Inpatient Endoscopic Retrograde Cholangiopancreatography Research Articles

Impact of COVID-19 Infection on Pancreato-Biliary Diseases Requiring Endoscopic Retrograde Cholangiopancreatography.

Viral infections are known to impact the pancreato-biliary system; however, there are limited data showing that the same is true of COVID-19. Endoscopic retrograde cholangiopancreatography (ERCP) can safely be performed in patients with COVID-19 infection, but outcomes of patients with COVID-19 infections and concomitant pancreatic and biliary disease requiring endoscopic intervention are unknown. This study aims to evaluate the severity of pancreaticobiliary diseases and post-ERCP outcomes in COVID-19 patients. Patients with pancreato-biliary disease that required inpatient ERCP from five centers in the United States and South America between January 1, 2020, and October 31, 2020 were included. A representative cohort of patients from each month were randomly selected from each site. Disease severity and post-ERCP outcomes were compared between COVID-19 positive and COVID-19 negative patients. A total of 175 patients were included: 95 COVID positive and 80 COVID negative. Mean CTSI score for the patients who had pancreatitis was higher in COVID-positive cohort by 3.2 points (p < .00001). The COVID-positive group had more cases with severe disease (n = 41) versus the COVID-negative group (n = 2) (p < .00001). Mortality was higher in the COVID-19 positive group (19%) compared to COVID-negative group (7.5%) even though the COVID-19-negative group had higher incidence of malignancy (n = 17, 21% vs n = 7, 7.3%) (p = 0.0455). This study shows that patients with COVID infection have more severe pancreato-biliary disease and worse post-ERCP outcomes, including longer length of stay and higher mortality rate. These are important considerations when planning for endoscopic intervention. gov: (NCT05051358).

Increasing Antibiotic-Resistant Infections With Inpatient Endoscopic Retrograde Cholangioscopies (ERCP) Is Associated With Higher Mortality in the United States: A Cross-sectional Cohort Study.

This study aims to investigate associated mortality with inpatient endoscopic retrograde cholangiopancreatography (ERCP) with and without resistant infections. The co-primary objective compares frequencies of inpatient ERCP with resistant infections to overall hospitalizations with resistant infections. The risks of inpatient antibiotic-resistant organisms are known, but the associated mortality for inpatient ERCP is unknown. We aim to use a national database of hospitalizations and procedures to understand trends and mortality for patients with antibiotic-resistant infections during inpatient ERCP. The largest publicly available all-payer inpatient database in the United States (National Inpatient Sample) was used to identify hospitalizations associated with ERCPs and antibiotic-resistant infections for MRSA, VRE, ESBL, and MDRO. National estimates were generated, frequencies were compared across years, and multivariate regression for mortality was performed. From 2017 to 2020, national weighted estimates of 835,540 inpatient ERCPs were generated, and 11,440 ERCPs had coincident resistant infections. Overall resistant infection, MRSA, VRE, and MDRO identified at the same hospitalization of inpatient ERCPs were associated with higher mortality (OR CI(95%): Overall: 2.2(1.77-2.88), MRSA: 1.90 (1.34-2.69), VRE: 3.53 (2.16-5.76), and MDRO: 2.52 (1.39-4.55)). While overall hospitalizations with resistant infections have been decreasing annually, there has been a yearly increase in admissions requiring ERCPs with simultaneous resistant infections ( P =0.001-0.013), as well as infections with VRE, ESBL, and MDRO ( P =0.001-0.016). Required Research Practices for Studies Using the NIS scoring was 0, or the most optimal. Inpatient ERCPs have increasing coincident resistant infections and are associated with higher mortality. These rising infections during ERCP highlight the importance of endoscopy suite protocols and endoscopic infection control devices.

Outcomes of ERCP in Patients With Cystic Fibrosis: A Nationwide Inpatient Assessment.

Cystic fibrosis (CF) is a multisystem disorder that leads to abnormal transport of chloride and sodium across secretory epithelia resulting in thickened, viscous secretions in the bronchi, biliary tract, pancreas, intestine, and the reproductive system. Defects in the biliary tract can predispose to stone formation requiring endoscopic retrograde cholangiopancreatography (ERCP). However, there is a paucity of data assessing ERCP outcomes in patients with CF. We identified patients from the Healthcare Cost and Utilization Project (HCUP)-National Inpatient Sample (NIS) between the years 2016 and 2020. Our study group included patients with CF of all ages who underwent an inpatient ERCP. We used ICD10 diagnostic and procedural codes to identify patients, procedures, and complications of the procedure. From 2016 to 2020, a total of 860,679 inpatient ERCPs were identified. Of these procedures, 535 (0.06%) were performed in patients with CF. The mean age of patients with CF undergoing ERCP was 60.62 years, of which 48% were males and 52% were females. Patients in the CF group had a higher incidence of post-ERCP pneumothorax (0.93%) than the patients in the non-CF group (0.15%). The occurrence of other ERCP-related adverse events was similar in both groups (P>0.05). On multivariate regression analysis, patients with CF were 1.75 times more likely to develop post-ERCP infections [odds ratio (OR): 1.75; 95% CI: 1.03-2.94; P=0.035) and 7.64 times more likely to develop post-ERCP pneumothorax (OR: 7.64; 95% CI: 1.03-56.5; P=0.046) compared to patients without CF after adjusting for confounders. The groups had no significant difference in mortality, post-ERCP pancreatitis, bleeding, perforation, pneumoperitoneum, and gas embolism. There was also no significant difference in the length of stay between the study and control groups. ERCP is a safe procedure in patients with CF with a comparable risk of postprocedural complications and mortality to those who do not have cystic fibrosis. However, patients with CF may experience a higher risk of post-ERCP infections and post-ERCP pneumothorax. Further studies are needed to prospectively evaluate outcomes of ERCP in patients with CF and to determine methods of mitigating adverse events.

S1269 Racial Disparities in All-Cause Inpatient Endoscopic Retrograde Cholangiopancreatography in the United States: How Important Is Race?

S1269 Racial Disparities in All-Cause Inpatient Endoscopic Retrograde Cholangiopancreatography in the United States: How Important Is Race?

Association between smoking status and inpatient outcomes of acute cholangitis in the United States: a propensity matched analysis.

Acute cholangitis (AC) is an infection of the biliary tract superimposed on stasis. This study aimed to investigate the effects of smoking on inpatient outcomes of AC. We identified primary AC hospitalizations using the National Inpatient Sample database (2017-2020). Using a 1:1 matching method, we created a matched comparison cohort of AC patients who were non-smokers, based on demographics, hospital characteristics and comorbidities. We matched 3960 smoker patients with 3960 non-smoker patients within the AC population. Non-smokers were older than smokers (70 vs. 59 years, P<0.001). Smokers had a stronger association with bile duct calculi (74.37% vs. 69.29%, P<0.001) and other bile duct disorders (clots, parasites, extrinsic compression and other rare disorders) (6.82% vs. 5.05%, P=0.011). No significant difference in inpatient mortality, median length of stay (LOS), or median inpatient cost (MIC) was found between the matched cohorts (P>0.05). However, smoking was associated with higher odds of complications, including sepsis without shock (0.88% vs. 0.51%, P=0.042), sepsis with shock (1.26% vs. 0.51%, P<0.001), biliary pancreatitis (6.57% vs. 4.42%, P<0.001) and myocardial infarction (6.19% vs. 3.54%, P<0.001), as well as a greater need for inpatient endoscopic retrograde cholangiopancreatography (ERCP) (72.85% vs. 63.76%, P<0.001) and early ERCP (50.76% vs. 42.32%, P<0.001) compared to non-smokers. This study found no difference in mortality, LOS, or MIC in acute cholangitis-related hospitalizations associated with smoking. However, smoking was associated with a higher risk of complications and a greater need for ERCP and early ERCP.

The role and timing of endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis without cholangitis: A nationwide analysis.

The role and optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis without cholangitis (ABPwoC) remains unclear. Using a large national database, we aimed to examine hospitalization outcomes of patients with ABPwoC as a function of the performance and timing of ERCP. This was a retrospective study of adult patients with ABPwoC utilizing the National Inpatient Sample from 2016-2017. Patients who underwent inpatient ERCP were stratified into performance: within 24, 24-48, 48-72, and >72 h of hospital admission. The primary outcome was all-cause inpatient mortality as a function of the performance and timing of ERCP; secondary outcomes, including healthcare utilization, were assessed. Multivariate modeling was used to adjust for potential confounders. Statistical analyses were conducted using STATA, version 16.0. Of the 70 030 patients with ABPwoC, 31.37% underwent inpatient ERCP. Performance (aOR: 0.6, p< .05), but not timing (aOR: 0.98, p= .9), of inpatient ERCP was associated with significantly lower all-cause inpatient mortality. Urgent ERCP (within 24 h) was associated with shorter hospital length of stay, lower charges and cost, and less need for pancreatic drainage procedures, while ERCP within 72 h was associated with less frequent intensive care unit admission (all p< .05). Based on this large, nationwide analysis, inpatient ERCP for ABPwoC is associated with lower all-cause mortality. ERCP within 24 and 72 h, though not associated with lower mortality, are associated with multiple improved clinical outcomes, including lower healthcare charges and costs.

