Huang YC, Wu CH, Lee MH, Wang SF, Tsou YK, Lin CH, Sung KF, Liu NJ. Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity. World J Gastroenterol 2022; 28(38): 5602-5613 [PMID: 36304084 DOI: 10.3748/wjg.v28.i38.5602]
Corresponding Author of This Article
Yung-Kuan Tsou, MD, Associate Professor, Doctor, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, No. 5 Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan. flying@adm.cgmh.org.tw
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Cohort Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastroenterol. Oct 14, 2022; 28(38): 5602-5613 Published online Oct 14, 2022. doi: 10.3748/wjg.v28.i38.5602
Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity
Yao-Chi Huang, Chi-Huan Wu, Mu Hsien Lee, Sheng Fu Wang, Yung-Kuan Tsou, Cheng-Hui Lin, Kai-Feng Sung, Nai-Jen Liu
Yao-Chi Huang, Yung-Kuan Tsou, Department of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
Chi-Huan Wu, Mu Hsien Lee, Sheng Fu Wang, Yung-Kuan Tsou, Cheng-Hui Lin, Kai-Feng Sung, Nai-Jen Liu, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
Author contributions: Huang YC contributed to the conceptualization of the study and original manuscript; Wu CH, Lee MH and Wang SF contributed to data planning, interpretation and formal analysis; Lin CH and Sung KF contributed to data collection; Tsou YK is committed to the conceptualization of the study, manuscript writing, review and editing; Liu NJ contributed to revising the final version of the manuscript for submission.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of the Chang Gung Memorial Hospital (IRB No. 202200881B0).
Informed consent statement: Since this was a retrospective study using clinical routine treatment or diagnostic medical records, the Chang Gung Medical Foundation Institutional Review Board approved the waiver of the participant's consent.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: Technical appendix, statistical code and dataset available from the corresponding author at flying@adm.cgmh.org.tw.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Yung-Kuan Tsou, MD, Associate Professor, Doctor, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, No. 5 Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan. flying@adm.cgmh.org.tw
Received: June 27, 2022 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 Processing time: 106 Days and 14.1 Hours
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.
Core Tip: Compared with endoscopic retrograde cholangiopancreatography (ERCP) > 24 h, ERCP ≤ 24 h group had a significantly higher intensive care unit (ICU) admission rate and shorter length of hospital stay (LOHS). Subgroup analysis showed higher ICU admission rate was only in grade III acute cholangitis (AC); shorter LOHS was only in grade II and I AC. Compared with ERCP > 48 h, ERCP ≤ 48 h group had significantly lower 30-d mortality and shorter LOHS. Subgroup analysis revealed lower 30-d mortality was only in grade III AC; shorter LOHS was only in grade II and I AC. We concluded that ERCP ≤ 48 h conferred a survival benefit in grade III AC; early ERCP shortened LOHS in grade II and I AC.
