Urgent one-stage endoscopic treatment for choledocholithiasis related moderate to severe acute cholangitis: A propensity score-matched analysis

Table 1 Characteristics of the study population and endoscopic retrograde cholangiopancreatography procedures

	Before matching				After matching
	Total, n = 254	ERCP ≤ 24 h, n = 102	ERCP > 24 h, n = 152	P value	Total, n = 186	ERCP ≤ 24 h, n = 93	ERCP > 24 h, n = 93	P value
Age, yr	69.47 ± 15.81	70.73 ± 15.24	68.63 ± 16.18	0.362	70.32 ± 15.39	71.05 ± 15.26	69.58 ± 15.56	0.515
Male sex, n (%)	121 (47.6)	58 (56.9)	63 (41.4)	0.016	94 (50.5)	54 (58.1)	40 (43)	0.04
CCI	1 (0-7)	1 (0-5)	1 (0-7)	0.108	1 (0-7)	1 (0-3)	1 (0-7)	0.187
Past medical history
ERCP, n (%)	30 (11.8)	13 (12.7)	17 (11.2)	0.706	22 (11.8)	13 (14)	9 (9.7)	0.364
Cholecystectomy, n (%)	67 (26.4)	27 (26.5)	40 (26.3)	0.978	44 (23.7)	22 (23.7)	22 (23.7)	1
Lab values
WBC count as/μL	10.32 ± 6.71	12.57 ± 6.61	8.81 ± 6.37	< 0.001	10.58 ± 7.03	12.11 ± 6.44	9.06 ± 7.3	0.003
Platelet count as/μL	173.96 ± 71.08	164.21 ± 73.35	180.5 ± 68.99	0.594	168.11 ± 71.33	164.85 ± 74.65	171.38 ± 68.09	0.534
CRP in mg/L	75.17 ± 76.03	94.9 ± 79.32	61.75 ± 70.95	< 0.001	78.53 ± 76.6	89.66 ± 76.37	76.37 ± 75.75	0.079
NLR (%)	7.94 (0.81-106.31)	15.67 (1.36-106.31)	6.9 (0.805-64.13)	< 0.001	18.545 (2.55-64.13)	19.87 (11.2)	16.42 (2.55-64.13)	< 0.001
INR	1.2 ± 0.22	1.23 ± 0.97	1.14 ± 0.92	< 0.001	1.21 ± 0.23	1.25 ± 0.27	1.17 ± 0.17	0.012
D2 polymers	657 (0.21-26652)	1567 (76-26652)	504 (0.38-15502)	< 0.001	1193.5 (479-15502)	1455 (479-4811)	832 (504-15502)	0.005
Creatinine in mg/dL	0.826 (0.34-8.32)	1.01 (0.34-5.86)	0.76 (0.44-8.32)	< 0.001	1.10 (0.77-5.86)	1.15 (0.77-5.86)	1.02 (0.79-3.1)	0.013
TB in mg/dL	2.61 (0.28-22.52)	3.7 (0.29-15.02)	2.14 (0.28-22.52)	0.021	3.58 ± 2.98	3.78 ± 2.8	3.38 ± 3.14	0.363
AST in U/L	108.5 (13-4051)	128.5 (13-744)	104 (15-4051)	0.168	118 (40-539)	131 (40-497)	116 (46-539)	0.53
ALT in U/L	201.68 ± 206.61	196.67 ± 173.10	205.03 ± 226.84	0.652	222 (68-512)	259 (68-512)	209 (88-479)	0.55
γ-GT in U/L	406.66 ± 354.98	425.8 ± 376.89	393.82 ± 340.16	0.463	383.61 ± 332.61	405.97 ± 347.74	361.25 ± 361.25	0.361
Albumin in g/dL	35.8 (15.9-46.6)	35.9 (15.9-48.7)	37.8 (25.1-49.1)	0.033	33.7 (24.3-36.1)	32.6 (24.3-35.7)	33.8 (25.4-36.1)	0.163
Tokyo Score
3	48 (28)	39 (38.2)	32 (21.1)	0.003	58 (31.2)	35 (37.6)	23 (24.7)	0.058
2	206 (72)	63 (61.8)	120 (78.9)		128 (68.8)	58 (62.4)	70 (75.3)
ERCP procedure
Door to ERCP time in h	48 (1-312)	8.5 (1-24)	120 (27-312)	< 0.001	25.5 (1-312)	9 (1-24)	120 (27-312)	< 0.001
ERCP procedure time (min)	60 (25-780)	60 (30-200)	60 (30-335)	0.714	60 (26-780)	60 (30-200)	60 (30-335)	0.52
One-stage ERCP, n (%)	254 (100)	102 (100)	152 (100)	1	186 (100)	93 (100)	93 (100)	1
CBD, n (%)	254 (100)	102 (100)	152 (100)	1	186 (100)	93 (100)	93 (100)	1
Stones size (mm)	8 (2-25)	9 (2-25)	8 (2-25)	0.222	8 (2-25)	9 (2-25)	8 (2-25)	0.368
Multiple stones, n (%)	109 (42.9)	35 (34.3)	74 (48.7)	0.023	79 (42.5)	32 (34.4)	47 (50.5)	0.026
Common bile duct width (mm)	13 (4-33)	14 (4-33)	14 (5-33)	0.016	13 (4-33)	13 (4-33)	12.1 (5-25)	0.038
EST, n (%)	177 (69.7)	75 (73.5)	102 (67.1)	0.275	128 (68.8)	69 (74.2)	59 (63.4)	0.113
EPBD, n (%)	204 (80.3)	90 (88.2)	114 (75)	0.009	149 (80.1)	83 (89.2)	66 (71)	0.002
Pancreatic stent placement, n (%)	21 (8.3)	5 (4.9)	16 (10.5)	0.111	15 (8.1)	5 (5.4)	10 (10.8)	0.178
Nasal Biliary Drainage Catheter placement, n (%)	251 (98.8)	100 (98)	151 (99.3)	0.346	183 (98.4)	91 (97.8)	92 (98.9)	0.561
HLL, n (%)	21 (8.3)	11 (10.8)	10 (6.6)	0.233	16 (8.6)	11 (11.8)	5 (5.4)	0.117

