38) and benign bile duct stricture(52.6%, 20/38). Mean duration of retained plastic stent was 22.6 ± 12.2 mo, and in 10 cases(26.3%), stents were retained for more than 24 mo. Common bile duct(CBD) stones or sludgewere found in most cases(92.1%, 35/38). The most common complication was acute cholangitis(94.7%, 36/38). Stent removal by endoscopic approach was successfully performed in 92.1%(35/38) of the cases. In 3 cases, an additional plastic stent was inserted alongside the previous stent due to failure of the stent removal. Endoscopic removal of bile duct stones was successful in 73.7%(28/38) of the cases. When patients were divided into two groups by duration of stent placement(12 to 24 mo vs over 24 mo), there were no differences in the development of cholangitis, presence of biliary stones, and success rate of endoscopic removal of stones and biliary stents. CONCLUSION The most common complication of retained long-term plastic biliary stents was acute cholangitis associated with CBD stones. Endoscopic management was successfully performed in most cases.

Comparison of the impact of endoscopic retrograde cholangiopancreatography between pre-COVID-19 and current COVID-19 outbreaks in South Korea:Retrospective survey

BACKGROUND The coronavirus disease 2019(COVID-19)outbreak has markedly influenced the endoscopic patterns.Endoscopic retrograde cholangiopancreatography(ERCP)is an essential technique for pancreatobiliary disease but increases the risk of exposure to the virus-containing body fluid;however,the impact of COVID-19 on ERCP is unknown.AIM To compare the number of endoscopic activities and to analyze the clinical outcomes of ERCPs before and during the COVID-19 outbreak in Daegu,South Kore.METHODS This retrospective cohort study included patients aged≥18 years who underwent ERCP between February 18 and March 28,2020,at a tertiary hospital.ERCP indications and endoscopic details were compared with those from the same period in 2018 and 2019 as control groups.RESULTS Of the 269 ERCP procedures,113(42.0%)cases were performed as emergency procedures.The number of ERCP procedures in 2018 and 2019 decreased by 20.2%and 56.6%,respectively,compared with that in 2020(P<0.01);among the 113 emergency ERCPs,the observed numbers in 2018(n=42)and 2019(n=55)dramatically dropped by 61.9%and 70.9%,respectively,compared with that in 2020(n=16).Of the 16 cases in 2020,stone removal was performed in five,biliary stenting in five,sphincterotomy in five,and nasobiliary drainage in one.No case of ERCP-related infection in medical workers or other patients has been reported.CONCLUSION The COVID-19 outbreak significantly reduced the number of ERCPs;however,there is no difference in the indications and endoscopic interventions before and during the COVID-19 outbreak.

Changes in endoscopic patterns before and during COVID-19 outbreak:Experience at a single tertiary center in Korean

BACKGROUND The surge of coronavirus disease 2019(COVID-19)patients has markedly influenced the treatment policies of tertiary hospitals because of the need to protect medical staff and contain viral transmission,but the impact COVID-19 had on emergency gastrointestinal endoscopies has not been determined.AIM To compare endoscopic activities and analyze the clinical outcomes of emergency endoscopies performed before and during the COVID-19 outbreak in Daegu,the worst-hit region in South Korea.METHODS This retrospective cohort study was conducted on patients aged≥18 years that underwent endoscopy from February 18 to March 28,2020,at a tertiary hospital in Daegu.Demographics,laboratory findings,types and causes of emergency endoscopies,and endoscopic reports were reviewed and compared with those obtained for the same period in 2018 and 2019.RESULTS From February 18 to March 28,a total of 366 emergent endoscopic procedures were performed:Upper endoscopy(170,50.6%),endoscopic retrograde cholangiopancreatography(113,33.6%),and colonoscopy with sigmoidoscopy(53,15.8%).The numbers of procedures performed in 2018 and 2019 dropped by 48.8%and 54.8%,respectively,compared with those in 2020.During the COVID-19 outbreak,the main indications for endoscopy were melena(36.7%),hematemesis(30.6%),and hematochezia(10.2%).Of the endoscopic abnormalities detected,gastrointestinal bleeding was the most common:39 cases in 2018,51 in 2019,and 35 in 2020.CONCLUSION The impact of COVID-19 is substantial and caused dramatic reductions in endoscopic procedures and changes in patient behaviors.Long-term follow-up studies are required to determine the effects of COVID-19 induced changes in the endoscopy field.