Same-day discharge after endoscopic biliary sphincterotomy: observations from a prospective multicenter complication study. The Multicenter Endoscopic Sphincterotomy (MESH) Study Group.
BACKGROUND
Same-day discharge after endoscopic biliary sphincterotomy (ES) is a common clinical practice, but there have been few data to guide appropriate selection of patients. Using a prospective, multicenter database of complications, we examined outcomes after same-day discharge as it was practiced by a variety of endoscopists and evaluated the ability of a multivariate risk factor analysis to predict which patients would require readmission for complications.


METHODS
A 150-variable database was prospectively collected at time of ES, before discharge and again at 30 days in consecutive patients undergoing ES at 17 centers. Complications were defined by consensus criteria and included all specific adverse events directly or indirectly related to ES requiring more than 1 night of hospitalization.


RESULTS
Six hundred fourteen (26%) of 2347 patients undergoing ES were discharged on the same day as the procedure, ranging from none at 6 centers to about 50% at 2 centers. After initial observation and release, readmission to the hospital for complications occurred in 35 (5.7%) of 614 same-day discharge patients (20 pancreatitis and 15 other complications, 3 severe). Of the same-day discharge patients, readmission was required for 14 (12.2%) of 115 who had at least one independently significant multivariate risk factor for overall complications (suspected sphincter of Oddi dysfunction, cirrhosis, difficult bile duct cannulation, precut sphincterotomy, or combined percutaneous-endoscopic procedure) versus 21 (4.2%) of 499 without a risk factor (odds ratio 3.1: 95% confidence interval [1.6, 6.3], p < 0.001). Of complications presenting within 24 hours after ES, only 44% presented within the first 2 hours, but 79% presented within 6 hours.


CONCLUSIONS
Same-day discharge is widely utilized and relatively safe but results in a significant number of readmissions for complications. For patients at higher risk of complications, as indicated by the presence of at least one of five independent predictors, observation for 6 hours or overnight may reduce the need for readmission.
Freeman
M L
ML
Hennepin County Medical Center and Minneapolis Veterans Administration Medical Center, MN 55415, USA.
Nelson
D B
DB
Sherman
S
S
Haber
G B
GB
Fennerty
M B
MB
DiSario
J A
JA
Ryan
M E
ME
Kortan
P P
PP
Dorsher
P J
PJ
Shaw
M J
MJ
Herman
M E
ME
Cunningham
J T
JT
Moore
J P
JP
Silverman
W B
WB
Imperial
J C
JC
Mackie
R D
RD
Jamidar
P A
PA
Yakshe
P N
PN
Logan
G M
GM
Pheley
A M
AM
D000328:Adult; D000368:Aged; D000556:Ambulatory Surgical Procedures / Q000009:adverse effects* / Q000706:statistics & numerical data; D002170:Canada / Q000453:epidemiology; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000706:statistics & numerical data; D015331:Cohort Studies; D006801:Humans; D008875:Middle Aged; D015999:Multivariate Analysis; D010351:Patient Discharge / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D011446:Prospective Studies; D012307:Risk Factors; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects* / Q000706:statistics & numerical data; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology