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Endoscopy 2021; 53(04): 357-366
DOI: 10.1055/a-1220-2242
Original article

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

Hemant Raj Mutneja
1   Gastroenterology, Cook County Health and Hospitals System, Chicago, Illinois, United States
,
Ishaan Vohra
1   Gastroenterology, Cook County Health and Hospitals System, Chicago, Illinois, United States
,
Andrew Go
2   Medicine, Loyola University Medical Center, Chicago, Illinois, United States
,
Abhishek Bhurwal
3   Gastroenterology, Robert Wood Johnson University Hospital, Chicago, Illinois, United States
,
Vatsala Katiyar
4   Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois, United States
,
Emmanuel Palomera Tejeda
4   Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois, United States
,
Kapil Thapa Chhetri
4   Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois, United States
,
Muhammad Arslan Baig
5   Gastroenterology, University of Illinois College of Medicine, Peoria, Illinois, United States
,
Shilpa Arora
6   Medicine, Rush University Medical Center, Chicago, Illinois, United States
,
Bashar Attar
7   Gastroenterology and Hepatology, John H. Stroger Hospital of Cook County, Chicago, Illinois, United States
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Post-ERCP pancreatitis: still a major issue despite all effortsEndoscopy 2021; 53(04): 367-368
DOI: 10.1055/a-1369-9031

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.

Supplementary material



Publication History

Received: 27 March 2020

Accepted: 15 July 2020

Accepted Manuscript online:
15 July 2020

Article published online:
09 September 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 3 Freeman ML, Nelson DB, Sherman S. et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335: 909-918
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Pekgöz M. Post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review for prevention and treatment. World J Gastroenterol 2019; 25: 4019-4042
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 18 Yadav D, O’Connell M, Papachristou GI. Natural history following the first attack of acute pancreatitis. Am J Gastroenterol 2012; 107: 1096-1103
    CrossrefPubMedGoogle Scholar
  • 19 Sherman S. ERCP and endoscopic sphincterotomy-induced pancreatitis. Am J Gastroenterol 1994; 89: 303-305
    PubMedGoogle Scholar
  • 20 Ratani RS, Mills TN, Ainley CC. et al. Electrophysical factors influencing endoscopic sphincterotomy. Gastrointest Endosc 1999; 49: 43-52
    CrossrefPubMedGoogle Scholar
  • 21 Tryliskyy Y, Bryce GJ. Post-ERCP pancreatitis: pathophysiology, early identification and risk stratification. Adv Clin Exp Med 2018; 27: 149-154
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Chandrasekhara V, Khashab MA. ASGE Standards of Practice Committee. et al. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85: 32-47
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 25 Rabenstein T, Hahn EG. Post-ERCP pancreatitis: is the endoscopist’s experience the major risk factor?. JOP 2002; 3: 177-187
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 33 Ekkelenkamp VE, Koch AD, Rauws E. et al. Competence development in ERCP: the learning curve of novice trainees. Endoscopy 2014; 46: 949-955
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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; DOI: 10.1007/s00464-020-07403-z.
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar