Analysis Of Risk Factors Of Pancreatitis After ERCP For Choledocholithiasis

[Objective]In this study,the risk factors of PEP(post-ERCP pancreatitis)in patients with choledocholithiasis after endoscopic retrograde cholangiopancreatography for the first time were investigated to access the effective evaluation on the risk of PEP so as to provide risk reference for clinicians,optimize clinical decision-making,and reduce the incidence rate of PEP.[Method]From September 1st,2015 to September 1st,2019,ERCP was performed on 944 cases of choledocholithiasis in the Digestive Endoscope Center of our hospital.Finally,502 patients with choledocholithiasis first undergoing ERCP were included as subjects,with an exclusion of preoperative pancreatitis,non-first onset of ERCP,drainage operation only,and incomplete clinical data etc.The basic information of patients,preoperative laboratory indexes,ERCP operation records and other clinical data were collected.The possible risk factors included age,sex,cholecystolithiasis,history of cholecystectomy,preoperative serum total bilirubin level,preoperative alkaline phosphatase level,preoperativeγ-glutamyltransferase level,appearance type of duodenal papilla,intubation mode,operation,stone extraction device,choledocholithiasis related factors(size,character,quantity),etc.According to the type of data,independent sample t-test,chi-square test or nonparametric test were selected for univariate analysis.The statistically significant factors in univariate analysis were further analyzed by multivariate Logistic regression analysis,and finally determined the independent risk factors of PEP.The difference is statistically significant with p<0.05.[Results]1.Operations were successfully performed on the included 502 patients with choledocholithiasis with a stone clearance rate of 99.2%,among whom the average age was 58 years(range,13-90 years),with 284 males(56.6%)and 218females(43.4%).There were 61 PEP complication cases(12.2%)after ERCP,30cases(49.2%)in male,31 cases(50.8%)in female.According to the Atlanta classification,54 cases were mild,5 cases were moderately severe and 2 cases were severe.In univariate analysis of PEP,age,preoperative fibrinogen level,preoperative alkaline phosphatase level,preoperative γ-glutamyltransferase level,lithotripsy device,guide wire entering pancreatic duct and appearance type of duodenal papilla were associated with PEP.However,gender,diabetes,hypertension,liver cirrhosis,cholecystolithiasis,previous cholecystectomy history,preoperative total bilirubin,alanine aminotransferase,aspartate aminotransferase,white blood cell count,serum albumin,bile duct dilatation,operation,stone size and other factors were not statistically significant with the occurrence of PEP.Multivariate logistic regression analysis showed that age < 70 years old,γ-glutamyltransferase < 250U/L,guide wire entering the pancreatic duct,type 2 nipple(small nipple)and type 3 nipple(protruding or draping type)were independent risk factors for PEP.2.Among the 502 patients,there were 188 patients with type 2 and type 3 nipples,including 111 males(59.0%)and 77 females(41.0%).There were 42cases(22.3%)of PEP,including 37 mild cases,4 moderate severe cases and 1severe case.Univariate analysis showed that age,stone extraction device and operation were related to the occurrence of PEP.Multivariate Logistic analysis showed that patients with choledocholithiasis who were treated with balloon catheter alone and whose age was less than 70 years old were associated with PEP(p < 0.05).[Conclusion]1.This study shows that in the preoperative evaluation of ERCP,patients with choledocholithiasis who are less than 70 years old and whoseγ-glutamyltransferase is less than 250U/L should be fully informed of the risk of PEP and timely implement preoperative intervention measures to prevent and treat PEP.2.During ERCP operation,the appearance of duodenal papilla should be observed and classified accurately.If patients with choledocholithiasis manifest as type 2 papilla(small papilla)or type 3 papilla(protruding or draping papilla),the operator should standardize the manipulation and reduce the number of attempts to intubate.Patients with difficulty in intubation should be referred to experts in time or actively take intervention measures to prevent and treat PEP after operation.Patients with difficulty to be intubated should be referred to specialists promptly for treatment or active intervention measures should be taken to prevent and treat PEP after the operation.Furthermore,a prophylactic placement of a pancreatic duct stent is recommended for those who should be intubated with double-guided wire or those who have a guide wire into the pancreatic duct.3.In patients with type 2 papilla(small papilla)or type 3 papilla(protruding or pendulous papilla),appropriate stone extraction device should be selected when ERCP stone extraction is performed.It is not recommended to remove stone by balloon catheter alone,but net basket should be considered.