Published online Nov 16, 2019. doi: 10.4253/wjge.v11.i11.523
Peer-review started: May 20, 2019
First decision: August 2, 2019
Revised: August 14, 2019
Accepted: October 15, 2019
Article in press: October 15, 2019
Published online: November 16, 2019
Liver cirrhosis is a major health issue around the world and is associated with physiologic changes that have been shown to increase the risk of adverse events in surgical and other interventional procedures. Prior studies examining endoscopic retrograde cholangiopancreatography (ERCP) specifically have demonstrated increased risk of adverse outcomes with worsening cirrhosis severity within these individuals. We sought to evaluate the risk of adverse outcomes against cirrhosis severity with ERCP and interventional endoscopic ultrasound (EUS) procedures within our safety net hospital population as data on this population is lacking.
The study is designed to evaluate the risk of adverse events when performing ERCP and/or interventional EUS procedures on patients with liver cirrhosis. Knowing the adverse event risk against cirrhosis severity will help clinicians assess the risks/benefits of gastrointestinal (GI) procedures in cirrhotic individuals through the use of Child-Pugh Class or Model for End-stage Liver Disease (MELD-Na) score.
Our objective was to examine whether increasing severity of cirrhosis is associated with greater incidence of adverse events after interventional ERCP/EUS procedures in cirrhotic individuals within our safety net population.
We performed a retrospective study of patients diagnosed with hepatic cirrhosis who underwent ERCP and/or EUS-guided fine needle aspirations/fine needle biopsies over a 3 years span at our safety net hospital. 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/laser lithotripsy, or needle-knife techniques) were associated with higher complication rates.
Our study included 77 procedures with the study population consisting primarily of middle-aged Hispanic men. 30-d procedure-related adverse events included GI 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 (P < 0.01). MELD-Na scores also significantly predicted adverse events (P < 0.01). The 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. Our findings demonstrated that Child-Pugh class C and increasing MELD-Na scores were significant predictors of adverse events.
Increasing cirrhosis severity (as defined by MELD-Na score and Child-Pugh Class C) predicted adverse events while the presence of advanced techniques did not. The findings were largely in line with our initial hypothesis and the conclusions drawn by prior studies. Our research suggests that advanced techniques should not be withheld in cirrhotic individuals as they did not significantly contribute to increased adverse event rates. Additionally, our data implies that MELD-Na score may be more useful in predicting adverse events than Child-Pugh class.
The study confirms the results of prior studies and replicates those findings within a safety-net population, a population that has not been studied comprehensively in regards to this subject. Future research can consider comparing the usefulness of MELD-Na score vs Child-Pugh Class in assessing risk with ERCP/EUS procedures in patients with cirrhosis or consider replicating this study with a larger-scale safety net population.