ERCP in Super-Aged Patients Considering Difficult Cannulation: Challenges and Adverse Events

Endoscopic retrograde cholangiopancreatography (ERCP) is a routinely used therapeutic procedure for the biliary and pancreatic diseases. Population aging may increase the typical indications of ERCP and come with more complexity and difficulties, especially in cannulation. This study aimed to evaluate the incidence, causes, and management of difficult biliary cannulation during ERCP in super-aged patients and the role of difficult cannulation as a risk factor for adverse events. A total of 614 patients, underwent ERCP, were prospectively studied as a cohort and divided into two groups based on their age. There were 146 patients aged 80 years or older in group A and 468 patients aged less than 80 years in group B. The primary outcome measures were the difficulty grade of papilla cannulation, clinical outcomes, and ERCP-related complications in the two groups. The adverse events were analyzed using logistic regression for patient age, co-morbidities, indications, and cannulation difficulty grade variables. There was no difference in the incidence of difficult cannulation between the two groups (32.9% vs. 34.4%, p=0.765) though, as expected, super-aged Group A had a higher prevalence of periampullary diverticulum (29.5% vs. 16.7%, p=0.001). The technical cannulation success rate was (96.6% vs. 96.8%, p= 0.54). All used cannulation techniques in the elderly group were efficient and safe. Logistic regression showed that age ≥80 was not associated with increased adverse events; however, difficult cannulation (adjusted odds ratio [AOR]=3.478; 95% confidence interval [CI]=1.877, 6.442; p<0.001) and CCI ≥2 (AOR=1.824; 95% CI=0.993, 3.349; p=0.045) were more likely to have adverse events. Age ≤65 (AOR=3.460; 95% CI=1.511, 7.922; p=0.003), female gender (AOR=2.362; 95% CI=1.089, 5.124; p=0.030), difficult cannulation (AOR=4.527; 95% CI=2.078, 9.860; p<0.001), and patients with cholangitis (AOR=3.261; 95% CI=1.204, 8.832; p=0.020) were strongly associated with increasing Post-ERCP Pancreatitis (PEP). Advanced age has not proved to be a risk factor of difficult cannulation, and secondary cannulation techniques can be safely and efficaciously utilized for this group. CCI ≥2 and difficult cannulation are associated with increased overall adverse events rate while age ≥80 factor is not.

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Multiple Factor Analysis of Symptomatic Intracranial Arterial Stenosis

Translational Neuroscience and Clinics ◽

10.18679/cn11-6030_r.2017.011 ◽

2017 ◽

Vol 3 (2) ◽

pp. 84-89

Author(s):

Chuanqiang Qu ◽

Yuanyuan Zhao ◽

Qinjian Sun ◽

Yifeng Du

Keyword(s):

Risk Factors ◽

Coronary Heart Disease ◽

Logistic Regression ◽

Regression Analysis ◽

Risk Factor ◽

Protective Factor ◽

Arterial Stenosis ◽

Intracranial Arterial Stenosis ◽

Group A ◽

Group B

Objective To discuss the correlation among intracranial arterial stenosis and its risk factors. Methods A total of 486 patients with transient ischemic attack (TIA) or ischemic cerebral infarction were examined using color doppler flow imaging (CDFI) and transcranial doppler ultrosonography (TCD). According to the degrees of extracranial arterial stenosis, patients with mild-to-moderate extracranial stenosis were classified into group A (435 cases) while those with constant severe stenosis or occlusion were classified into group B (51 cases). The differences between the two groups of risk factors were compared, and the multi-factor logistic regression analysis of risk factors associated with moderately severe intracranial arterial stenosis was performed. Results ① The risk factors that were significantly associated with intracranial arterial stenosis included age (P = 0.034) and gender (P = 0.044). ② Intracranial artery stenosis was observed in both anterior and posterior cerebral arteries in patients with hypertension, diabetes, and coronary heart disease respectively (P < 0.05). ③ Compared with group A, patients in group B were older (P = 0.000), with a higher proportion of men (P = 0.037), and the intracranial arterial stenosis degrees were significantly higher (P = 0.013). ④ Multi-factor logistic regression analysis showed that diabetes is a risk factor for moderately severe intracranial arterial stenosis (P < 0.05), and hyperlipidemia is a protective factor (P = 0.012). Conclusions Age, gender, hypertension, diabetes, coronary heart disease, and smoking are risk factors for the distribution of intracranial arterial stenosis. The degrees of intracranial arterial stenosis are related with extracranial arterial stenosis. Diabetes is a risk factor for moderately severe intracranial arterial stenosis while hyperlipidemia is a protective factor.

