Temporal trends and mortality of post-ERCP pancreatitis in the United States: a nationwide analysis

Abstract

Background Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common and most serious complication of ERCP. Our aim was to estimate the nationwide incidence, temporal trends, and mortality of PEP in the United States and to establish risk factors associated with PEP development.

Methods This was a retrospective cohort study analyzing Nationwide Inpatient Sample data from 2011 to 2017 using International Classification of Diseases codes. The primary outcomes were trends in PEP incidence and predictors of PEP development. Secondary outcomes were in-hospital mortality, length of hospital stay, and admission to the intensive care unit.

Results Of 1 222 467 adult patients who underwent inpatient ERCP during the study period, 55 225 (4.5 %) developed PEP. The hospital admission rate of PEP increased by 15.3 %, from 7735 in 2011 to 8920 in 2017 (odds ratio [OR] 1.23, 95 % confidence interval [CI] 1.04 – 1.46; P = 0.02). The overall rate of mortality increased from 2.8 % of PEP cases in 2011 to 4.4 % in 2017 (OR 1.62, 95 %CI 1.10 – 2.38; P = 0.01). Multiple patient-related (alcohol use, cocaine use, obesity, chronic kidney disease, heart failure), procedure-related (therapeutic ERCP, sphincterotomy, pancreatic duct stent placement, sphincter of Oddi dysfunction), and hospital-related (teaching hospitals, hospitals located in the West and Midwest) factors that impact the occurrence of PEP were identified.

Conclusions Our study showed rising hospital admission and mortality rates associated with PEP in the United States. This calls for a greater recognition of this life-threatening complication and amelioration of its risk factors, whenever possible.