Racial disparities in endoscopic retrograde cholangiopancreatography (ERCP) utilization in the United States: are we getting better?

We identified trends of inpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the United States (US), focusing on outcomes related to specific patient demographics. The National Inpatient Sample was utilized to identify all adult inpatient ERCP in the US between 2007-2018. Trends of utilization and adverse outcomes were highlighted. P-values ≤ 0.05 were considered statistically significant. We noted a rising trend for total inpatient ERCP in the US from 126,921 in 2007 to 165,555 in 2018 (p = 0.0004), with a significant increase in utilization for Blacks, Hispanics, and Asians. Despite an increasing comorbidity burden [Charlson Comorbidity Index (CCI) score ≥ 2], the overall inpatient mortality declined from 1.56% [2007] to 1.46% [2018] without a statistically significant trend (p = 0.14). Moreover, there was a rising trend of inpatient mortality for Black and Hispanic populations, while a decline was noted for Asians. After a comparative analysis, we noted higher rates of inpatient mortality for Blacks (2.4% vs 1.82%, p = 0.0112) and Hispanics (1.17% vs 0.83%, p = 0.0052) at urban teaching hospitals between July toand September compared to the October to June study period; however, we did not find a statistically significant difference for the Asian cohort (1.9% vs 2.10%, p = 0.56). The mean length of stay (LOS) decreased from 7days in 2007 to 6days in 2018 (p < 0.0001), while the mean total hospital charge (THC) increased from $48,883 in 2007 to $85,909 in 2018 (p < 0.0001) for inpatient ERCPs. Compared to the 2015-2018 study period, we noted higher rates of post-ERCP pancreatitis (27.76% vs 17.25%, p < 0.0001) from 2007-2014. Therapeutic ERCP utilization and inpatient mortality were on the rise for a subset of the American minority population, including Black and Hispanics.

Malnutrition Is Associated With Worse Outcomes of Inpatient Endoscopic Retrograde Cholangiopancreatography.

ObjectivesEndoscopic retrograde cholangiopancreatography (ERCP) is frequently used to manage pancreaticobiliary disorders in an inpatient setting. Malnutrition is prevalent among hospitalized patients, and it is generally associated with poor clinical outcomes. However, there is a lack of studies on how malnutrition affects the outcomes of inpatient ERCP. Thus, we investigated the outcomes of inpatient ERCP among patients with malnutrition.MethodsAdult patients who underwent ERCP from the 2014 National Inpatient Sample database were selected to conduct retrospective analysis. Patient demographics and outcomes of ERCP were compared between the groups with and without malnutrition. The outcomes of interest were inpatient mortality, length of stay, total hospital charge, and ERCP complications, including pancreatitis, cholecystitis, cholangitis, sepsis, hemorrhage, and intestinal perforation.ResultsPatients with malnutrition had longer length of stay (15.5 days vs. 6.7 days, p < 0.05) and higher total hospital charge ($149,699 vs. $71,723, p < 0.05). Malnutrition was an independent risk factor for inpatient mortality (adjusted odds ratio (aOR) 2.54, 95% confidence interval (CI): 1.70-3.82, p < 0.05), sepsis (aOR 2.20, 95% CI: 1.82-2.65, p < 0.05), hemorrhage (aOR 1.64, 95% CI: 1.05-2.56, p < 0.05), and intestinal perforation (aOR 4.29, 95% Cl:1.61-11.46, p < 0.05).ConclusionsOur study indicates that patients with malnutrition are more likely to have worse outcomes, such as increased inpatient mortality, sepsis, hemorrhage, and intestinal perforation. Understanding the nutrition status of patients undergoing ERCP can be a useful approach for risk stratification and determining if closer surveillance of the complications is warranted.

S3077 Acute Pancreatitis Without Early Imaging Changes Has Similar Outcomes to Those With Early Changes

INTRODUCTION: Increased use of abdominal computed tomography (CT) in the emergency department (ED) has led to a diagnostic dilemma where patients present with abdominal pain and lipase levels three times the upper limit of normal (ULN) while abdominal imaging may not support a diagnosis of acute pancreatitis (AP). This study seeks to determine whether early imaging findings are associated with change in clinical outcomes in AP patients. METHODS: The study is a single-center, retrospective cohort study with patients from 1/1/2016 to 12/31/2018 presenting to the ED and tested for serum lipase levels (N = 1464). Those with serum lipase of three times ULN (N = 209) and with CT imaging of the abdomen and pelvis with contrast performed in the ED were included in the cohort (N = 93). All charts were reviewed for repeat CT imaging, magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) during admission, bedside index for severity in AP (BISAP) score criteria, intensive care unit (ICU) admission, hospital length of stay (LOS), in-hospital mortality and hospital disposition. Outcome measurements consisted of RR of death, ICU admission, BISAP score >=2, BISAP >=3, inpatient ERCP and median length of hospital stay for patients with CT changes suggesting AP at ED presentation versus those patients with CT not notable for changes of AP. RESULTS: CT findings consistent with AP were associated with a RR for ICU admission of 1.47 [CI: 0.41-5.33, P = 0.55] , RR of 3.79 [CI:0.48-30.20, P = 0.21] for repeat inpatient CT imaging, RR of 0.95 [CI:0.48-2.33, P = 0.89] for MRCP, RR of 1.05 [CI:0.42-2.65, P = 0.91] for ERCP, RR of 0.32 [CI:0.03-3.36, P = 0.34] for death, RR of 0.63 [CI:0.09-4.29, P = 0.64] for non-home disposition, RR of 0.32 [CI:0.03-3.35, P = 0.34] for BISAP >=3, RR of 1.26 [CI:0.52-3.07, P = 0.61) for BISAP >=2. Difference in mean LOS for CT positive AP was 1.73 [CI:0.21-3.67, P = 0.08] 4.7 days versus 2.97 days in CT negative AP. CONCLUSION: Ninety-three out of 209 (44%) patients with lipase levels three times the ULN underwent CT imaging during ED assessment. Relative risk of ICU admission, difference in mean hospital LOS, risk of BISAP≥2 and BISAP≥3, risk of mortality and non-home disposition rate were all statically non-significant. These findings suggest that patients with early CT imaging not showing changes of AP have an unchanged clinical course. Therefore, they should be treated similarly as those with CT imaging displaying AP.

Tu1029 POST BARIATRIC ANATOMY AS A RISK FACTOR FOR POST ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PANCREATITIS: A NATIONWIDE, MATCHED, CASE-CONTROL ANALYSIS

Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis (PEP) is a common complication occurring at a rate of 1-15%. Predictors of PEP include the type of intervention, age, and hospital setting. Performing ERCP in patients with altered anatomy, such as those with roux-en-Y gastric bypass (RYGB), is becoming increasingly common. However, data is limited on the risk of PEP in this patient population. The aim of this study is to evaluate post bariatric anatomy as a risk factor for PEP. The study population was extracted from the Nationwide Inpatient Sample (NIS) for the years 2000-2014. Adult patients, who were admitted with biliary obstruction without acute pancreatitis as their primary diagnosis and had an inpatient ERCP were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes. PEP was defined as having a diagnosis of acute pancreatitis after index ERCP. Patients with bariatric anatomy were identified by the code V45.86 and the above timeframe was chosen in an effort to capture the RYGB population while minimizing the more recent sleeve gastrectomy procedure which does not require an altered approach to ERCP. Cases were matched in a 4:1 fashion to controls by age, gender, race, geographic region, hospital teaching status, and ERCP intervention (diagnostic, biliary without pancreatic and biliary with pancreatic cannulation or intervention). Rates of PEP were calculated based on the bariatric surgery status and by ERCP intervention type and were compared using Chi square and regression analyses. A total of 3,890 patients with bariatric anatomy who were admitted with biliary obstruction and had inpatient ERCP were identified. Mean age was 51 years, 81% were female and 69% were of white ethnicity. These patients were matched to 12,784 patients without bariatric anatomy (Table 1). Overall rate of PEP was 6.3%. Patients with bariatric anatomy had a PEP rate of 8.1% as compared to 5.8% for those without bariatric anatomy (p<0.001). After matching for intervention and the above-mentioned demographics, odds ratio of PEP was 1.4 (CI 1.2-1.6, p <0.001). The rate varied significantly based on the ERCP intervention as below (Figure 1). In this nationwide analysis, bariatric surgical anatomy was associated with a significant increase in the post ERCP pancreatitis rate even after controlling for classic procedural and patient risk factors. Since most of these procedures were being performed with forward viewing deep enteroscopy, the increased risk could be attributed to the technical difficulty of cannulation. This might be ameliorated with the use of newer techniques that involve access to the excluded stomach.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Su1450 OUTCOMES OF ERCP IN PATIENTS WITH ACUTE STROKE: A NATIONAL STUDY

