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ERCP-Induced Bili-Enteric Perforations: Good Outcomes Even for Those Requiring Surgical Intervention
*Rogeh Habashi, Kevin Schuster
Yale University, New Haven, CT

Objective: Bili-enteric perforation (BEP) is a rare but potentially devastating complication of endoscopic retrograde cholangiopancreatography (ERCP). This study examines the outcome differences between the non-operative (NO), surgery (S) and interventional radiology (IR) managements. Design, Setting and Patients: Using the National Inpatient Sample database (NIS), a retrospective cohort of 473, 621 patients undergoing ERCP in a 16-year period (2000-2015) were analyzed. Interventions and Main Outcome Measures: Differences between NO, S and IR managements were investigated using univariate analyses for demographics and log-transformed linear regression or logistic regression for length of stay (LOS), total charges and mortality. Results: The cumulative incidence of BEP is 0.68% (n=3,228), predominantly enteric (97%, n=3,135/3,228). Females, age >60, and Elixhauser comorbidity index (ECI) >15 were associated with increased risk of BEP (p<0.0001). 56% (n=1,799/3,228) were non-operatively managed and 25% (n=809/3,228) required surgery, of whom 7% (n=55/809) underwent IR postoperatively. Percutaneous drainage represented 6% (172/3,228) with 12 % (20/172) failing and requiring surgery. There was no difference in in-hospital mortality between NO, S and IR groups (NO: 53/1797 (3%) vs. IR: 9/152 (6%) vs. S: 54/754 (7%); pNO-IR=0.642, pNO-S=0.0589 and pIR-S=0.0589). NO had the shortest LOS (7d [4-11]; p<0.0001) and lowest total charges ($38, 785 [23, 052 – 75, 389]; p<0.0001) relative to the IR and S groups. Relative to the S group, IR was associated with slightly longer LOS (IR:13d [8-20.5] vs. S: 11d [7-16]; p LOS =0.0966) and significantly higher total charges (IR: $87, 167 [55, 208-147, 567] vs. S: $74, 225-129, 287]; p costs = 0.0318). Conclusions: Surgery for BEP is associated with similar in-hospital mortality relative to non-invasive management with shorter LOS and lower costs relative to percutaneous drainage.


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