BackgroundPalliative endobiliary drainage is the mainstay treatment for unresectable malignant biliary obstruction (MBO). Despite optimal drainage, the survival benefit is arguable. This study aimed to identify factors predicting post-endoscopic drainage mortality and develop and validate a mortality prediction model.MethodsWe retrospectively analyzed data for 451 patients with unresectable pancreatobiliary cancers undergoing first endoscopic retrograde cholangiopancreatography (ERCP)-guided endobiliary stent placement between 2007 and 2017. We randomly assigned patients in a 3:1 fashion into a derivation cohort (n=339) and validation cohort (n=112). Predictors for 90-day mortality post-stenting were identified from the derivation cohort. A prediction model was subsequently developed and verified with the validation cohort.ResultsThe overall 90-day mortality rate of the derivation cohort was 46.9%, and the mean age was 64.2 years. The 2 most common diagnoses were cholangiocarcinoma (53.4%) and pancreatic cancer (35.4%). In all, 34.2% had liver metastasis. The median total bilirubin (TB) level was 19.2 mg/dL, and the mean serum albumin was 3.2 g/dL. A metallic stent was used for 64.6% of the patients, and the median stent patency time was 63 days. A total of 70.8% had TB improvement of more than 50% within 2 weeks after stenting, and 14.5% were eligible for chemotherapy. Intrahepatic obstruction (OR=5.69; P=0.023), stage IV cancer (OR=3.01; P=0.001), pre-endoscopic serum albumin (OR=0.48; P=0.001), TB improvement within 2 weeks after stenting (OR=0.57; P=0.036), and chemotherapy after ERCP (OR=0.11; P<0.001) were associated with 90-day mortality after stenting. The prediction model was developed to identify the risk of death within 90 days post-stent placement. The AUROC was 0.76 and 0.75 in derivation and validation cohorts. Patients with a score ≥ 1.40 had a high likelihood of death, whereas those scoring < -1.50 had a low likelihood of death. Additionally, a score ≥ 0.58 provided a 75.2% probability of death, which highlights the usability of the model.ConclusionsThis study proposes a useful validated prediction model to forecast the 90-day mortality of unresectable MBO patients after stenting. The model permits physicians to stratify the death risk and may be helpful to provide a proper palliative strategy.
Background The recurrence rate of spontaneous bacterial peritonitis (SBP) is increasing in cirrhotic patients. Antibiotic prophylaxis should be prescribed in all cirrhotic patients after the first episode of SBP. However, antibiotics promote the development of antibiotic‐resistant bacteria. Objective To identify the factors that predict the recurrence of SBP after the first episode in cirrhotic patients to optimise the stratification for secondary antibiotic prophylaxis. Methods This retrospective study included 145 cirrhotic patients who had their first SBP episode during 2011‐2015. The 86 patients who survived were divided into either the SBP recurrence or non‐recurrence group according to patient SBP outcome during the 2‐year follow‐up. Demographical, clinical and laboratory parameters were recorded at SBP diagnosis and before hospital discharge. SBP recurrence rate, recurrence‐free survival and in‐hospital mortality were also analysed. Results The recurrence rate of SBP after the first episode was 69.8% (60/86), and the median recurrence‐free survival time was 142 days. The in‐hospital mortality rate was 40.7% (59/145). The significant predictive factors for recurrence of SBP were serum potassium ≥4 mEq/L (HR: 1.89; P = .028), serum albumin ≤2 g/dL (HR: 2.5; P = .003) at diagnosis of SBP and platelet count before discharge ≤100 000/microliter (HR: 1.93; P = .029). Conclusion SBP frequently recurs in cirrhotic patients. Serum potassium ≥4 mEq/L, serum albumin ≤2g/dL at SBP diagnosis and platelet count ≤100 000/microliter before discharge were identified as factors that may predict the recurrence of SBP after the first episode.
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