Risk Factors for Peritonitis Associated With Endoscopic Ultrasound-guided Hepaticogastrostomy.
A bile duct diameter of ≤3 mm during EUS-HGS is a significant risk factor for peritonitis, suggesting careful consideration during the procedure.
Where it sits
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This study retrospectively evaluated 188 patients who underwent endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) to identify risk factors for peritonitis. The analysis found that a bile duct diameter of ≤3 mm significantly increased the risk of peritonitis. The study focused on patients with malignant biliary obstruction, primarily due to pancreatic cancer.
Abstract
<h4>Background and objectives</h4>Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an alternative therapeutic option for unsuccessful endoscopic retrograde cholangiopancreatography in patients with malignant biliary obstruction. Procedure-related adverse events (AEs), such as bile leakage and peritonitis, can lead to prolonged hospitalization and delay the initiation of chemotherapy for underlying malignancies. This study aimed to identify factors associated with the development of peritonitis following EUS-HGS.<h4>Methods</h4>Consecutive patients who underwent initial EUS-HGS between July 2016 and November 2022 were retrospectively evaluated. We assessed the preprocedural characteristics (cholangitis and duodenal invasion) and intraprocedural technical factors (small bile duct diameter, short hepatic parenchymal distance at puncture, antegrade stenting, and the use of a plastic stent for HGS). Multivariate logistic regression analysis was conducted to evaluate the factors associated with peritonitis after EUS-HGS.<h4>Results</h4>A total of 188 patients were included. The cause of biliary obstruction was malignancy in 96% of the cases, with the majority being pancreatic cancer. The rate of early AEs was 15% and included peritonitis (7%), pancreatitis (3%), cholangitis (3%), cholecystitis (1%), and bleeding (1%). Multivariable logistic regression analysis revealed that the diameter of a punctured bile duct ≤3 mm (odds ratio, 4.0; 95% confidence interval, 1.1-15; <i>p</i> = 0.039) independently increased the risk of peritonitis after EUS-HGS.<h4>Conclusions</h4>A punctured bile duct diameter of ≤3 mm was identified as a significant independent risk factor for the development of peritonitis after EUS-HGS. <b>Trial Registration</b>: N/A.
Background
The study addresses the clinical question of identifying risk factors for peritonitis following endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), a procedure used when endoscopic retrograde cholangiopancreatography fails in patients with malignant biliary obstruction. Peritonitis is a significant adverse event that can delay necessary chemotherapy. Understanding these risk factors is crucial for improving patient outcomes and procedural safety.
Methods
This retrospective study included 188 consecutive patients who underwent initial EUS-HGS between July 2016 and November 2022. The study evaluated preprocedural characteristics such as cholangitis and duodenal invasion, as well as intraprocedural factors like bile duct diameter and stenting techniques. Multivariate logistic regression was used to identify factors associated with peritonitis.
Results
Among the 188 patients, 96% had biliary obstruction due to malignancy, predominantly pancreatic cancer. The overall rate of early adverse events was 15%, with peritonitis occurring in 7% of cases. The multivariable logistic regression identified a bile duct diameter of ≤3 mm as a significant independent risk factor for peritonitis, with an odds ratio of 4.0 and a p-value of 0.039.
Interpretation
The study highlights a specific procedural risk factor for peritonitis, a serious complication of EUS-HGS. The finding that a bile duct diameter of ≤3 mm significantly increases the risk of peritonitis is statistically significant but may have limited clinical applicability due to the study's retrospective nature and potential confounding factors. These results should be interpreted with caution and validated in prospective studies.
Key findings
- 188 patients underwent EUS-HGS.
- 96% of biliary obstructions were due to malignancy.
- The early adverse event rate was 15%.
- Peritonitis occurred in 7% of cases.
- Bile duct diameter ≤3 mm had an odds ratio of 4.0 for peritonitis, p=0.039.
Limitations
- Retrospective study design
- Single-center data
- Potential selection bias
- Specific to EUS-HGS procedure
- No prospective validation