There is limited data on the safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients with recent acute stroke. The objective of this study is to better assess safety and outcomes in patients with admission for acute stroke that undergo ERCP for a variety of reasons during the same admission in a national inpatient database. The National Inpatient Sample (NIS) is the largest all-payer inpatient database in the United States. Data from the years 2008 to 2014 were collected. Patients older than 18 years with an admission diagnosis of acute stroke (ischemic or hemorrhagic) and who underwent ERCP were included. Case-control matching (2:1) for patients that underwent ERCP but did not have acute stroke was done based on age and sex. Complications related to the ERCP were measured against these case controls. Limitations of the study are that the NIS is an administrative database which predisposes to errors from coding inaccuracies as well as the inability to distinguish temporal relationships between variables. Between 2008 and 2014, there were 562 patients older than 18 years with acute stroke who underwent inpatient ERCP during the same hospital admission. Baseline patient demographics and hospital characteristics is available in Table 1. Complications related to ERCP occurred more frequently in the stroke group (13.8% vs. 8.7%, p=0.001). The rate of post-ERCP pancreatitis (10.4% vs. 7.4%, p=0.04) as well as post-ERCP bleeding (2.5% vs. 1.2%, p=0.07) was higher in the stroke group compared to the control. The risk of bleeding was not statistically different between groups however. This is outlined in Table 3.The primary indication for ERCP in patients with acute stroke was biliary stricture while that in the control group was biliary pancreatitis (Table 2). Although overall complications are higher in the acute stroke setting, ERCP can be performed when indicated. Caution should be exercised to avoid or minimize complications such as risks of post-ERCP pancreatitis and bleeding. Prospective randomized controlled studies are needed to better define the timing of the ERCP in this setting.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Use of ERCP in the United States over the past decade.

Abstract Background and study aims With newer imaging modalities, indications for use of endoscopic retrograde cholangiopancreatography (ERCP) have changed in the last decade. Despite advances in ERCP, paucity in recent literature regarding utilization and outcomes of ERCP exists. Thus, the aim of this study was to assess the inpatient use of ERCP, outcomes, and most common indications. Patients and methods Retrospective-cohort study using the Nationwide Inpatient Sample 2007–2016. All patients with ICD9–10CM procedural codes for ERCP were included. The primary outcome was the use of ERCP. Secondary outcomes included determining procedural specifics (stenting, sphincterotomy and dilation), complications (post-ERCP pancreatitis [PEP], bile duct perforation), hospital length of stay, total hospital costs and charges. Multivariate regression analysis was used to adjust for confounders. Results A total of 1,606,850 patients underwent inpatient ERCP. The mean age was 59 years (60 % female). The total number of ERCPs increased over the last decade. Patients undergoing ERCP in 2016 had greater odds of undergoing bile duct stent placement, pancreatic duct (PD) stenting, biliary dilation, pancreatic sphincterotomy, PEP and biliary perforation. Inpatient mortality decreased. Hospital charges increased, while length of stay (LOS) decreased. Conclusions The number of ERCPs increased in the past decade. Odds of therapeutic interventions and complications increased. The most common principal diagnoses were choledocholithiasis and gallstone-related AP. Hence, physicians must be aware to promptly diagnose and treat complications. These findings may reflect the increased case complexity and fact that ERCP continues to evolve into an increasingly interventional tool, contrasting from its former role as a predominantly diagnostic and gallstone extraction tool.

Predictors of postendoscopic retrograde cholangiopancreatography pancreatitis, analysis of more than half a million procedures performed nationwide over the last 15 years.

