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- Langerth, Ann
(author)
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Endoscopic retrograde cholangiopancreatography : Perforation and long-term outcomes after endoscopic sphincterotomy
- 2020
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Doctoral thesis (other academic/artistic)abstract
- Endoscopic retrograde cholangio pancreatography (ERCP) is a commonly used procedure in various disorders of the pancreatobiliary tract. When extracting common bile duct stones (CBDS), the major duodenal papilla is divided using a papillotome to perform an endoscopic sphincterotomy (ES). Adverse events occurring shortly after ES are well-known and include perforation which, however, is difficult to investigate due to its low frequency. ES is often used in elderly and/or infirm patients with gallstone pancreatitis and cholangitis, to prevent relapse in biliary events linked to CBDS. Subsequent cholecystectomy in these patients remains controversial. What happens in the long term after ES is still partially unknown.In Paper I, we found an increased risk for both cholangitis and pancreatitis after ES for CBDS, without synchronic relapse of CBDS and when compared with the general population was found. In Paper II, we retained the ES group, but replaced the control group with controls with a history of gallstone disease. The increased risk for both cholangitis and pancreatitis without relapse of CBDS still remains but, no higher risk for malignancy in the pancreatobiliary tract was noted.We conducted study III, a prospective follow-up after ES, to evaluate to what extent ES prevents relapse into biliary events after cholangitis and pancreatitis caused by bile duct stones. We included 100 patients who did not have earlier gallbladder surgery and who were treated for pancreatitis and/or cholangitis. The patients then underwent ES but not cholecystectomy and were followed for a mean of 42 months. None of the patients had recurrent pancreatitis and one had cholangitis. This indicates that ES alone is an alternative to cholecystectomy in the prevention of further attacks of acute pancreatitis and cholangitis.Paper IV consists of 52,140 ERCPs that were registered with GallRiks, a Swedish population based register. A total of 376 cases were registered as perforations and 75 patients had a fatal outcome. These data showed that sphincterotomy in the pancreatic duct increased the risk of death from perforation but the risk of death was reduced when ERCP was performed at a Q4 centre.
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- Langerth, Ann, et al.
(author)
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ERCP‑related perforations : a population‑based study of incidence,mortality, and risk factors
- 2020
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In: Surgical Endoscopy. - : Springer Science and Business Media LLC. - 0930-2794 .- 1432-2218. ; 34, s. 1939-1947
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Journal article (peer-reviewed)abstract
- Background: Perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare but feared adverse events with highly reported morbidity and mortality rates. The aim was to evaluate the incidence and outcome of ERCP-related perforations and to identify risk factors for death due to perforations in a population-based study.Methods: Between May 2005 and December 2013, a total of 52,140 ERCPs were registered in GallRiks, a Swedish nationwide, population-based registry. A total of 376 (0.72%) were registered as perforations or extravasation of contrast during ERCP or as perforation in the 30-day follow-up. The patients with perforation were divided into fatal and non-fatal groups and analyzed for mortality risk factors. The case volume of centers and endoscopists were divided into the upper quartile (Q4) and the lower three quartile (Q1-3) groups. Furthermore, fatal group patients' records were reviewed.Results: Death within 90 days after ERCP-related perforations or at the index hospitalization occurred in 20% (75 out of 376) for all perforations and 0.1% (75 out of 52,140) for all ERCPs. The independent risk factors for death after perforation were malignancy (OR 11.2, 95% CI 5.8-21.6), age over 80 years (OR 3.8, 95% CI 2.0-7.4), and sphincterotomy in the pancreatic duct (OR 2.8, 95% CI 1.1-7.5). In Q4 centers, the mortality was similar with or without pancreatic duct sphincterotomy (14% vs. 13%, p = 1.0), but in Q1-3 centers mortality was higher (45% vs. 21%, p = 0.024).Conclusions: ERCP-related perforations are severe adverse events with low incidence (0.7%) and high mortality rate up to 20%. Malignancy, age over 80 years, and sphincterotomy in the pancreatic duct increase the risk to die after a perforation. The risk of a fatal outcome in perforations after pancreatic duct sphincterotomy was reduced when occurred at a Q4-center. In the case of a complicated perforation a transfer to a Q4-center may be considered.
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- Langerth, Ann, et al.
(author)
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Long-term risk for acute pancreatitis, cholangitis, and malignancy more than 15 years after endoscopic sphincterotomy : a population-based study
- 2015
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In: Endoscopy. - : Georg Thieme Verlag KG. - 0013-726X .- 1438-8812. ; 47:12, s. 1132-1136
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Journal article (peer-reviewed)abstract
- Background and study aims: It has been suggested that endoscopic sphincterotomy predisposes a patient to cholangitis, pancreatitis, and carcinoma in the pancreaticobiliary tract in the long term. Previous studies have shown an increased risk for acute cholangitis and pancreatitis but not for carcinoma. The aim of this study was to analyze these risks by conducting a long-term follow-up study of patients who underwent treatment for gallstone disease, comparing patients who underwent endoscopic sphincterotomy with those who did not. Patients and methods: A cohort of 1113 Swedish patients who were treated with endoscopic sphincterotomy between 1977 and 1990 for common bile duct stones was compared with two age-and sex-matched control groups with a history of cholecystectomy or cholecystectomy and cholangiotomy. Results: Over a median follow-up of more than 15 years after endoscopic sphincterotomy, the hazard ratio for endoscopic sphincterotomy versus cholecystectomy was 5.5 (95 % confidence interval [CI] 3.5 - 8.4) for cholangitis and 4.9 (95 %CI 2.8 - 8.6) for pancreatitis. The hazard ratio for endoscopic sphincterotomy versus cholangiotomy was 1.7 (95 %CI 1.3 - 2.4) for cholangitis and 1.5 (95 %CI 1.0 - 2.4) for pancreatitis. There was no significant increase in risk for malignant diagnoses. Conclusion: Patients who underwent endoscopic sphincterotomy for choledocholithiasis had an increased risk for acute pancreatitis and cholangitis in the long term compared with those not treated with endoscopic sphincterotomy. There was no increase in risk for malignancy in the pancreaticobiliary tract.
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