OPTIMAL TIMING FOR ENDOSCOPIC MANAGEMENT OF POST CHOLECYSTECTOMY BILIARY LEAK: A 15-YEAR NATIONWIDE DATABASE ANALYSIS

Biliary duct leak (BDL) is a serious complication of cholecystectomy. Endoscopic therapy of BDL with ERCP is safe, effective and considered the first line therapy. However, whether ERCP should be done emergently or expectantly remains controversial. Our aim was to evaluate the relationship between the timing of ERCP after BDL and the development poor clinical outcomes. We used the Nationwide Inpatient Sample (NIS) for the years 2000-2014. NIS is the largest inpatient database that is nationally representative for the US population. Adult patients who underwent ERCP with intervention for BDL following cholecystectomy were identified using the ICD9 codes. Data were abstracted on demographics, Charlson comorbidity index, and ERCP intervention (sphicterotomy, biliary stent, or both). Endotherapy was classified into 3 groups based on timing of ERCP: within 1 day (emergent), on day 2-3 (urgent), and greater than 3 days (expectant) after BDL. Successful endotherapy was defined by the lack of need for surgical biliary repair or percutaneous biliary drainage following ERCP. Clinical adverse events (AEs) were defined by the presence of any of sub-phrenic abscess/hepatic abscess, pneumonia, sepsis, or acute kidney dysfunction. In-hospital mortality is provided in the NIS. The relationship between timing of ERCP after BDL, its success, AEs, and in-hospital mortality were evaluated using multivariate logistic regression analysis. A total of 1,028 patients met our inclusion criteria with median age of 56 (IQR 40-70), male 52%, Caucasians (57%). Success of endotherapy was achieved in 94%. Most of the patients (87%) required one ERCP, whereas 11% required two and 2% required three during admission. ERCP was done emergently in 19%, urgently in 30%, and expectantly in 51% of the patients following BDL. Two percent of patients died during hospitalization and 31% had AEs. Patients who had urgent ERCP following the BDL had the lowest rate of AE of 14% as compared to those who had emergent 27%, and expectant 43%, (p <0.001). Multivariate analysis showed that patients who had urgent ERCP had the half the odds (OR 0.5, p=0.013), whereas those who had expectant ERCP had double the odds (OR 2.2, p=0.001) of developing of AE as compared to those who had emergent ERCP. A similar trend was observed with the in-hospital mortality rate, with the lowest being 0% among urgent group, compared to 5% for emergent, and 2% for expectant (p<0.001, Figure). Other variables that were associated with worse outcomes included advanced age, higher comorbidity, open cholecystectomy, and failure of ERCP endotherapy (Table). In this nationwide study, patients who had ERCP endotherapy for BDL urgently (in 2-3 days) had better outcomes compared to patients who had it emergently (<1 day) or expectantly (>3 day) following biliary injury.View Large Image Figure ViewerDownload Hi-res image Download (PPT)