Background and AimPost‐ERCP pancreatitis (PEP) is the most common complication following endoscopic retrograde cholangiopancreatography (ERCP). It is still controversial whether the presence of a trainee would increase the risk of PEP. Additionally, the effects of demographic factors and comorbidities on the risk and severity of PEP are not fully understood. Our aim was to evaluate these factors using national database.MethodsNationwide Inpatient Sample 2000–2014 was used to identify adult patients admitted with biliary obstruction without acute pancreatitis and had an inpatient ERCP. PEP was defined as having a subsequent diagnosis of acute pancreatitis. The presence of major organs failure marked moderate–severe PEP. Demographic information, hospital characteristics, and ERCP intervention types were collected.ResultsWe included 654 394 patients. Overall PEP rate was 5.4%. The PEP rate was lower in teaching (4.8%) compared with nonteaching (6.2%, P < 0.001) hospitals. The highest PEP rate was observed among patients undergoing Sphincter of Oddi Manometry (15.1%, odds ratio [OR] = 2.5, P < 0.001) as compared to diagnostic cholangiography (4.4%). Asians and Hispanics had higher rate of PEP (10% and 7.9%, respectively) compared with Caucasians and African Americans (4.9% and 5%, respectively, P < 0.001). Multivariate analysis showed that after controlling for the ERCP intervention types, Asians and Hispanics continued to have higher odds of PEP (OR = 1.3, P < 0.001). Seventeen percent of patients were classified as moderate–severe PEP. Older patients (OR = 3.2, P < 0.001), males (OR = 1.4, P < 0.001), and high comorbidities (1.3, P < 0.001) were major predictors of moderate–severe PEP.ConclusionNo evidence of higher PEP rates in teaching hospitals. Asians and Hispanics had higher PEP rates. Although ERCP intervention type is the major PEP predictor, its severity is dependent on patient characteristics.

885 Outcomes of ERCP in Patients With Acute Myocardial Infarction: A National Study

INTRODUCTION: There is limited data on the safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients with recent myocardial infarction. The objective of this study is to better assess safety and outcomes in patients with admission for acute myocardial infarction (MI) that undergo ERCP for a variety of reasons during the same admission in a national inpatient database. METHODS: The National Inpatient Sample (NIS) is the largest all-payer inpatient database in the United States. Data from the years 2008 to 2014 were collected. Patients older than 18 years with an admission diagnosis of myocardial infarction and who underwent ERCP were included (n = 259). Case-control matching (3:1) based on age and race were selected (n = 762). Mortality, length of stay, cost of hospitalization, and complications were measured against case controls. RESULTS: Between 2008 and 2014, there were 259 patients older than 18 years with acute myocardial infarction who underwent inpatient ERCP. Baseline patient demographics and hospital characteristics is available in Table 1. Complications related to ERCP were infrequent though the rate of post-ERCP bleeding was higher in patients with recent MI compared to controls (4.2% vs. 1.6%; P = 0.012). Rates of cholecystitis, post-ERCP pancreatitis and perforation were not different between groups. There was no significant difference in mortality between patients that had recent MI vs those who did not (4.6% vs. 2.5%, P = 0.083). Length of stay was higher in patients with recent MI (median 9 days vs. 5 days, P &lt; 0.001). Cost of hospitalization was also significantly higher in the MI group ($22,197.86 vs. $25,937, P &lt; 0.001). The primary indication for ERCP in patients with acute MI was choledocholithiasis while that in the control group was cholangitis. Furthermore, the time to ERCP (emergent, urgent or delayed) did not significantly affect the risk of mortality and post-ERCP hemorrhage. CONCLUSION: Patients with acute MI that undergo ERCP during the same admission have a higher risk of post-ERCP hemorrhage with longer LOS and cost of hospitalization. However, the mortality and other ERCP-related complications are not significantly different when compared to patients undergoing ERCP without recent MI. Therefore, in general it would be considered safe to perform ERCP in patients with recent MI with precautions to monitor or prevent post-ERCP bleeding.

Sa1535 – Predictors of 30-Day Readmission After Inpatient Endoscopic Retrograde Cholangiopancreatography

Sa1535 – Predictors of 30-Day Readmission After Inpatient Endoscopic Retrograde Cholangiopancreatography

Hospital Teaching Status and the Effect on Endoscopic Retrograde Cholangiopancreatography Mortality and Complications in the United States

