Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity

Abstract

BACKGROUND The optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis (AC) is uncertain, especially in patients with AC of varying severity. AIM To report whether the timing of ERCP is associated with outcomes in AC patients with different severities. METHODS According to the 2018 Tokyo guidelines, 683 patients who met the definite diagnostic criteria for AC were retrospectively identified. The results were first compared between patients receiving ERCP ≤ 24 h and > 24 h and then between patients receiving ERCP ≤ 48 h and > 48 h. Subgroup analyses were performed in patients with grade I, II or III AC. The primary outcome was 30-d mortality. Secondary outcomes were intensive care unit (ICU) admission rate, length of hospital stay (LOHS) and 30-d readmission rate. RESULTS Taking 24 h as the critical value, compared with ERCP > 24 h, malignant biliary obstruction as a cause of AC was significantly less common in the ERCP ≤ 24 h group (5.2% vs 11.5%). The proportion of cardiovascular dysfunction (11.2% vs 2.6%), respiratory dysfunction (14.2% vs 5.3%), and ICU admission (11.2% vs 4%) in the ERCP ≤ 24 h group was significantly higher, while the LOHS was significantly shorter (median, 6 d vs 7 d). Stratified by the severity of AC, higher ICU admission was only observed in grade III AC and shorter LOHS was only observed in grade I and II AC. There were no significant differences in 30-d mortality between groups, either in the overall population or in patients with grade I, II or III AC. With 48 h as the critical value, compared with ERCP > 48 h, the proportion of choledocholithiasis as the cause of AC was significantly higher in the ERCP ≤ 48 h group (81.5% vs 68.3%). The ERCP ≤ 48 h group had significantly lower 30-d mortality (0 vs 1.9%) and shorter LOHS (6 d vs 8 d). Stratified by AC severity, lower 30-d mortality (0 vs 6.1%) and higher ICU admission rates (22.2% vs 10.2%) were only observed in grade III AC, and shorter LOHS was only observed in grade I and II AC. In the multivariate analysis, cardiovascular dysfunction and time to ERCP were two independent factors associated with 30-d mortality. CONCLUSION ERCP ≤ 48 h conferred a survival benefit in patients with grade III AC. Early ERCP shortened the LOHS in patients with grade I and II AC.

Comparison of the results of early and elective endoscopic retrograde cholangiopancreatography in patients with mild cholangitis

“…However, this study included all grades of acute cholangitis together. 5 The findings and hypotheses of a recent retrospective study by Huang et al 14 are interesting. In this study, subgroup analyses were performed in all patients with severe, moderate and mild cholangitis.…”

Timing of biliary decompression for acute cholangitis

“…Second, recent clinical studies have produced controversial results in terms of early implementation of BD for patients with grade III AC. In addition to the study by Huang et al [ 3 ] discussed herein (BD at ≤ 48 but not ≤ 24 h), another retrospective study by Lu et al [ 7 ] showed that BD is recommended at 24 h of admission for patients with grade III AC and within 12 h for those with AC accompanied by neurological or cardiovascular dysfunction. However, a study by Becq et al [ 8 ] using a propensity score matching approach indicated that the use of BD within 6h or 12 h of AC onset was not associated with better clinical outcomes, but possibly reduced readmission rates.…”

“…We recently became extremely interested in a retrospective study by Huang et al [ 3 ] published in the October 2022 issue of the World Journal of Gastroenterology . This was a high-quality observational study with a Newcastle-Ottawa Quality Assessment Scale score of 7 (3, 2, 2)[ 4 ].…”

“…The authors’ data indicated that 30-d mortality in patients with AC was not significantly different between ERCP performed at > 24 and ≤ 24 h. However, patients with AC had lower 30-d mortality and a shorter length of stay when ERCP was performed at ≤ 48 h. Additionally, patients with grade III AC had lower 30-d mortality rates than patients with grade I and II AC, although they had higher intensive care unit admission rates and longer lengths of stay[ 3 ]. Huang et al [ 3 ] suggested that a ≤ 48-h duration from the patient’s presentation to initiation of ERCP therapy, rather than a ≤ 24-h duration, provided the best survival benefit for patients with AC, especially for patients with grade III AC. This unique insight breaks with the traditional treatment concept that earlier performance of BD is associated with better outcomes in patients with severe AC.…”

“…This unique insight breaks with the traditional treatment concept that earlier performance of BD is associated with better outcomes in patients with severe AC. We thank Huang et al [ 3 ] for their study, which provides clinical evidence for the optimal timing of BD in patients with grade III AC.…”