Outcomes and Trends of Endoscopic Retrograde Cholangio-Pancreatography in Bariatric Surgery Patients - A National Inpatient Sample (NIS) Study

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). 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). Conclusion: 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, indications of bariatric and nonbariatric surgery patients 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