Aspects on the role of prophylactic procedures to influence post-ERCP complication rates
Author: Olsson, Greger
Date: 2017-09-15
Location: Föreläsningssal B64, Karolinska Universitetssjukhuset, Huddinge
Time: 13.00
Department: Inst för klinisk vetenskap, intervention och teknik / Dept of Clinical Science, Intervention and Technology
View/ Open:
Thesis (1.755Mb)
Abstract
Background: When the technique to use ERCP was introduced almost fifty years ago, the
morbidity in treatment of hepato-biliary diseases decreased due to the introduction of this miniinvasive
modality, reducing the need for open surgical procedures. However, ERCP procedures
are still marred with complications such as pancreatitis, cholangitis, hemorrhage and
perforation and every measure must be undertaken to reduce these adverse events.
Objectives: The hypotheses of this thesis were: 1) Prophylactic antibiotics in ERCP do not reduce the complication rates enough to recommend it generally. 2) Prophylactic pancreatic stents reduce the PEP risk more the larger they are. 3) A grading scale for the complexity of the ERCP procedure (HOUSE) was validated in relation to success-rates, complications and duration of the procedure. 4) Preoperative SEMS in periampullary tumors show less bacterial contamination in intraoperatively collected bile than plastic stents, thereby reducing perioperative complications.
Methods: In the first study all ERCPs, included in GallRiks between May 2005 and June 2013, were studied regarding complication rates in relation to prophylactic antibiotics. Further, in the second paper, all ERCPs between 2006 and 2014 where an accidental pancreatic cannulation occurred and a prophylactic pancreatic stent was used were investigated, determinating how the diameter and length of the stent affected the adverse events. In the third study, an ERCP complexity classification, (HOUSE), was validated in relation to success-rates, complications and duration of the procedure. The final study, an RCT compared preoperative SEMS to plastic stents in resectable periampullary tumors regarding intraoperative bacterial, histopathological and surgical technical findings as well as perioperative complications.
Results: In the first study complications were studied in relation to prophylactic antibiotics. We found a reduction of 26 % of OR in overall complications if prophylactic antibiotics were given, but in absolute figures reduction of the risk was a modest 2.6% and the NNT 38 patients to avoid one complication. In our second study an almost fourfold OR elevation (OR 3.58) in complication rates was seen if prophylactic pancreatic stents with a diameter ≤5 Fr were used compared to stents >5 Fr, the complication rates were further lowered (1.4 %) if the stents were >5 cm. The third paper validated a new three-graded ERCP complexity grading scale (HOUSE) in relation to success and complication rates, demonstrating a doubled PEP rate in HOUSE 2 and 3 (7.0 % and 6.8 %) compared to class 1 (3.4%) and longer procedure times, the higher the HOUSE class (HOUSE 1, 40 min; 2, 65 min; and 3, 106 min). In the final study, comparing preoperative SEMS to plastic stents in resectable periampullary tumors, higher preoperative stent dysfunction rates were found among the plastic stents (19 % vs 0 %, p=0.03). Intraoperatively, no differences were seen in bacterial occurrence in collected bile or in operative technical difficulties, but a higher histopathological foreign body reaction (sinus histiocytos) in lymph nodes in the hepatoduodenal ligament in the plastic stent group. Also, the overall postoperative complication rates were increased in the group where plastic stents were used (72 % vs 52 %), as were the frequency of anastomotic leakages (12 % vs 3.7 %), but none of these postoperative complications reached statistical significance.
Conclusion: Prophylactic antibiotics in ERCP lower the overall complication rates but not sufficiently to recommend this as prophylaxis in every ERCP procedure. On the contrary, prophylactic pancreatic stents could be used more frequently in ERCP and larger diameters and longer stents demonstrated lower complications rates. We also launched an ERCP complexity grading scale (HOUSE) and validated it in relation to complication rates and procedure duration. Finally, we demonstrated that SEMS could be used in resectable periampullary tumors and found no differences in bacterial growth in intraoperatively collected bile but a lower preoperative stent dysfunction rate if SEMS were used. Neither did we find any intraoperative technical downsides when using SEMS, or any disadvantages in postoperative complication rates.
