Welcome to PracticeUpdate! We hope you are enjoying access to a selection of our top-read and most recent articles. Please register today for a free account and gain full access to all of our expert-selected content.
Already Have An Account? Log in Now
First-Time ERCP for Benign Indications More Than 1 Year After Cholecystectomy: Incidence and Outcomes
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersBACKGROUND & AIMS
Greater availability of less invasive biliary imaging to rule out choledocholithiasis should reduce the need for diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in patients who have a remote history of cholecystectomy. The primary aims were to determine the incidence, characteristics, and outcomes of individuals who undergo first-time ERCP > 1 year after cholecystectomy (late-ERCP).
METHODS
Data from a commercial insurance claim database (Optum Clinformatics) identified 583,712 adults who underwent cholecystectomy, 4,274 of whom underwent late-ERCP, defined as first-time ERCP for nonmalignant indications > 1 year after cholecystectomy. Outcomes were exposure and temporal trends in late-ERCP, biliary imaging utilization, and post-ERCP outcomes. Multivariable logistic regression was used to examine patient characteristics associated with undergoing late ERCP.
RESULTS
Despite a temporal increase in the use of non-invasive biliary imaging (35.9% in 2004 to 65.6% in 2021, p<0.001), the rate of late-ERCP increased eight-fold: 0.5 to 4.2/1,000 person-years from 2005 to 2021, p<0.001). While only 44% of patients who underwent late-ERCP had gallstone removal, there were high rates of post-ERCP pancreatitis (7.1%), hospitalization (13.1%), and new chronic opioid use (9.7%). Factors associated with late-ERCP included concomitant disorder of gut-brain interaction (OR 6.48, 95%CI:5.88-6.91) and metabolic dysfunction steatotic liver disease (OR 3.27 95%CI:2.79-3.55) along with use of anxiolytic (OR 3.45 95%CI:3.19-3.58), anti-spasmodic (OR 1.60 95%CI:1.53-1.72), and chronic opioids (OR 6.24 95%CI:5.79-6.52).
CONCLUSION
The rate of late-ERCP post-cholecystectomy is increasing significantly, particularly in patients with comorbidities associated with disorder of gut-brain interaction and mimickers of choledocholithiasis. Late-ERCPs are associated with disproportionately higher rates of adverse events, including initiation of chronic opioid use.
Additional Info
Disclosure statements are available on the authors' profiles:
Rise In First-Time ERCP For Benign Indications >1 Year After Cholecystectomy Is Associated With Worse Outcomes
Clin. Gastroenterol. Hepatol. 2024 Apr 08;[EPub Ahead of Print], NR Thiruvengadam, M Saumoy, DE Schaubel, PB Cotton, BJ Elmunzer, ML Freeman, S Varadarajulu, ML Kochman, GA CotéFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Thiruvengadam et al conducted an impactful population-level claims database study in which they evaluated trends in biliary imaging and endoscopic retrograde cholangiopancreatography (ERCP) from 2004 to 2021. They note a striking increase of approximately 30% in utilization of noninvasive biliary imaging in 2021 relative to 2004, which confirms the impression of many advanced endoscopists and aligns with previously reported trends regarding utilization of cross-sectional imaging. This trend is also consistent with the reduction in diagnostic ERCP over the past decades.
The unique angle of this study is its focus on ‘late’ index (first-time) ERCP performed for benign indications over a year after cholecystectomy. Even with the rise in biliary imaging and low rates of diagnostic ERCP, late index ERCPs have increased eightfold in the interval from 2004 to 2021. Only 44% of patients undergoing these late ERCPs had removal of stones as part of their ERCP, and ERCP adverse event rates were quite high for this population, notably including a 7.1% post-ERCP pancreatitis rate.
The population of patients undergoing late ERCP is notable for enrichment of patients with disorders of gut–brain interaction (DGBI) and chronic opioid use. These concomitant comorbidities are of interest for a few reasons. First, in the era following the EPISOD trial, the high risk and low utility of ERCP performed for the indication of sphincter of Oddi dysfunction (SOD) is recognized and, consequently, ERCPs are less commonly performed for SOD. One may postulate that these patients with DGBI and chronic pain who undergo late ERCP are comparable to those who previously underwent ERCP for SOD. Second, it has been demonstrated by our group and others that chronic opiate use and a history of cholecystectomy are associated with biliary dilation. Biliary dilation, coupled with DGBI and pain, may prompt ERCP in some settings, even in the absence of abnormal liver function test results and absence of a stone on biliary imaging. Taken together, these converging realities may lead to a rise in the performance of what effectively becomes a diagnostic ERCP — with associated high rates of adverse events.
This study substantially contributes to the literature characterizing trends in performance of and adverse events associated with ERCP and highlights the important role for novel analyses to identify and define emerging procedure trends. It would be of interest to conduct a multicenter study, which would enable analysis of granular patient-level factors to understand more about clinical decisions to perform ERCP in this population of patients undergoing late ERCP. This could help guide risk stratification, patient selection, and eventual development of recommendations to maximize the utility of and minimize adverse events associated with late ERCP.