Adverse Event Rates After ERCP in Asymptomatic Choledocholithiasis
Rajesh N. Keswani, MD, MS, reviewing Obaitan I, et al. Dig Dis Sci 2024 Mar 30.
There are varying opinions on whether ERCP with biliary sphincterotomy and stone removal is appropriate in patients with asymptomatic choledocholithiasis. This generally requires a discussion with patients about the risks and benefits, but the adverse event (AE) rates after ERCP for asymptomatic choledocholithiasis are not clearly delineated.
This systematic review and meta-analysis identified 6 observational studies comparing the AE rate after ERCP for symptomatic or asymptomatic choledocholithiasis in 2178 patients (392 asymptomatic and 1786 symptomatic). The overall post-ERCP AE rates were 16% in the asymptomatic group and 9% in the symptomatic group. Post-ERCP pancreatitis (PEP) occurred significantly more often in the asymptomatic group than in the symptomatic group (11.7% vs 4.8%; P ≤ .001); of note, there was significant heterogeneity in the studies about whether and what PEP prophylaxis was utilized. There were no significant differences in post-ERCP bleeding, cholangitis, or perforation.
COMMENT
As expected, this systematic review and meta-analysis shows that ERCP is not benign in patients with asymptomatic choledocholithiasis. In fact, the data would suggest that ERCP may be riskier in this asymptomatic patient population, predominantly due to elevated PEP rates. Because some small studies have demonstrated a persistent asymptomatic nature of choledocholithiasis in some patients, and this study demonstrated an associated AE risk after ERCP, observation may be appropriate for some patients with asymptomatic choledocholithiasis.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
Rajesh N. Keswani, MD, MS
CITATION
Obaitan I, Mohamed MFH, Beran A, et al. Comparative risks of post-ERCP adverse events in patients with asymptomatic and symptomatic choledocholithiasis: a systematic review and meta-analysis. Dig Dis Sci 2024 Mar 30. (Epub ahead of print) (https://doi.org/10.1007/s10620-024-08374-0)
COMMENT
This study affirms important principles for FIT screening. First, cancers detected by FIT remain in an early stage during subsequent screening rounds. Further, increasing the cutoff level of hemoglobin for positive test results reduces sensitivity but does not shift the fraction of detected cancers substantially toward later-stage CRC. Thus, programs can adjust the cutoff to levels appropriate for their colonoscopy resources, and the detected cancers will be in an early stage across a range of hemoglobin thresholds for positive tests.