Introduction: There is limited data in the literature on the outcomes of patients that undergo Endoscopic Retrograde Cholangiopancreatography (ERCP) in teaching versus non-teaching hospitals. Since ERCP has the potential for numerous complications, our aim was to assess the differences in post-ERCP outcomes of infection rates, pancreatitis, gastrointestinal (GI) bleed, perforation and mortality in teaching versus nonteaching hospitals nationwide. We hypothesized that ERCP complication rates would be higher in teaching hospitals given the involvement of trainees and the greater complexity of patient populations. Methods: Data from the National Inpatient Sample (NIS), the largest national inpatient database, was used from the years 2008 to 2012. Individuals that underwent inpatient ERCPs were identified using the International Classification of Diseases, Ninth Edition (ICD-9) codes. NIS classifies hospitals as teaching urban, non-teaching urban, and rural. AMA-approved residency programs are required to qualify as teaching hospitals. Non-teaching urban and rural hospitals were grouped together for the analysis. We then identified hospital stays complicated by pancreatitis, infection, GI hemorrhage, perforation and mortality. Using ANOVA analysis in STATA, the differences in infection rates, pancreatitis, GI hemorrhage, perforation and mortality between teaching and non-teaching hospitals were calculated. Results: A total of 296,835 inpatient ERCPs was included in this study. 75,268 ERCPs were diagnostic, while 267,990 were therapeutic; 154,553 were performed at teaching hospitals and 142,282 at non-teaching hospitals. ERCP infection rates (Odds Ratio [OR] = 1.041, 95% Confidence Interval [CI]:1.012-1.071, p 1.095-1.071, p<0.001) were higher in teaching hospitals when compared to non-teaching hospitals. There was no difference observed among the rates of post-ERCP pancreatitis or GI perforation between the two groups. Among diagnostic ERCPs, GI hemorrhage was higher in teaching compared to non-teaching hospitals (OR = 1.206 95% CI:1.068-1.362, p <0.001). Likewise, length of stay was increased in teaching hospitals (8.3 vs 7.2 days, p<0.05 for diagnostic and 6.5 vs 5.8 days, p<0.05 for therapeutic ERCPs). Conclusion: In conclusion, teaching hospitals were noted to have a higher mortality rate associated with inpatient ERCPs as well as higher rates for infection and GI hemorrhage. Additionally, length of stay was longer for patients that underwent inpatient ERCPs in teaching hospitals.782_A Figure 1. Differences in ratios of pancreatitis, GI hemorrhage, GI perforation, infection and mortality in inpatient diagnostic and therapeutic ERCPs among teaching versus non-teaching hospitals782_B Figure 2. Percentages of demographic variables among therapeutic and diagnostic ERCPs between teaching and non-teaching hospitals

Complications of Inpatient Endoscopic Retrograde Cholangiopancreatography in Pancreatic Cancer versus Biliary Obstruction

Complications of Inpatient Endoscopic Retrograde Cholangiopancreatography in Pancreatic Cancer versus Biliary Obstruction

ERCP Improves Mortality in Acute Biliary Pancreatitis Without Cholangitis

Introduction: Acute pancreatitis (AP) is an increasingly common indication for hospitalization in the United States. Two-thirds of cases of AP are attributed to gallstones or alcohol. The necessity for Endoscopic Retrograde Cholangiopancreatography (ERCP) and the timing of ERCP in acute gallstone-related pancreatitis without cholangitis (AGPNC) is controversial. Our aim was to evaluate the association of ERCP and time to its performance during admission on mortality and length of stay (LOS) in patients with AGPNC. Methods: We queried the Nationwide Inpatient Sample (NIS) from 2004 to 2014 to identify all patients with admissions for gallstone AP. We excluded patients with chronic pancreatitis, patients with concurrent cholangitis, or those who were transferred from elsewhere for treatment. Our primary outcome measure was in-patient mortality. Our secondary outcome measure was hospital length of stay (LOS). Results: We identified 491,011 records eligible for analysis. 150,101 (30.6%) of patients with AGPNC underwent inpatient ERCP. There were 1.34 deaths per 100 admissions in patients with AGPNC. The average LOS was 5.88 (+- 6.38) days with median stay of 4 [3, 7] days. When adjusted for age, Elixhauser Comorbidity Index and severe pancreatitis, patients with ERCP during admission were 43% less likely to die. ERCP performed between day 3 and 9 of hospitalization resulted in a significant mortality benefit. Among those who had ERCP, a shorter wait time for ERCP was associated with a shorter LOS after adjustment for demographics and severity of illness. Conclusion: ERCP performed during in-patient admission for AGPNC was associated with decreased mortality with best results occurring when intervention was performed between 3 and 9 days post admission. Patients who had shorter time to ERCP had shorter LOS, when compared to those who had procedures later. This data supports ERCP in patients with acute gallstone pancreatitis without cholangitis.

