Evaluating the risk of adverse events with interventional endoscopic retrograde cholangiopancreatography and endoscopic ultrasound procedures in cirrhotic patients

Abstract

BACKGROUNDHepatic cirrhosis is associated with greater adverse event rates following surgical procedures and is thought to have a higher risk of complications with interventional procedures in general. However, these same patients often require interventional gastrointestinal procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). While studies examining this scenario exist, the overall body of evidence for adverse event rates associated with ERCP/EUS procedures is more limited. We sought add to the literature by examining the incidence of adverse events after ERCP/EUS procedures in our safety-net hospital population with the hypothesis that severity of cirrhosis correlates with higher adverse event rates.AIMTo examine whether increasing severity of cirrhosis is associated with greater incidence of adverse events after interventional ERCP/EUS procedures.METHODSWe performed a retrospective study of patients diagnosed with hepatic cirrhosis who underwent ERCP and/or EUS-guided fine needle aspirations/fine needle biopsies from January 1, 2016 to March 14, 2019 at our safety net hospital. We recorded Child-Pugh and Model for End-stage Liver Disease (MELD-Na) scores at time of procedure, interventions completed, and 30-day post-procedural adverse events. Statistical analyses were done to assess whether Child-Pugh class and MELD-Na score were associated with greater adverse event rates and whether advanced techniques (single-operator cholangioscopy, electrohydraulic lithotripsy/laser lithotripsy, or needle-knife techniques) were associated with higher complication rates.RESULTS77 procedures performed on 36 patients were included. The study population consisted primarily of middle-aged Hispanic males. 30-d procedure-related adverse events included gastrointestinal bleeding (7.8%), infection (6.5%), and bile leak (2%). The effect of Child-Pugh class C vs class A and B significantly predicted adverse events (β = 0.55, P < 0.01). MELD-Na scores also significantly predicted adverse events (β = 0.037, P < 0.01). Presence of advanced techniques was not associated with higher adverse events (P > 0.05). When MELD-Na scores were added as predictors with the effect of Child-Pugh class C, logistic regression showed MELD-Na scores were a significant predictor of adverse events (P < 0.01). The findings held after controlling for age, gender, ethnicity and repeat cases.CONCLUSIONIncreasing cirrhosis severity predicted adverse events while the presence of advanced techniques did not. MELD-Na score may be more useful in predicting adverse events than Child-Pugh class.

Analysis of risk factors associated with endoscopic retrograde cholangiopancreatography for patients with liver cirrhosis: a multicenter, retrospective, clinical study

“…Our study preliminarily showed that the risk of postoperative complications for patients with cirrhosis was higher than that for patients without cirrhosis. This is consistent with the results of previous studies that showed that many patients with cirrhosis require ERCP in clinical practice [1–3] . Patients with cirrhosis are considered unsuitable for ERCP because of poor hepatic synthesis often associated with platelet dysfunction and coagulopathy, which places them at a higher risk for intraoperative bleeding.…”

“…This is consistent with the results of previous studies that showed that many patients with cirrhosis require ERCP in clinical practice. [1][2][3] Patients with cirrhosis are considered unsuitable for ERCP because of poor hepatic synthesis often associated with platelet dysfunction and coagulopathy, which places them at a higher risk for intraoperative bleeding. Poor coagulation during sphincterotomy can result in acute or delayed bleeding.…”

“…In addition, patients with cirrhosis who undergo endoscopy are at higher risk for dysfunction, portal hypertension, coagulopathy, and other difficulties [1] . However, many patients with cirrhosis and a variety of other diseases, especially obstructive jaundice caused by choledocholithiasis and malignant bile duct obstruction, develop medical problems that are best treated using ERCP [2,3] . They are also at increased risk for adverse events because of underlying liver dysfunction and esophageal varices.…”

“…[ 1 ] However, many patients with cirrhosis and a variety of other diseases, especially obstructive jaundice caused by choledocholithiasis and malignant bile duct obstruction, develop medical problems that are best treated using ERCP. [ 2 , 3 ] They are also at increased risk for adverse events because of underlying liver dysfunction and esophageal varices. Surgery has been considered a contraindication for advanced liver disease because cirrhosis is a significant risk factor for postoperative perioperative complications.…”

Safety of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhosis compared to non-cirrhosis and effect of Child-Pugh score on post-ERCP complications: a systematic review and meta-analysis

“…The pooled incidence of adverse events in patients with cirrhosis was 15.5% (95% CI, 11.8%–19.2%; I 2 =96.2%). The pooled incidence of PEP reported in 21 studies 6 , 7 , 10 - 12 , 15 - 28 , 30 , 31 was 5.1% (95% CI, 3.1%–7.2%; I 2 =91.5%). The pooled incidence of ERCP-related bleeding in 24 studies 6 , 7 , 10 - 31 was 3.6% (95% CI, 2.8%–4.5%; I 2 =67.5%).…”