Deepa P. Budh, MD1, Pranav D. Patel, MD2, Yash Shah, MD3, Sahil Raval, MD4, Deep Mehta, MD5, Pooja Shah, MBBS, MS6, Dhruvan Patel, MD7, Harshit S. Khara, MD, FACG8 1St. Barnabas Health System, Bronx, NY; 2Geisinger Medical Center, Danville, PA; 3Hackensack Meridian Ocean Medical Center, Brick, NJ; 4Saint Peter's University Hospital, New Brunswick, NJ; 5St. Francis Medical Center, Trenton, NJ; 6Baroda Medical College, Brick, NJ; 7Mercey Fitzgerald Hospital, Darby, PA; 8Geisinger Health System, Danville, PA
Introduction: Bariatric surgery (BS) is a widely used modality of treatment in patients with morbid obesity. The lifetime risk of these patients needing Endoscopic Retrograde Cholangio-Pancreatography (ERCP) has increased. ERCP in this population is time-consuming and technically challenging due to altered anatomy. Despite several techniques, there are complications associated with each type of ERCP. Our aim was to assess trends and outcomes of ERCP in BS patients.
Methods: We utilized the Nationwide Inpatient Sample (NIS) database from 2007 to 2018. We identified adult hospitalized patients who underwent ERCP using CPT procedure codes. These were divided based on the presence of bariatric surgery (BS) status and nonbariatric surgery (NBS). All procedures were captured using previously validated CPT codes, comorbidities were captured using previously validated ICD 9 and 10 codes. Univariate and multivariate logistic regression for categorical variables and linear regression for continuous variables was carried out to identify independent associations at p < 0.05. Statistical Analysis was performed using R studio.
Results: Total 2,178,983 patients had ERCP between 2007 and 2018, from which 36,713 (1.7%) were performed in BS patients. Among the patients who received ERCP, 68% were females, 72% were Caucasians (Table 1). Rates of ERCP in BS patients increased from 1,593 (4.3%) in 2007 to 5075 (14%) in 2018 (p < 0.01). Total charges associated with BS was $76,902 vs $55,252 (p< 0.001). ERCP for Cholecdocholithiaisis (2.1% vs 1.4%) was more common in BS patients. On univariate analysis, bleeding, intra-abdominal infections, bile duct perforation, and inpatient mortality were statistically significant amongst BS patients as compared to NBS patients. On multivariate analysis, BS patients had higher risk of death (aOR: 1.38, 1.18-1.63) and bleeding complications (aOR: 1.73, 1.44-2.07) as compared to NBS patients. While acute pancreatitis was significantly higher in NBS patients as compared to BS patients. Acute cholangitis was comparable in BS and NBS patients (Table 2).
Discussion: The utilization of ERCP has been increasing over the last decade. The BS group had younger females and had higher utilization of health care resources. BS group despite being younger had a higher mortality rate and had more bleeding complications as compared to NBS. ERCP should be performed with caution in patients with BS to avoid mortality and worse inpatient outcomes.
Table 1. Demographics
Non Bariatric Surgery Group (n = 2,142,270)
Bariatric Surgery Group (n= 36,713)
p-value
AGE
62 (46, 76)
57 (44, 67)
< 0.001
AGE GROUP
< 0.001
18-27
116,840 (5.5%)
425 (1.2%)
28-37
343,200 (16%)
2,262 (6.2%)
38-47
391,922 (18%)
5,754 (16%)
48-57
387,558 (18%)
8,811 (24%)
58-67
313,532 (15%)
8,042 (22%)
68-77
216,827 (10%)
6,094 (17%)
78-87
197,928 (9.2%)
4,015 (11%)
88 and above
174,463 (8.1%)
1,311 (3.6%)
GENDER
< 0.001
Male
879,110 (41%)
11,618 (32%)
Female
1,262,064 (59%)
25,080 (68%)
Unknown
1,097 (< 0.1%)
15 (< 0.1%)
RACE
< 0.001
White
1,326,854 (68%)
24,424 (72%)
African American
178,702 (9.1%)
3,558 (10%)
Hispanic
305,630 (16%)
4,081 (12%)
Asian/Pacific Islander
72,335 (3.7%)
852 (2.5%)
Native American
13,664 (0.7%)
153 (0.4%)
Other
66,140 (3.4%)
1,016 (3.0%)
Unknown
178,946 (8.4%)
2,628 (7.2%)
LENGTH OF STAY (Days)
4.0 (3.0, 7.0)
6.0 (3.0, 12.0)
< 0.001
YEAR
< 0.001
2007
157,405 (7.3%)
1,593 (4.3%)
2008
172,320 (8.0%)
1,829 (5.0%)
2009
170,895 (8.0%)
2,135 (5.8%)
2010
176,302 (8.2%)
2,661 (7.2%)
2011
179,012 (8.4%)
2,440 (6.6%)
2012
168,425 (7.9%)
2,500 (6.8%)
2013
167,540 (7.8%)
2,540 (6.9%)
2014
168,515 (7.9%)
3,145 (8.6%)
2015
174,610 (8.2%)
3,440 (9.4%)
2016
200,030 (9.3%)
4,595 (13%)
2017
201,935 (9.4%)
4,760 (13%)
2018
205,280 (9.6%)
5,075 (14%)
OBESITY
309,544 (14%)
11,259 (31%)
< 0.001
TOTAL CHARGES ($)
$55,252 (34,801, 87,258)
$76,902 (46,432, 139,565)
< 0.001
INDICATIONS FOR ERCP
Acute Pancreatitis
14,015 (0.7%)
255 (0.7%)
0.7
Acute Cholangitis
124,546 (5.8%)
1,498 (4.1%)
< 0.001
Choledocholithiasis
30,785 (1.4%)
765 (2.1%)
< 0.001
Pancreatic Cancer
25,946 (1.2%)
460 (1.3%)
0.7
Hilar Cholangiocarcinoma
20,022 (0.9%)
278 (0.8%)
0.12
Table 2: Multivariate Logistic Regression of ERCP Complications and Inpatient Mortality
Adjusted Odds Ratio
95% CI
p-value
Inpatient Mortality
1.75
1.49-2.07
< 0.01
Acute Pancreatitis
0.36
0.15-0.86
0.02
Acute Cholangitis
1
0.92-1.11
0.84
Bleeding
2.05
1.71-2.45
< 0.01
Cholecystitis
1.18
0.79-1.77
0.42
Intraabdominal Infections
4.12
3.33-5.11
< 0.01
Bile Duct Perforation
3.77
3.07-4.63
< 0.01
Table: Table 1: Demographics, indications of bariatric and nonbariatric surgery patients Table 2: Multivariate logistic regression of ERCP complications and inpatient mortality
Disclosures:
Deepa Budh indicated no relevant financial relationships.
Pranav Patel indicated no relevant financial relationships.
Yash Shah indicated no relevant financial relationships.
Sahil Raval indicated no relevant financial relationships.
Deep Mehta indicated no relevant financial relationships.
Pooja Shah indicated no relevant financial relationships.
Dhruvan Patel indicated no relevant financial relationships.
Harshit Khara indicated no relevant financial relationships.
Deepa P. Budh, MD1, Pranav D. Patel, MD2, Yash Shah, MD3, Sahil Raval, MD4, Deep Mehta, MD5, Pooja Shah, MBBS, MS6, Dhruvan Patel, MD7, Harshit S. Khara, MD, FACG8. A0428 - Outcomes and Trends of Endoscopic Retrograde Cholangio-Pancreatography in Bariatric Surgery Patients - A National Inpatient Sample (NIS) Study, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