Tu1419 SAME HOSPITALIZATION CHOLECYSTECTOMY FOR ACUTE GALLSTONE PANCREATITIS: A NATIONWIDE ANALYSIS ACROSS A DECADE

Gallstones are the leading cause of acute pancreatitis in developed countries. The International Association of Pancreatology and American Pancreatic Association recommend a cholecystectomy or at least a biliary sphincterotomy during the index hospitalization for acute gallstone pancreatitis (AGP). Prior data has shown that adherence to this recommendation is low. We aimed to delineate the national trends for same hospitalization cholecystectomy (SHC) for AGP over the last ten years. This was a retrospective cohort study using the 2004, 2009 and 2014 national inpatient sample, the largest nationally representative inpatient database in the United States. Inclusion criteria were a principal diagnosis of acute pancreatitis and a secondary diagnosis of choledocholithiasis or cholelithiasis. Exclusion criteria were age < 18 years and elective admission. The primary outcome was SHC trend over time. Secondary outcomes were: i) trends of inpatient endoscopic retrograde cholangiopancreatography (ERCP), ii) In-hospital mortality, length of stay (LOS) and total hospitalization costs and charges associated with SHC. A subgroup analysis was performed for teaching and non-teaching hospitals separately. All costs and charges were adjusted for inflation using the consumer price index. The yearly incidence was calculated using the corresponding July 1 Census estimate of the US population. Confounders (listed in Table 1) were accounted for using multivariable regression analysis. The results are summarized in Table 1 and Table 2. The incidence and number of admissions for AGP as well as the proportion of AGP among all acute pancreatitis were stable over the past decade. However, SHC (2004: 48.7%, 2009: 46.9%, 2014: 45%) and ERCP rates slowly declined over the same time period. Among patients who had a SHC, the mortality rate and LOS decreased, whereas total hospitalization charges and costs significantly increased from 2004 to 2014. After adjusting for confounders, the rate of in-hospital ERCP was higher in teaching compared with non-teaching hospitals, but both groups had similar SHC rate and mortality rate after cholecystectomy. In addition, teaching hospitals had longer LOS and higher total hospitalizations costs and charges compared with non-teaching hospitals. Adherence to the guidelines for in-hospital cholecystectomies and ERCP for patients admitted with AGP have been declining over the past decade. This decline is associated with, and therefore possibly motivated by, a significant decrease in-hospital mortality and resource utilization. Compared with non-teaching hospitals, teaching hospitals had higher adherence to the guidelines for inpatient ERCP. Despite the apparent financial reward, concerted efforts are needed to avoid interval cholecystectomy, which has been linked to recurrence of AGP and readmissions.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Utilization trends in inpatient endoscopic retrograde cholangiopancreatography (ERCP): A cross-sectional US experience.

Study aims The goal of our study was to determine the current trends for inpatient utilization for endoscopic retrograde cholangiopancreatography (ERCP) and its economic impact in the United States between 2002 and 2013. Patients and methods A Nationwide Inpatient Sample from 2002 through 2013 was examined. We identified ERCPs using International Classification of Diseases (ICD-9) codes; Procedure codes 51.10, 51.11, 52.13, 51.14, 51.15, 52.14 and 52.92 for diagnostic and 51.84, 51.86, 52.97 were studied. Rate of inpatient ERCP was calculated. The trends for therapeutic ERCPs were compared to the diagnostic ones. We analyzed patient and hospital characteristics, length of hospital stay, and cost of care after adjusting for weighted samples. We used the Cochran-Armitage test for categorical variables and linear regression for continuous variables. Results A total of 411,409 ERCPs were performed from 2002 to 2013. The mean age was 59 ± 19 years; 61 % were female and 57 % were white. The total numbers of ERCPS increased by 12 % from 2002 to 2011, which was followed by a 10 % decrease in the number of ERCPs between 2011 and 2013.There was a significant increase in therapeutic ERCPs by 37 %, and a decrease in diagnostic ERCPs by 57 % from 2002 to 2013. Mean length of stay was 7 days (SE = 0.01) and the mean cost of hospitalization was $20,022 (SE = 41). Conclusions Our large cross-sectional study shows a significant shift in ERCPs towards therapeutic indications and a decline in its conventional diagnostic utility. Overall there has been a reduction in inpatient ERCPs.