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Chandan S, Desai A, Dahiya DS, Ramai D, Mohan BP, Facciorusso A, Adler DG, Kochhar GS. Risk of post-sphincterotomy bleeding with antiplatelet and anticoagulant use: a propensity-matched analysis of the U.S. Collaborative Network. Gastrointest Endosc 2023; 97:1129-1136.e3. [PMID: 36731579 DOI: 10.1016/j.gie.2023.01.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/28/2022] [Accepted: 01/23/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS GI bleeding after ERCP is a serious adverse event and most commonly occurs after endoscopic biliary and/or pancreatic sphincterotomy. Although the strength of available evidence for post-sphincterotomy GI bleeding risk is high for therapeutic warfarin and heparin, it remains unknown for antiplatelet agents like clopidogrel and prasugrel. We conducted a retrospective United States-based, propensity-matched cohort study to assess the risk of post-sphincterotomy bleeding in patients receiving anticoagulant (AC) and antiplatelet (APT) therapy. METHODS We analyzed the U.S. Collaborative Network in the TriNetX platform through December 27, 2022, to include patients receiving APT and AC therapy who underwent ERCP within 7 days of hospitalization. One-to-one propensity score matching was performed. The primary outcome was the incidence of GI bleeding within 7 days of sphincterotomy. Secondary outcomes included need for blood transfusion, intensive care unit care, and all-cause mortality within 30 days of bleeding. RESULTS Overall, 2806 patients (1806 in the AC cohort and 1000 in the APT cohort) underwent ERCP with sphincterotomy. One-to-one propensity score matching was performed for age, body mass index ≥30 kg/m2, gender, race, ethnicity, diabetes mellitus, nicotine dependence, presence and severity of chronic kidney disease, cirrhosis, and thrombocytopenia between the cohorts. Patients in both cohorts had an increased risk of post-sphincterotomy bleeding compared with matched control subjects (adjusted odds ratios of 3.6 [95% confidence interval, 2.58-5.06] and 2.2 [95% confidence interval, 1.43-3.56], respectively). Although heparin bridging therapy and concurrent use of aspirin did not further increase the risk of GI bleeding, resumption of AC within 24 hours' postprocedure did. Neither cohort of patients was at an increased risk for blood transfusion, intensive care unit care, or all-cause mortality. CONCLUSIONS Our database analysis shows that patients receiving AC and APT therapy are at a higher risk of post-sphincterotomy bleeding compared with matched control subjects. An appropriate drug cessation period or alternative biliary decompression modalities may be used in these patients.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, Nebraska, USA.
| | - Aakash Desai
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Dushyant S Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, Michigan, USA
| | - Daryl Ramai
- Department of Gastroenterology, University of Utah, Salt Lake City, Utah, USA
| | - Babu P Mohan
- Department of Gastroenterology, University of Utah, Salt Lake City, Utah, USA
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy (CATE), Centura Health, Porter Adventist Hospital, Denver, Colorado, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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Zhang WG, Chai NL, Zhang B, Li X, Wang JF, Dong H, Feng YJ, Linghu EQ. Cholangioscopy-assisted extraction through novel papillary support for small-calibre and sediment-like common bile duct stones. World J Gastroenterol 2023; 29:2495-2501. [PMID: 37179586 PMCID: PMC10167904 DOI: 10.3748/wjg.v29.i16.2495] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/09/2023] [Accepted: 04/07/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND To date, endoscopic retrograde cholangiopancreatography has become a well-established treatment for common bile duct (CBD) stones. However, it is not suitable for some special patients, such as pregnant women, children or those who cannot stop taking anti-coagulation/anti-platelet agents because of radiation injury and the risk of postoperative bleeding resulting from endoscopic sphincterotomy. To overcome these two problems, this study introduced cholangioscopy-assisted extraction through a novel papillary support for small-calibre and sediment-like CBD stones. AIM To assess the feasibility and safety of cholangioscopy-assisted extraction through a novel papillary support (CEPTS) for small-calibre and sediment-like common bile duct (CBD) stones. METHODS This Retrospective study was approved by the Ethics Committee of the Chinese PLA General Hospital. We designed a covered single dumbbell-style papillary support between 2021 and 2022. Between July 2022 and September 2022, 7 consecutive patients with small-calibre (cross diameter ≤ 1.0 cm) or sediment-like CBD stones underwent CETPS procedures in our center. The clinical characteristics and treatment outcomes of these 7 patients were extracted from a prospectively collected database. And the related data were analyzed. Informed consent was obtained from all participating patients. RESULTS A total of 2 patients had yellow sediment-like CBD stones, and aspiration extraction was performed after the insertion of papillary support. Of the 5 patients with clumpy CBD stones (0.4-1.0 cm), 2 underwent basket extraction under direct vision for a single stone (0.5-1.0 cm, black and black grey), 1 underwent balloon plus aspiration extraction under direct vision for 5 stones (0.4-0.6 cm, brown), and 2 underwent aspiration extraction only for a single stone (0.5-0.6 cm, yellow, none). Technical success, namely, no residual stones in the CBD or left and right hepatic ducts, was achieved in all 7 cases (100%). The median operating time was 45.0 minutes (range 13.0-87.0 minutes). Postoperative pancreatitis (PEP) occurred in one case (14.3%). Hyperamylasaemia without abdominal pain was noted in 2 of 7 patients. No residual stones or cholangitis were found during the follow-up. CONCLUSION CETPS appeared to be feasible to treat patients with small-calibre or sediment-like CBD stones. Patients, especially pregnant women and those who cannot stop anticoagulation/anti-platelet agents, could benefit from this technique.