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Thirty-Day Mortality and Survival in Elderly Patients Undergoing Neurosurgery

Neurosurgery ◽

10.1093/neuros/nyz001.3 ◽

2019 ◽

Vol 84 (5) ◽

pp. E270-E271

Author(s):

Emily Rose Bligh ◽

Yahia Al-Tamimi ◽

Priyank Sinha ◽

Daisy Smith

Keyword(s):

Logistic Regression ◽

Elderly Patients ◽

Current Model ◽

Frailty Index ◽

The Elderly ◽

Ageing Population ◽

Predictors Of Mortality ◽

Significant Difference ◽

Group A ◽

Group B

Abstract INTRODUCTION With an ageing population and advances in neuroanaesthesia and critical care, there is an increasing subgroup of patients greater than 70 yr of age presenting to neurosurgical departments and undergoing surgery. We are now moving towards the idea of a frailty index. The aim of the current study is to investigate 30-d mortality and survival in this cohort following emergency and elective neurosurgery. METHODS Retrospective cohort study. All patients aged 70 yr and above, who had undergone a neurosurgical procedure from April 2015 to April 2017 were identified. Online patient electronic records were retrieved to gather information related to procedure type, co-morbidities, days in hospital, discharge destination, complications and mortality. Logistic regression analysis was used to identify predictors of mortality. RESULTS A total of 798 patients in total of whom 623 were <80 yr (group A) and 175 were >80 yr (group B). Male : Female = 3 : 1. Mean age of the study was 76 yr. There were 390 elective and 408 emergency admissions. Overall 30-d mortality = 5.6% (8% in group B). Overall survival was 86.5% in group A and 79.4% in group B. There was a significant difference in 30-d mortality between elective (0.8%) and emergency (10.3%) patients. About 84.5% of patients were discharged back to their usual place of residence in group A but this figure was 68.9% for group B. Logistic regression found emergency surgery (P > .001) and degenerative spine diagnosis to be independent predictors of mortality (P = .05). CONCLUSION The current model for accepting elderly patients is associated with a good overall outcome. The elderly should not be refused neurosurgery on their age per se. We have applied fairly strict and stringent criteria particularly in SAH and TBI.

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Impact of Periampullary Diverticulum on Biliary Cannulation and ERCP Outcomes: A Single-Center Prospective Study

10.20944/preprints202001.0076.v2 ◽

2020 ◽

Author(s):

Fatema Tabak ◽

Guo-Zhong Ji ◽

Lin Miao

Keyword(s):

Adverse Events ◽

Success Rate ◽

Biliary Cannulation ◽

Periampullary Diverticulum ◽

Group A ◽

Group B ◽

Cannulation Success Rate ◽

Cannulation Success ◽

Selective Cannulation ◽

The Impact

Aim: This study aimed to investigate the association between periampullary diverticulum (PAD) and difficult biliary cannulation, as well as to evaluate the impact of different types of PAD on the cannulation success rate and adverse events. Methods: A total of 636 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) during the study period were prospectively studied and divided into two groups based on the presence or absence of PAD. In group A, 126 patients had PAD compared with 510 patients in group B without PAD. The primary outcome measurements were ERCP procedures time, selective cannulation techniques, and cannulation difficulty in addition to cannulation success rate and ERCP-related adverse events. The difficult cannulation was analyzed using logistic regression considering age, co-morbidities, the presence of PAD types, and indications as independent factors. Results: The average cohort age was 65.30±16.67 years, and 52.7% were male. Significant higher rates of choledocholithiasis, cholangitis, and biliary pancreatitis were reported in the group of PAD (p<0.05). Successful selective cannulation was achieved in 97.6% in group A and 95.3% in group B (p>0.05). The cannulation time was significantly longer in the presence of PAD (5.1 min, vs. 4.09 min, p<0.05). There was no significant difference in the rate of overall adverse events and post ERCP pancreatic PEP. Conclusion: The presence of PAD did not affect the duration or success of the ERCP procedure. Furthermore, it was associated with longer cannulation time and increase in the cannulation difficulty, especially with PAD type 1.

