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
ARTICLE HIGHLIGHTS
Research background

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.

Research motivation

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.

Research objectives

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.

Research 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 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.

Research results

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.

Research conclusions

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.

Research perspectives

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.