Objectives: The hypotheses of this thesis were: 1) Prophylactic antibiotics in ERCP do not reduce the complication rates enough to recommend it generally. 2) Prophylactic pancreatic stents reduce the PEP risk more the larger they are. 3) A grading scale for the complexity of the ERCP procedure (HOUSE) was validated in relation to success-rates, complications and duration of the procedure. 4) Preoperative SEMS in periampullary tumors show less bacterial contamination in intraoperatively collected bile than plastic stents, thereby reducing perioperative complications.
Methods: In the first study all ERCPs, included in GallRiks between May 2005 and June 2013, were studied regarding complication rates in relation to prophylactic antibiotics. Further, in the second paper, all ERCPs between 2006 and 2014 where an accidental pancreatic cannulation occurred and a prophylactic pancreatic stent was used were investigated, determinating how the diameter and length of the stent affected the adverse events. In the third study, an ERCP complexity classification, (HOUSE), was validated in relation to success-rates, complications and duration of the procedure. The final study, an RCT compared preoperative SEMS to plastic stents in resectable periampullary tumors regarding intraoperative bacterial, histopathological and surgical technical findings as well as perioperative complications.
Results: In the first study complications were studied in relation to prophylactic antibiotics. We found a reduction of 26 % of OR in overall complications if prophylactic antibiotics were given, but in absolute figures reduction of the risk was a modest 2.6% and the NNT 38 patients to avoid one complication. In our second study an almost fourfold OR elevation (OR 3.58) in complication rates was seen if prophylactic pancreatic stents with a diameter ≤5 Fr were used compared to stents >5 Fr, the complication rates were further lowered (1.4 %) if the stents were >5 cm. The third paper validated a new three-graded ERCP complexity grading scale (HOUSE) in relation to success and complication rates, demonstrating a doubled PEP rate in HOUSE 2 and 3 (7.0 % and 6.8 %) compared to class 1 (3.4%) and longer procedure times, the higher the HOUSE class (HOUSE 1, 40 min; 2, 65 min; and 3, 106 min). In the final study, comparing preoperative SEMS to plastic stents in resectable periampullary tumors, higher preoperative stent dysfunction rates were found among the plastic stents (19 % vs 0 %, p=0.03). Intraoperatively, no differences were seen in bacterial occurrence in collected bile or in operative technical difficulties, but a higher histopathological foreign body reaction (sinus histiocytos) in lymph nodes in the hepatoduodenal ligament in the plastic stent group. Also, the overall postoperative complication rates were increased in the group where plastic stents were used (72 % vs 52 %), as were the frequency of anastomotic leakages (12 % vs 3.7 %), but none of these postoperative complications reached statistical significance.
Conclusion: Prophylactic antibiotics in ERCP lower the overall complication rates but not sufficiently to recommend this as prophylaxis in every ERCP procedure. On the contrary, prophylactic pancreatic stents could be used more frequently in ERCP and larger diameters and longer stents demonstrated lower complications rates. We also launched an ERCP complexity grading scale (HOUSE) and validated it in relation to complication rates and procedure duration. Finally, we demonstrated that SEMS could be used in resectable periampullary tumors and found no differences in bacterial growth in intraoperatively collected bile but a lower preoperative stent dysfunction rate if SEMS were used. Neither did we find any intraoperative technical downsides when using SEMS, or any disadvantages in postoperative complication rates.
List of papers:
I. The role of prophylactic antibiotics in routine endoscopic retrograde cholangiopancreatography as assessed prospectively in a nationwide study cohort. Olsson, G., Arnelo, U., Lundell, L., Persson, G., Törnqvist, B., and Enochsson, L. Scandinavian Journal of Gastroenterology. 2015; 50:7, 924-32.
Fulltext (DOI)
Pubmed
View record in Web of Science®
II. The impact of prophylactic pancreatic stenting on post-ERCP pancreatitis: A nationwide, register-based study. Olsson, G., Lübbe, J., Arnelo, U., Jonas, E., Törnqvist, B., Lundell, L., and Enochsson, L. United European Gastroenterology Journal 2017; Vol. 5(1): 111–118.