• References

• 1 Jowell PS, Baillie J, Branch MS. et al. Quantitative assessment of procedural competence. A prospective study of training in endoscopic retrograde cholangiopancreatography. . Ann Intern Med 1996; 125: 983-989
• 2 Loperfido S, Angelini G, Benedetti G. et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 1998; 48: 1-10
• 3 Freeman ML, Nelson DB, Sherman S. et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335: 909-918
• 4 Freeman ML, DiSario JA, Nelson DB. et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc 2001; 54: 425-434
• 5 Cheng CL, Sherman S, Watkins JL. et al. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol 2006; 101: 139-147
• 6 Kochar B, Akshintala VS, Afghani E. et al. Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials. Gastrointest Endosc 2015; 81: 143-149.e9
• 7 Elmunzer BJ, Scheiman JM, Lehman GA. et al. U.S. Cooperative for Outcomes Research in Endoscopy (USCORE). A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med 2012; 366: 1414-1422
• 8 Singh P, Das A, Isenberg G. et al. Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials. . Gastrointest Endosc 2004; 60: 544-550
• 9 Buxbaum J, Yan A, Yeh K. et al. Aggressive hydration with lactated Ringer’s solution reduces pancreatitis after endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol 2014; 12: 303-307.e1
• 10 Tse F, Yuan Y, Moayyedi P. et al. Guide wire-assisted cannulation for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis. Endoscopy 2013; 45: 605-618
• 11 Pekgöz M. Post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review for prevention and treatment. World J Gastroenterol 2019; 25: 4019-4042
• 12 Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality. Rockville, MD: HCUP Databases; 2019 Available at (Accessed Apr 12 2020): https://www.hcup-us.ahrq.gov/nisoverview.jsp
• 13 Agency for Healthcare Policy and Research. Comparative analysis of HCUP and NHDS inpatient discharge data. Technical supplement 13. NIS release 5. Available at (Accessed Apr 12 2020): https://www.ahrq.gov/data/hcup/index.html
• 14 Agency for Healthcare Research and Quality. HCUP quality control procedures. Healthcare Cost and Utilization Project. Available at (Accessed Apr 12 2020): http://www.hcup-us.ahrq.gov/db/quality.pdf
• 15 Agency for Healthcare Research and Quality. Introduction to the HCUP nationwide inpatient sample (NIS). Rockville, MD: Available at (Accessed Apr 03 2020): https://www.hcup-us.ahrq.gov/db/nation/nis/NIS_Introduction_2016.jsp
• 16 Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45: 613-619
• 17 Inamdar S, Berzin TM, Sejpal DV. et al. Pregnancy is a risk factor for pancreatitis after endoscopic retrograde cholangiopancreatography in a national cohort study. Clin Gastroenterol Hepatol 2016; 14: 107-114
• 18 Yadav D, O’Connell M, Papachristou GI. Natural history following the first attack of acute pancreatitis. Am J Gastroenterol 2012; 107: 1096-1103
• 19 Sherman S. ERCP and endoscopic sphincterotomy-induced pancreatitis. Am J Gastroenterol 1994; 89: 303-305
• 20 Ratani RS, Mills TN, Ainley CC. et al. Electrophysical factors influencing endoscopic sphincterotomy. Gastrointest Endosc 1999; 49: 43-52
• 21 Tryliskyy Y, Bryce GJ. Post-ERCP pancreatitis: pathophysiology, early identification and risk stratification. Adv Clin Exp Med 2018; 27: 149-154
• 22 Dumonceau JM, Andriulli A, Elmunzer BJ. et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – updated June 2014. Endoscopy 2014; 46: 799-815
• 23 Chandrasekhara V, Khashab MA. ASGE Standards of Practice Committee. et al. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85: 32-47
• 24 Avila P, Holmes I, Kouanda A. et al. Practice patterns of post-ERCP pancreatitis prophylaxis techniques in the United States: a survey of advanced endoscopists. Gastrointest Endosc 2020; 91: 568-573.e2
• 25 Rabenstein T, Hahn EG. Post-ERCP pancreatitis: is the endoscopist’s experience the major risk factor?. JOP 2002; 3: 177-187
• 26 Varadarajulu S, Kilgore ML, Wilcox CM. et al. Relationship among hospital ERCP volume, length of stay, and technical outcomes. Gastrointest Endosc 2006; 64: 338-347
• 27 Wang P, Li ZS, Liu F. et al. Risk factors for ERCP-related complications: a prospective multicenter study. Am J Gastroenterol 2009; 104: 31-40
• 28 Masci E, Toti G, Mariani A. et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001; 96: 417-423
• 29 Sawas T, Bazerbachi F, Haffar S. et al. End-stage renal disease is associated with increased post endoscopic retrograde cholangiopancreatography adverse events in hospitalized patients. World J Gastroenterol 2018; 24: 4691-4697
• 30 Fujisawa T, Kagawa K, Hisatomi K. et al. Obesity with abundant subcutaneous adipose tissue increases the risk of post-ERCP pancreatitis. J Gastroenterol 2016; 51: 931-938
• 31 Keswani RN, Qumseya BJ, O’Dwyer LC. et al. Association between endoscopist and center endoscopic retrograde cholangiopancreatography volume with procedure success and adverse outcomes: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2017; 15: 1866-1875.e3
• 32 Iida T, Kaneto H, Wagatsuma K. et al. Can trainees safely perform endoscopic treatments for common bile duct stones? A single-center retrospective study. . Intern Med 2018; 57: 923-928
• 33 Ekkelenkamp VE, Koch AD, Rauws E. et al. Competence development in ERCP: the learning curve of novice trainees. Endoscopy 2014; 46: 949-955
• 34 Rotundo L, Afridi F, Feurdean M. et al. Effect of hospital teaching status on endoscopic retrograde cholangiopancreatography mortality and complications in the USA. Surg Endosc 2020;
• 35 Voiosu T, Boskoski I, Voiosu AM. et al. Impact of trainee involvement on the outcome of ERCP procedures: results of a prospective multicenter observational trial. Endoscopy 2020; 52: 115-122
• 36 Cotton PB, Lehman G, Vennes J. et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393