Published online Oct 14, 2022. doi: 10.3748/wjg.v28.i38.5602
Peer-review started: June 27, 2022
First decision: August 1, 2022
Revised: August 12, 2022
Accepted: September 23, 2022
Article in press: September 23, 2022
Published online: October 14, 2022
The optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis has been inconsistently reported and there are few studies on the timing of ERCP in acute cholangitis of varying severity.
On the one hand, unnecessary emergent ERCP increases medical costs and the burden on physicians and technicians; on the other hand, delayed ERCP may increase morbidity and mortality in patients with acute cholangitis. The findings of this study may guide the avoidance of unnecessary urgent and delayed ERCP for acute cholangitis.
This study aims to answer the optimal timing of ERCP for acute cholangitis of different severity according to 30-d mortality after ERCP. Answering this question can serve as important evidence for future guideline development.
The retrospective cohort study included 683 patients who met the diagnostic criteria for acute cholangitis defined by the 2018 Tokyo Guidelines. Among them, there were 170 (24.9%) grade III acute cholangitis patients, 179 grade II acute cholangitis patients (26.4%) and 334 grade I acute cholangitis patients (48.9%). Results are first compared between patients receiving ERCP ≤ 24 h and > 24 h, and then between patients receiving ERCP ≤ 48 h and > 48 h. Subgroup analyses are performed on patients with grade III, II or I acute cholangitis.
When 24 h was considered a critical value for ERCP timing, we found that patients with malignant biliary obstruction received ERCP ≤ 24 h less frequently when compared with ERCP > 24 h (5.2% vs 11.5%). Patients with organ dysfunction such as cardiovascular dysfunction (11.2% vs 2.6%) and respiratory dysfunction (14.2% vs 5.3%) or those admitted to the ICU (11.2% vs 4%) tended to receive ERCP ≤ 24 h. Patients with ERCP ≤ 24 h had significantly shorter hospital stays (median, 6 d vs 7 d). Stratified by the severity of acute cholangitis, higher ICU admission was only observed in grade III acute cholangitis and a shorter length of hospital stay was only observed in grade I and II acute cholangitis. Regarding 30-d mortality, the results of ERCP ≤ 24 h and > 24 h were not significantly different, either in the overall population or in patients with grade I, II or III acute cholangitis. When 48 h was considered a critical value for ERCP timing, patients with choledocholithiasis received ERCP ≤ 48 h more frequently (81.5% vs 68.3%). Patients who received ERCP ≤ 48 h had significantly lower 30-d mortality (0 vs 1.9%) and shorter hospital stays (6 d vs 8 d). Stratified by the severity of acute cholangitis, lower 30-d mortality (0 vs 6.1%) and higher ICU admission rates (22.2% vs 10.2%) were only observed in grade III acute cholangitis and a shorter length of hospital stay was only observed in grade I and II acute cholangitis. In the multivariate analysis, cardiovascular dysfunction and time to ERCP were two independent factors associated with 30-d mortality.
ERCP ≤ 48 h but not ≤ 24 h has a survival benefit in acute cholangitis patients; this benefit is only observed in patients with grade III acute cholangitis. Early ERCP is also recommended for patients with grade I and II acute cholangitis because it shortens the length of hospital stay.
Of the five organ failure criteria used to diagnose grade III AC, cardiovascular dysfunction was the only independent factor associated with 30-d mortality in the current study. Therefore, cardiovascular dysfunction should be weighed more heavily in the development of new guidelines in the future.