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Impact of Periampullary Diverticulum on ERCP Papillary Cannulation

10.20944/preprints202001.0076.v1 ◽

2020 ◽

Cited By ~ 2

Author(s):

Fatema Tabak ◽

Guo-Zhong Ji ◽

Lin Miao

Keyword(s):

Adverse Events ◽

Success Rate ◽

Periampullary Diverticulum ◽

Group A ◽

Group B ◽

Cannulation Success Rate ◽

Cannulation Success ◽

Selective Cannulation ◽

The Impact

Objectives: This study aimed to investigate the association between periampullary diverticulum (PAD) and difficult biliary cannulation, as well as to evaluate the impact of different types of PAD on the cannulation success rate and adverse events. Methods: A total of 636 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) during the study period were prospectively studied and divided into two groups based on the presence or absence of PAD. In group A, 126 patients had PAD compared with 510 patients in group B without PAD. The primary outcome measurements were ERCP procedures time, selective cannulation techniques, and cannulation difficulty in addition to cannulation success rate and ERCP-related adverse events. The difficult cannulation was analyzed using logistic regression considering age, co-morbidities, the presence of PAD types, and indications as independent factors. Results: The average cohort age was 65.30±16.67 years, and 52.7% were male. Significant higher rates of choledocholithiasis, cholangitis, and biliary pancreatitis were reported in the group of PAD (p<0.05). Successful selective cannulation was achieved in 97.6% in group A and 95.3% in group B (p>0.05). The cannulation time was significantly longer in the presence of PAD (5.1 min, vs. 4.09 min, p<0.05). There was no significant difference in the rate of overall adverse events and post ERCP pancreatic PEP. Conclusions: The presence of PAD did not affect the duration or success of the ERCP procedure. Furthermore, it was associated with longer cannulation time and increase in the cannulation difficulty, especially with PAD type 1. The presence of PAD did not affect the duration or success of the ERCP procedure. Furthermore, it was associated with longer cannulation time and increase in the cannulation difficulty, especially with PAD type 1.

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Atrioventricular block in acute coronary syndrome: Portuguese experience

EP Europace ◽

10.1093/europace/euab116.317 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

H Santos ◽

M Santos ◽

I Almeida ◽

H Miranda ◽

C Sa ◽

...

Keyword(s):