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Affiliation(s)
- Wen-Gang Zhang
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Ning-Li Chai
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Bo Zhang
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Xiao Li
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Jia-Feng Wang
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Hao Dong
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Yu-Jie Feng
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - En-Qiang Linghu
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
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Koksal AS, Eminler AT, Parlak E. Fully Covered Metal Stents Safely Facilitate Extraction of Difficult Bile Duct Stones. Surg Laparosc Endosc Percutan Tech 2023; 33:152-161. [PMID: 36821696 DOI: 10.1097/sle.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 01/02/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Ten to 15% of the common bile duct (CBD) stones require advanced endoscopic extraction techniques during endoscopic retrograde cholangiopancreatography. The study aimed to evaluate the efficacy and safety of fully covered self-expandable metal stents (FC-SEMS) for facilitating the extraction of difficult bile duct stones. METHODS Patients who received FC-SEMS for the extraction of difficult CBD stones were retrospectively reviewed. Group 1 included patients with extrahepatic stones above a distal CBD stricture, Group 2 included patients with intrahepatic stones above a hilar stricture, and Group 3 included patients with complex stone(s) and no biliary stricture. Complete stone clearance rate and complications of FC-SEMS treatment were evaluated. RESULTS The study group included 33 procedures on 32 patients (mean age: 55±17, 56.3% male). FC-SEMS was placed as a primary treatment in 15 (45.5%) procedures. Complete stone clearance was achieved in 84.6% of the procedures in Group 1, 100% in Group 2, and 87.5% in Group 3 ( P =0.23). Overall, complete stone clearance was achieved in 30 of the 33 procedures (90.9%). None of the patients developed pancreatitis, cholecystitis, or cholangitis. Stent migration occurred in 4 procedures (12.1%), and all were clinically insignificant. CONCLUSION FC-SEMS is effective and safe for facilitating treatment of difficult bile duct stones.
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Affiliation(s)
- Aydin Seref Koksal
- Faculty of Medicine, Department of Gastroenterology, Sakarya University, Sakarya
| | - Ahmet Tarik Eminler
- Faculty of Medicine, Department of Gastroenterology, Sakarya University, Sakarya
| | - Erkan Parlak
- Faculty of Medicine, Department of Gastroenterology, Hacettepe University, Ankara, Turkey
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Huang C, Cai XB, Guo LL, Qi XS, Gao Q, Wan XJ. Drug-eluting fully covered self-expanding metal stent for dissolution of bile duct stones in vitro. World J Gastroenterol 2019; 25:3370-3379. [PMID: 31341362 PMCID: PMC6639552 DOI: 10.3748/wjg.v25.i26.3370] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/26/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The treatment of difficult common bile duct stones (CBDS) remains a big challenge around the world. Biliary stenting is a widely accepted rescue method in patients with failed stone extraction under endoscopic retrograde cholangiopancreatography. Fully covered self-expanding metal stent (FCSEMS) has gained increasing attention in the management of difficult CBDS.
AIM To manufacture a drug-eluting FCSEMS, which can achieve controlled release of stone-dissolving agents and speed up the dissolution of CBDS.
