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

Abstract

BACKGROUND

Hepatic 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.

AIM

To examine whether increasing severity of cirrhosis is associated with greater incidence of adverse events after interventional ERCP/EUS procedures.

METHODS

We 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.

RESULTS

77 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.

CONCLUSION

Increasing 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.

Keywords: Endoscopic retrograde cholangiopancreatography, Endoscopic ultrasound, Fine-needle aspiration, Fine-needle biopsy, Hepatic cirrhosis, Model for End-stage Liver Disease, Child-Pugh Class, Adverse events

Core tip: We performed a retrospective review of all patients with hepatic cirrhosis who underwent interventional endoscopic retrograde cholangiopancreatography/ endoscopic ultrasound procedures over a 3 years span at our safety-net hospital and evaluated outcomes within a 30-d period. 77 cases were included. Both Model for End-stage Liver Disease (MELD-Na) score and Child-Pugh class C predicted adverse events (P < 0.01). When MELD-Na scores were added as predictors with the effect of Child-Pugh class C, only MELD-Na scores were a significant predictor of adverse events (P < 0.01). Our data demonstrates a correlation between cirrhosis severity and adverse events and suggests that MELD-Na score may be useful in assessing procedural risk.