Clinical prediction rule to determine the need for repeat ERCP after endoscopic treatment of postsurgical bile leaks.
OBJECTIVE
In patients who have undergone ERCP with biliary stenting for postsurgical bile leaks, the optimal method (ERCP or gastroscopy) and timing of stent removal is controversial. We developed a clinical prediction rule to identify cases in which a repeat ERCP is unnecessary.


METHODS
Population-based study of all patients who underwent ERCP for management of surgically induced bile leaks between 2000 and 2012. Multivariate and binary recursive partitioning analyses were performed to generate a rule predicting the absence of biliary pathology on repeat endoscopic evaluation.


RESULTS
A total of 259 patients were included. On multivariate analysis, postsurgical normal alkaline phosphatase (ALP; OR, 2.26; 95% CI, 1.03-4.99), time from surgery to first ERCP < 8 days (OR, 2.47; 95% CI, 1.15-5.31), and minor leak with no other pathology on initial ERCP (OR, 6.74; 95% CI, 1.75-25.89) were independently associated with the absence of persistent bile leak and other pathology on repeat ERCP. The derived rule included laparoscopic cholecystectomy, normal postsurgical ALP, minor leak with no other pathology on initial ERCP, and an interval from initial to repeat ERCP between 4 and 8 weeks. When all 4 criteria were met, the rule had a sensitivity of 94% (95% CI, 83%-99%) and a negative predictive value of 93% (95% CI, 81%-99%). Optimism-adjusted sensitivity and negative predictive value were 88% (95% CI, 76%-96%) and 86% (95% CI, 73%-96%), respectively.


CONCLUSIONS
This clinical decision rule identifies patients who can have their biliary stents removed via gastroscopy, which may improve patient safety and healthcare utilization.
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
Apostolos V
AV
Tsolakis
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
Paul D
PD
James
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Gilaad G
GG
Kaplan
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Robert P
RP
Myers
Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
James
J
Hubbard
Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Todd
T
Wilson
Medical Services, Alberta Health Services, Calgary, Alberta, Canada.
Scott
S
Zimmer
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Rachid
R
Mohamed
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Martin
M
Cole
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Sydney
S
Bass
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Mark G
MG
Swain
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Steven J
SJ
Heitman
D000328:Adult; D000416:Alberta; D000469:Alkaline Phosphatase / Q000097:blood; D001660:Biliary Tract Diseases / Q000097:blood / Q000601:surgery*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D017081:Cholecystectomy, Laparoscopic; D003661:Decision Support Techniques; D020878:Device Removal; D005260:Female; D005773:Gastroscopy; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000097:blood / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D016717:Sphincterotomy, Endoscopic; D015607:Stents; D013997:Time Factors
D000469:Alkaline Phosphatase