Heart Rate ◽

Acute Coronary Syndrome ◽

Logistic Regression ◽

Atrioventricular Block ◽

Female Gender ◽

Left Ventricular Ejection ◽

Coronary Syndrome ◽

Group A ◽

Artery Disease ◽

Group B

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf Portuguese Registry of Acute Coronary Syndromes Background The atrioventricular block (AVB) occurrence in acute coronary syndrome (ACS) is a potentially life-threatening complication, that demand a rapid and efficient response regarding reperfusion time and rhythm stabilization. Objective Evaluate the impact and prognosis of AVB in ACS patients, as well as predictors of AVB. Methods Multicenter retrospective study, based on the Portuguese Registry of ACS between 1/10/2010-3/05/2020. Patients were divided into two groups: A – patients without AVB, and B – patients that presented AVB. Were excluded patients without a previous cardiovascular history or clinical data regarding AVB occurrence. Logistic regression was performed to assess predictors of AVB in ACS patients. Results From 32157 patients, 23774 was included, 23148 in group A (97.4%) and 626 in group B (2.6%). Both groups were similar regarding initial symptons until first medical contact (p = 0.410), smoker status (p = 0.222), arterial hypertension (p = 0.776), diabetes mellitus (p = 0.508), peripheral artery disease (p = 0.479), chronic kidney disease (p = 0.467) and re-infarction during the hospitalization for ACS (p = 0.145). Group A had higher body mass index (27.4 ± 4.4 vs 26.9 ± 4.6, p = 0.005), dislipidaemia (59.6 vs 51.4%, p < 0.001), coronary artery disease (18.9 vs 13.0, p < 0.001), heart rate (78 ± 19 vs 65 ± 25, p < 0.001), systolic blood pressure (139 ± 29 vs 119 ± 32, p < 0.001) and left ventricular ejection fraction (LVEF) >50% (60.1 vs 51.7%, p < 0.001). On the other hand, group B was elderly (66 ± 13 vs 71 ± 13, p < 0.001), female (27.4 vs 32.4%, p < 0.001), previous stroke (6.9 vs 10.9%, p < 0.001), neoplasia (4.9 vs 6.8%, p = 0.031), ST-segment elevation myocardial infarction (46.2 vs 75.4%, p < 0.001), syncope as major symptom (1.3 vs 10.0%, p < 0.001), Killip-Kimball class > I (15.4 vs 31.6%, p < 0.001), multivessel diasease (52.1 vs 61.4%, p < 0.001), heart failure complication (15.5 vs 40.6%, p < 0.001), cardiogenic shock complication (3.8 vs 24.6%, p < 0.001), new-onset of atrial fibrillation (4.2 vs 14.1%, p < 0.001), ACS mechanical complication (0.6 vs 3.2%, p < 0.001), sustained ventricular tachycardia during ACS hospitalization (1.3 vs 10.0%, p < 0.001), cardiac arrest (2.7 vs 13.3%, p < 0.001), stroke complication (0.6 vs 1.9%, p < 0.001) and hospitalization death (3.5 vs 19.0%, p < 0.001). Logistic regression revealed that female gender (odds ratio (OR) 1.422, p = 0.015, confidence interval (CI) 1.072-1.885), age ≥75 years old (OR 1.560, p = 0.002, CI 1.174-2.073), heart rate <60 (OR 6.692, p < 0.001, CI 5.180-8.644) and Killip-Kimball class > I (OR 3.264, p < 0.001, CI 2.446-5.356) were predictors of AVB in ACS patients. Conclusions Female gender, age ≥75 years old, heart rate <60 and Killip-Kimball class > I were predictors of AVB in ACS patients.

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Efficacy and Safety of Endoscopic Papillary Large Balloon Dilation for Removal of Large Bile Duct Stones in Advanced Age

Canadian Journal of Gastroenterology and Hepatology ◽

10.1155/2016/6568989 ◽

2016 ◽

Vol 2016 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Kook Hyun Kim ◽

Tae Nyeun Kim

Keyword(s):

Bile Duct ◽

Adverse Events ◽

Clinical Outcomes ◽

Balloon Dilation ◽

The Elderly ◽

Major Hemorrhage ◽

Group A ◽

Large Balloon ◽

Large Balloon Dilation ◽

Group B

Objective. Bile duct stone-related adverse events can be detrimental in the elderly. However, little is known about clinical outcomes and adverse events following endoscopic papillary large balloon dilation (EPLBD) in the elderly. The aim of this study was to evaluate the safety and feasibility of EPLBD for the removal of CBD stones in patients aged ≥ 80 years.Methods. A total of 204 patients who underwent EPLBD from 2006 to 2012 were retrospectively reviewed. Patients were classified into two groups (148 patients < 80 years old, Group A; 56 patients ≥ 80 years old, Group B). Endoscopic findings, clinical outcomes, and adverse events in two groups were compared.Results. The number of underlying chronic diseases in Group B was significantly higher than in Group A (P=0.032). The rates of overall stone clearance were similar between two groups (P=0.145). No significant difference with regard to post-ERCP pancreatitis between two groups was observed (P=0.687). All episodes of pancreatitis had full recovery with conservative treatment. One major hemorrhage in Group A was successfully controlled endoscopically and one death caused by retroperitoneal perforation occurred in Group A.Conclusions. EPLBD appear to be safe and effective for CBD stone removal in patients aged ≥ 80 years.

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Laparoscopic Incisional and Ventral Hernia Repair with Absorbable Tacks in a Long Term Follow-up: A Retrospective Control Study

Reviews on Recent Clinical Trials ◽

10.2174/1574887114666190201111332 ◽

2019 ◽

Vol 14 (2) ◽

pp. 141-146

Author(s):

Simone Zanella ◽

Enrico Lauro ◽

Francesco Franceschi ◽

Francesco Buccelletti ◽

Annalisa Potenza ◽

...