METHODS Customized covered nitinol stents were adopted. Sodium cholate (SC) and disodium ethylene diamine tetraacetic acid (EDTA disodium, EDTA for short) were used as stone-dissolving agents. Three different types of drug-eluting stents were manufactured by dip coating (Stent I), coaxial electrospinning (Stent II), and dip coating combined with electrospinning (Stent III), respectively. The drug-release behavior and stone-dissolving efficacy of these stents were evaluated in vitro to sort out the best manufacturing method. And the selected stone-dissolving stents were further put into porcine CBD to evaluate their biosecurity.
RESULTS Stent I and Stent II had obvious burst release of drugs in the first 5 d while Stent III presented controlled and sustainable drug release for 30 d. In still buffer, the final stone mass-loss rate of each group was 5.19% ± 0.69% for naked FCSEMS, 20.37% ± 2.13% for Stent I, 24.57% ± 1.45% for Stent II, and 33.72% ± 0.67% for Stent III. In flowing bile, the final stone mass-loss rate of each group was 5.87% ± 0.25% for naked FCSEMS, 6.36% ± 0.48% for Stent I, 6.38% ± 0.37% for Stent II, and 8.15% ± 0.27% for Stent III. Stent III caused the most stone mass-loss no matter in still buffer or in flowing bile, which was significantly higher than those of other groups (P < 0.05). In vivo, Stent III made no difference from naked FCSEMS in serological analysis (P > 0.05) and histopathological examination (P > 0.05).
CONCLUSION The novel SC and EDTA-eluting FCSEMS is efficient in diminishing CBDS in vitro. When conventional endoscopic techniques fail to remove difficult CBDS, SC and EDTA-eluting FCSEMS implantation may be considered a promising alternative.
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Affiliation(s)
- Chao Huang
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201620, China
- Shanghai Key Laboratory for Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201620, China
| | - Xiao-Bo Cai
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201620, China
- Shanghai Key Laboratory for Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201620, China
| | - Li-Li Guo
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201620, China
- Shanghai Key Laboratory for Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201620, China
| | - Xiao-Sheng Qi
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201620, China
| | - Qiang Gao
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, College of Chemistry, Chemical Engineering and Biotechnology, Donghua University, Shanghai 201620, China
| | - Xin-Jian Wan
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201620, China
- Shanghai Key Laboratory for Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201620, China
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Zimmer V. A Novel Approach for Incisionless Stone Management: Transpapillary Lumen-Apposing Metal Stent for Duct Clearance and Cholangioscopy Access. Clin Endosc 2019; 52:201-202. [PMID: 30300978 PMCID: PMC6453842 DOI: 10.5946/ce.2018.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 09/05/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Vincent Zimmer
- Department of Medicine, Marienhausklinik St. Josef Kohlhof, Neunkirchen, Germany.,Department of Medicine II, Saarland University Medical Center, Saarland University Homburg, Homburg, Germany
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Self-expandable metal stents for choledocholithiasis in Billroth II gastrectomy patients. Hepatobiliary Pancreat Dis Int 2018; 17:546-552. [PMID: 30126827 DOI: 10.1016/j.hbpd.2018.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/26/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Efficient ampullary intervention is essential for endoscopic retrograde cholangiopancreatography (ERCP) in patients with a prior Billroth II gastrectomy. We retrospectively evaluated the safety and effectiveness of ampullary intervention using fully covered self-expandable metal stents (FCSEMSs) for the management of common bile duct (CBD) stones in a subset of patients with a history of Billroth II gastrectomy. METHODS This retrospective analysis involved patients with a prior Billroth II gastrectomy who underwent ampullary intervention with FCSEMSs for the management of CBD stones. The factors associated with FCSEMSs placement, treatment success, and procedural complications were analyzed. RESULTS A group of 15 patients (10 males; median age, 78 years) underwent biliary metal stent placement for high degree of CBD angulation (6), small or flat papilla with unclear margin (5), current use of double antiplatelet agents or an anticoagulant (2), unwanted instrumentation of the cystic duct (1), and insecure position of the scope (1). Ampullary intervention with FCSEMSs was successful in all patients. After dilating the ampulla of Vater and building a durable conduit with FCSEMSs immediately, CBD stones were removed successfully from all patients in a single session. A mild post-ERCP pancreatitis occurred in one patient, who recovered without complications. CONCLUSION Ampullary intervention with FCSEMSs is safe and effective for the management of CBD stones in a subset of patients with a history of Billroth II gastrectomy.
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