Increased Risk of Pyogenic Liver Abscess after Endoscopic Sphincterotomy for Treatment of Choledocholithiasis

Abstract

Background and Aim

Endoscopic sphincterotomy (ES) abolished the barrier between the hepatobiliary system and duodenum and might be at risk of pyogenic liver abscess (PLA). We aimed to identify the association factors of PLA in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) procedures for treatment of choledocholithiasis.

Methods

This study was based on the Chung Gung Research Database (CGRD) between January 1, 2001 and December 31, 2018. Those who had an International Classification of Diseases, Ninth and Tenth Revision (ICD9 and ICD10) codes of choledocholithiasis and received ERCP were enrolled. After strict exclusions, 11,697 patients were further divided into the endoscopic sphincterotomy (ES) group (n=7,111) and other ERCP group (n=4,586) for analysis.

Results

Patients receiving ES had significantly higher rates of PLA than those of the other ERCP group (5-year cumulative incidence 2.4% versus 1.7%; 10-year cumulative incidence 3.9% versus 3.2%, log-rank p=0.0177). Aging, male gender, surgery for hepato-pancreato-biliary system and hepatobiliary malignancy were significant association factors of PLA. On multivariate analysis, the ES increased the risk of PLA (adjusted hazard ratio [aHR]=1.49; 95% CI=1.12–1.98; p=0.0058) but decreased the risks for acute pancreatitis (aHR=0.72; 95% CI=0.60–0.85; p=0.0002) and cholangitis (aHR= 0.91; 95% CI=0.84–0.99; p=0.0259). There was no significant difference about recurrent choledocholithiasis between groups.

Conclusion

This study demonstrated a significant risk of PLA after patients receiving ES compared with the other ERCP group. We should also carefully monitor the association factors of PLA after ERCP treatment of choledocholithiasis including aging, male gender, surgery for the hepato-pancreato-biliary system and hepatobiliary malignancy.

Keywords:

• pyogenic liver abscess
• endoscopic sphincterotomy
• choledocholithiasis
• endoscopic retrograde cholangiopancreatography

Acknowledgments

The authors appreciate Miss Yi-Hsuan Tsai in the Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital for the assistance with programming and analyses. The authors would like to thank the Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chia-Yi Branch.

Data Sharing Statement

No data will be shared except besides what is included in the manuscript.

Ethics Approval and Informed Consent

The study protocol was approved by the Institutional Review Board and the Ethics Committee of Chang Gung Memorial Hospital at Taoyuan in Taiwan (permitted number 201900919B0C601). This study was performed in accordance with relevant guidelines and regulations. The Ethics Committee waived the requirement for informed consentfor this study, and the data were analyzed anonymously. This study was performed in accordance with the Declaration of Helsinki.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declared that they have no conflicts of interest.