Keyword(s):

Hernia Repair ◽

Ventral Hernia ◽

Ventral Hernia Repair ◽

The Elderly ◽

Long Term Follow Up ◽

Group A ◽

Group B ◽

Absorbable Tacks

Background: Laparoscopic Incisional and Ventral Hernia Repair (LIVHR) is a safe and worldwide accepted procedure performed using absorbable tacks. The aim of the study was to evaluate recurrence rate in a long term follow-up and whether the results of laparoscopic IVH repair in the elderly (≥65 years old) are different with respect to results obtained in younger patients. Methods: One hundred and twenty-nine consecutive patients (74 women and 55 men, median age 67 years, range = 30-87 years) with ventral (N = 42, 32.5%) or post incisional (N = 87, 67.5%) hernia were enrolled in the study. Patients were divided into two groups according to their age: group A (N = 55, 42.6%) aged <65 years and group B (N = 74, 57.4%) aged ≥65 years. Results: The mean operative time was not significantly different between groups (66.7 ± 37 vs. 74 ± 48.4 min, p = 0.4). To the end of 2016, seven recurrences had occurred (group A = 3, group B = 4, p = 1). Complications occurred in 8 (16%) patients in group A and 21 (28.3%) patients in group B. Conclusion: In conclusion, our results confirm that the use of absorbable tacks does not increase recurrence frequency and laparoscopic incisional and ventral repair is a safety procedure also in elderly patients.

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Management of walled-off necrosis with nasocystic irrigation with hydrogen peroxide versus biflanged metal stent: randomized controlled trial

Endoscopy International Open ◽

10.1055/a-1480-7115 ◽

2021 ◽

Vol 09 (07) ◽

pp. E1108-E1115

Author(s):

Sudhir Maharshi ◽

Shyam Sunder Sharma ◽

Sandeep Ratra ◽

Bharat Sapra ◽

Dhruv Sharma

Keyword(s):

Hydrogen Peroxide ◽

Adverse Events ◽

Clinical Success ◽

Controlled Trial ◽

Procedure Time ◽

Metal Stent ◽

Technical Success ◽

Group A ◽

Group B ◽

Walled Off Necrosis

Abstract Background and study aims Walled-off necrosis (WON) is a known complication of acute necrotizing pancreatitis (ANP). There is no study comparing nasocystic irrigation with hydrogen peroxide (H2O2) versus biflanged metal stent (BMS) in the management of WON. The aim of this study was to compare the clinical efficacy of both the treatment strategies. Patients and methods This study was conducted on patients with symptomatic WON who were randomized to nasocystic irrigation with H2O2 (Group A) and BMS placement (Group B). Primary outcomes were clinical and technical success while secondary outcomes were procedure time, adverse events, need for additional procedures, duration of hospitalization, and mortality. Results Fifty patients were randomized into two groups. Group A (n = 25, age 37.8 ± 17.6 years, 16 men) and Group B (n = 25, age 41.8 ± 15.2 years, 17 men). There were no significant differences in baseline characteristics between the two groups. The most common etiology of pancreatitis was alcohol, observed in 27 (54 %) patients. Technical success (100 % vs 96 %, P = 0.98), clinical success (84 % vs 76 %, P = 0.76), requirement of additional procedures (16 % vs 24 %, P = 0.70) and adverse events (4 vs 7, P = 0.06) were comparable in both the groups. The duration to clinical success (34.4 ± 12 vs 14.8 ± 10.8 days, P = 0.001) and procedure time (36 ± 15 vs 18 ± 12 minutes, P = 0.01) were longer in Group A compared to Group B. Conclusions Nasocystic irrigation with H2O2 and BMS are equally effective in the management of WON but time to clinical success and procedure time is longer with nasocystic irrigation.

