Clinical prediction rule to determine the need for repeat ERCP after endoscopic treatment of postsurgical bile leaks

Apostolos V. Tsolakis, Paul D. James, Gilaad G. Kaplan, Robert P. Myers, James Hubbard, Todd Wilson, Scott Zimmer, Rachid Mohamed, Martin Cole, Sydney Bass, Mark G. Swain, Steven J. Heitman
2017 Gastrointestinal Endoscopy  
and Aims: In patients who have undergone ERCP with biliary stenting for postsurgical bile leaks, the optimal method (ERCP or gastroscopy) and timing of stent removal is controversial. We developed a clinical prediction rule to identify cases in which a repeat ERCP is unnecessary. Methods: Population-based study of all patients who underwent ERCP for management of surgically induced bile leaks between 2000 and 2012. Multivariate and binary recursive partitioning analyses were performed to
more » ... performed to generate a rule predicting the absence of biliary pathology on repeat endoscopic evaluation. Results: A total of 259 patients were included. On multivariate analysis, postsurgical normal alkaline phosphatase (ALP; OR, 2.26; 95% CI, 1.03-4.99), time from surgery to first ERCP < 8 days (OR, 2.47; 95% CI, 1.15-5.31), and minor leak with no other pathology on initial ERCP (OR, 6.74; 95% CI, 1.75-25.89) were independently associated with the absence of persistent bile leak and other pathology on repeat ERCP. The derived rule included laparoscopic cholecystectomy, normal postsurgical ALP, minor leak with no other pathology on initial ERCP, and an interval from initial to repeat ERCP between 4 and 8 weeks. When all 4 criteria were met, the rule had a sensitivity of 94% (95% CI, 83%-99%) and a negative predictive value of 93% (95% CI, 81%-99%). Optimism-adjusted sensitivity and negative predictive value were 88% (95% CI, 76%-96%) and 86% (95% CI, 73%-96%), respectively. Conclusions: This clinical decision rule identifies patients who can have their biliary stents removed via gastroscopy, which may improve patient safety and healthcare utilization. (Gastrointest Endosc 2017;85:1047-56.) Biliary leaks are important adverse events associated with hepatobiliary surgeries, occurring in up to 2% of cholecystectomies and 13% of partial hepatectomies. 1-3 They are effectively managed by decreasing transpapillary pressure, allowing bile to flow preferentially into the duodenum and permitting upstream defects to close.
doi:10.1016/j.gie.2016.10.027 pmid:27810250 fatcat:4kj62j5hfzgirdkqizyg5jhgpm