Fulltext (DOI)
Pubmed
View record in Web of Science®
III. The HOUSE-classification: a novel endoscopic retrograde cholangio pancreatography (ERCP) complexity grading scale. Olsson, G., Arnelo, U., Swahn, F., Törnqvist, B., Lundell, L., and Enochsson, L. BMC Gastroenterology (2017) 17:38.
Fulltext (DOI)
Pubmed
View record in Web of Science®
IV. Preoperative biliary drainage by plastic or self-expandable metal stents in patients with periampullary tumors: results of a randomized clinical study. Olsson, G., Frozanpor, F., Lundell, L., Enochsson, L., Ansorge, C., Del Chiaro, M., Reuterwall-Hansson, M., Shetye, A., and Arnelo, U. Endosc Int Open. 2017 Sep;5(9):E798-E808. [Accepted]
Fulltext (DOI)
Pubmed
I. The role of prophylactic antibiotics in routine endoscopic retrograde cholangiopancreatography as assessed prospectively in a nationwide study cohort. Olsson, G., Arnelo, U., Lundell, L., Persson, G., Törnqvist, B., and Enochsson, L. Scandinavian Journal of Gastroenterology. 2015; 50:7, 924-32.
Fulltext (DOI)
Pubmed
View record in Web of Science®
II. The impact of prophylactic pancreatic stenting on post-ERCP pancreatitis: A nationwide, register-based study. Olsson, G., Lübbe, J., Arnelo, U., Jonas, E., Törnqvist, B., Lundell, L., and Enochsson, L. United European Gastroenterology Journal 2017; Vol. 5(1): 111–118.
Fulltext (DOI)
Pubmed
View record in Web of Science®
III. The HOUSE-classification: a novel endoscopic retrograde cholangio pancreatography (ERCP) complexity grading scale. Olsson, G., Arnelo, U., Swahn, F., Törnqvist, B., Lundell, L., and Enochsson, L. BMC Gastroenterology (2017) 17:38.
Fulltext (DOI)
Pubmed
View record in Web of Science®
IV. Preoperative biliary drainage by plastic or self-expandable metal stents in patients with periampullary tumors: results of a randomized clinical study. Olsson, G., Frozanpor, F., Lundell, L., Enochsson, L., Ansorge, C., Del Chiaro, M., Reuterwall-Hansson, M., Shetye, A., and Arnelo, U. Endosc Int Open. 2017 Sep;5(9):E798-E808. [Accepted]
Fulltext (DOI)
Pubmed
Institution: Karolinska Institutet
Supervisor: Enochsson, Lars
Co-supervisor: Arnelo, Urban; Persson, Gunnar; Offenbartl, Karsten
Issue date: 2017-08-17
Rights:
Publication year: 2017
ISBN: 978-91-7676-754-2
Statistics
Total Visits
Views | |
---|---|
Aspects ... | 637 |
Aspects ...(legacy) | 599 |
Total Visits Per Month
September 2023 | October 2023 | November 2023 | December 2023 | January 2024 | February 2024 | March 2024 | |
---|---|---|---|---|---|---|---|
Aspects ... | 9 | 27 | 14 | 18 | 15 | 14 | 16 |
File Visits
Views | |
---|---|
Thesis_Greger_Olsson.pdf | 1590 |
Thesis_Greger_Olsson.pdf(legacy) | 156 |
Top country views
Views | |
---|---|
Sweden | 280 |
United States | 166 |
Denmark | 133 |
Ireland | 65 |
Australia | 63 |
United Kingdom | 59 |
Germany | 57 |
China | 50 |
India | 21 |
South Korea | 19 |
Top cities views
Views | |
---|---|
Copenhagen | 69 |
Dublin | 62 |
Sydney | 62 |
Ashburn | 57 |
Lane | 19 |
Stockholm | 18 |
Vienna | 16 |
Menlo Park | 14 |
Seoul | 13 |
Woodbridge | 12 |