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Prognosis and risk factors of ERCP pancreatitis in elderly

Scientific Reports ◽

10.1038/s41598-021-95484-8 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Erhan Ergin ◽

Nevin Oruç ◽

Galip Ersöz ◽

Oktay Tekeşin ◽

Ömer Özütemiz

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Elderly Patients ◽

Biochemical Analysis ◽

Female Gender ◽

The Elderly ◽

Imaging Findings ◽

Endoscopic Retrograde ◽

Sphincter Oddi ◽

Oddi Dysfunction

AbstractPost Endoscopic Retrograde Cholangiopancreatography (ERCP) pancreatitis is one of the most serious complications of ERCP. Our study aims to investigate the risk, predisposing factors and prognosis of pancreatitis after ERCP in elderly patients. Patients referred to the ERCP unit between April 2008 and 2012 and admitted to the hospital at least 1 day after the ERCP procedure were included to the study. Information including patient’s demographics, diagnosis, imaging findings, biochemical analysis, details of the ERCP procedure and complications were recorded. The severity of post ERCP pancreatitis (PEP) was determined by revised Atlanta Criteria as well as APACHE II and Ranson scores. A total of 2902 ERCP patients were evaluated and 988 were included to the study. Patients were divided into two groups as ≥ 65 years old (494 patients, 259 F, 235 M) and < 65 years old (494 patients, 274 F, 220 M). PEP was diagnosed in 4.3% of patients aged 65 years and older. The female gender was risk factors in elderly for PEP. The Sphincter Oddi Dysfunction (SOD) and Juxta papillary diverticula (JPD) were higher in elderly patients with PEP. Age did not increase the risk of PEP development. The most important post ERCP pancreatitis risk factor in the elderly is the female gender, while the risk is enhanced slightly by SOD and JPD.

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Effectiveness and safety of secukinumab in 608 patients with psoriatic arthritis in real life: a 24-month prospective, multicentre study

RMD Open ◽

10.1136/rmdopen-2020-001519 ◽

2021 ◽

Vol 7 (1) ◽

pp. e001519

Author(s):

Roberta Ramonda ◽

Mariagrazia Lorenzin ◽

Antonio Carriero ◽

Maria Sole Chimenti ◽

Raffaele Scarpa ◽

...

Keyword(s):

Psoriatic Arthritis ◽

Adverse Events ◽

Disease Activity ◽

Biological Treatment ◽

Retention Rate ◽

Real Life ◽

Drug Retention ◽

Group A ◽

Group B ◽

Drug Retention Rate

ObjectivesTo evaluate in a multicentric Italian cohort of patients with psoriatic arthritis (PsA) on secukinumab followed for 24 months: (1) the long-term effectiveness and safety of secukinumab, (2) the drug retention rate and minimal disease activity (MDA), (3) diﬀerences in the outcomes according to the biological treatment line: biologic-naïve patients (group A) versus multifailure (group B) patients.MethodsConsecutive patients with PsA receiving secukinumab were evaluated prospectively. Disease characteristics, previous/ongoing treatments, comorbidities and follow-up duration were collected. Disease activity/functional/clinimetric scores and biochemical values were recorded at baseline (T0), 6(T6), 12(T12) and 24(T24) months. Effectiveness was evaluated overtime with descriptive statistics; multivariate Cox and logistic regression models were used to evaluate predictors of drug-discontinuation and MDA at T6. Infections and adverse events were recorded.Results608 patients (41.28% men; mean (SD) age 52.78 (11.33)) were enrolled; secukinumab was prescribed as first-line biological treatment in 227 (37.34%) patients, as second (or more)-line biological treatment in 381 (62.66%). Effectiveness of secukinumab was shown with an improvement in several outcomes, such as Ankylosing Spondylitis Disease Activity Score (T0=3.26 (0.88) vs T24=1.60 (0.69) ;p=0.02) and Disease Activity Index for Psoriatic Arthritis (T0=25.29 (11.14) vs T24=7.69 (4.51); p<0.01). At T24, group A showed lower Psoriasis Area Severity Index (p=0.04), erythrocyte sedimentation rate and C reactive protein (p=0.03 ;p=0.05) and joint count (p=0.03) compared with group B. At T24, MDA was achieved in 75.71% of group A and 70.37% of group B. Treatment was discontinued in 123 (20.23%) patients, mainly due to primary/secondary loss of effectiveness, and in 22 due to adverse events. Retention rate at T24 was 71% in the whole population, with some difference depending on secukinumab dosage (p=0.004) and gender (p=0.05).ConclusionsIn a real-life clinical setting, secukimumab proved safe and effective in all PsA domains, with notable drug retention rate.

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