Retrospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Nov 16, 2019; 11(11): 523-530
Published online Nov 16, 2019. doi: 10.4253/wjge.v11.i11.523
Evaluating the risk of adverse events with interventional endoscopic retrograde cholangiopancreatography and endoscopic ultrasound procedures in cirrhotic patients
Timothy Yoo, Raisa Epistola, Jordan Epistola, Lawrence Ku, Michael W Fleischman, Sofiya Reicher, Viktor E Eysselein, Linda A Hou
Timothy Yoo, Raisa Epistola, Lawrence Ku, Department of Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509, United States
Jordan Epistola, Department of Psychology, Social, Decision, and Organizational Sciences Program, University of Maryland, College Park, MD 20742, United States
Michael W Fleischman, Sofiya Reicher, Viktor E Eysselein, Linda A Hou, Department of Internal Medicine, Division of Gastroenterology, Harbor-UCLA Medical Center, Torrance, CA 90509, United States
Author contributions: Yoo T, Epistola R and Ku L assisted in data gathering; Yoo T contributed to data analysis; all authors contributed to writing/editing the paper; Epistola J performed the statistical analysis; Fleischman MW, Reicher S, Eysselein VE and Hou LA performed the procedures; Hou LA conceived and designed the study and supervised the entire project.
Institutional review board statement: The study was reviewed and approved by the John F. Wolf, M.D. Human Subjects Committee of the Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center.
Informed consent statement: Following review by the John F. Wolf, M.D. Human Subjects Committee of the Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, the project was granted a waiver of the requirement for individual authorization for use and disclosure of protected health information.
Conflict-of-interest statement: The authors have no conflicts of interest to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Timothy Yoo, MD, Doctor, Department of Internal Medicine, Harbor-UCLA Medical Center, 1000 W. Carson St, Box 400, Torrance, CA 90509, United States. tyoo2@dhs.lacounty.gov
Telephone: +1-310-2222401 Fax: +1-310-3209688
Received: May 20, 2019
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
Processing time: 179 Days and 1.7 Hours
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.