SMD: Standardized mean difference; CCI: Charlson Comorbidity Index; ERCP: Endoscopic retrograde cholangiopancreatography; WBC: White blood cell; CRP: C-reactive protein; NLR: Neutrophil-lymphocyte ratio; INR: International normalized ratio; TB: Total bilirubin; AST: Aspartate transaminase; ALT: Alanine transaminase; γ-GT: γ-glutamyl transpeptidase; CBD: Common bile duct stones; LC-IntraERCP: Laparoscopic cholecystectomy combined with intraoperative endoscopic retrograde cholangiopancreatography; EST: Endoscopic sphincterotomy; EPBD: Endoscopic papillary balloon dilatation; HLL: Holmium Laser Lithotripsy.

Table 2 Outcomes of endoscopic retrograde cholangiopancreatography

	Before matching				After matching
	Total, n = 254	ERCP ≤ 24 h, n = 102	ERCP > 24 h, n = 152	P value	Total, n = 186	ERCP ≤ 24 h, n = 93	ERCP > 24 h, n = 93	P value
ERCP intervention type, n (%)
Complete stone removal	250 (98.4)	101 (99)	149 (98)	0.533	184 (98.9)	92 (98.9)	92 (98.9)	1
Biliary stent insertion	4 (1.6)	1 (1)	3 (2)	0.533	2 (1.1)	1 (1.1)	1 (1.1)	1
Technical success rate, n (%)	250 (98.4)	101(99)	149 (98)	0.533	183 (98.4)	92 (98.9)	91 (98)	0.561
ERCP failure, n (%)	4 (1.6)	1 (1)	3 (2)	0.533	3 (1.6)	1 (1.1)	2 (2.2)	1
Duration of antibiotic use (d)	7 (1-28)	6 (2-15)	8 (2-26)	< 0.001	7 (2-28)	6 (2-18)	9 (2-28)	< 0.001
In-hospital mortality, n (%)	3 (1.2)	0	3 (2)	0.153	2 (1.1)	0	2 (2.2)	0.155
30-d mortality, n (%)	7 (2.8)	2 (2)	5 (3.3)	0.526	5 (2.7)	2 (2.2)	3 (3.2)	0.65
Recurrent cholangitis, n (%)	7 (2.8)	3 (2.9)	4 (2.6)	0.883	6 (3.2)	3 (3.2)	3 (3.2)	1
LOHS, (d)	10 (3-71)	9 (3-39)	18 (5-71)	< 0.001	9 (3-71)	9 (3-39)	18.5 (7-71)	< 0.001
Required ICU stay, n (%)	61 (24)	33 (32.4)	28 (18.4)	0.011	52 (28)	32 (34.4)	20 (21.5)	0.05
ICU stay length, (d)	9 (1-71)	3 (1-15)	8 (1-71)	0.003	4.5 (1-71)	3 (1-15)	9 (1-71)	< 0.001
30 d readmission, n (%)	33 (13)	15 (14.7)	18 (11.8)	0.506	29 (15.6)	14 (15.1)	15 (16.1)	0.84
ERCP-related complications, n (%)	42 (16.5)	18 (17.7)	24 (15.8)	0.696	29 (15.6)	16 (17.2)	13 (14)	0.544
PEP	23 (9.1)	9 (8.8)	14 (9.2)	0.916	17 (9.1)	9 (9.7)	8 (8.6)	0.799
Cholangitis	9 (3.5)	6 (5.9)	3 (2)	0.099	7 (3.8)	5 (5.4)	2 (2.2)	0.248
Bleeding	6 (2.4)	4 (3.9)	2 (1.3)	0.18	4 (2.2)	3 (3.2)	1 (1.1)	0.312
Others	2 (0.8)	2 (2)	0	0.083	2 (1.1)	2 (2.2)	0	0.155

ERCP: Endoscopic retrograde cholangiopancreatography; LOHS: Length of hospital stay; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis; ICU: Intensive care unit.

Table 3 Linear regression analyses to assess intensive care unit length of stay

	Univariate analysis		Multivariate analysis
	OR (95%CI)	P value	OR (95%CI)	P value
WBC count	0.503 (0.185 to 0.821)	0.003	-0.092 (-0.305 to 0.12)	0.387
Platelet count	-0.031 (-0.069 to 0.007)	0.105
CRP	0.046 (0.009 to 0.082)	0.015	0.002 (0.021 to 0.024)	0.877
NLR	-0.006 (-0.181 to 0.169)	0.945
INR	-4.986 (-15.932 to 5.961)	0.365
TB	-0.101 (-1.26 to 1.058)	0.862
Cr	6.248 (4.216 to 8.281)	< 0.001	1.818 (0.073 to 3.564)	0.042
Albumin	0.569 (0.043 to 1.095)	0.035	0.02 (-0.308 to 0.347)	0.905
ALT	-0.005 (-0.017 to 0.007)	0.375
AST	-0.001 (-0.007 to 0.005)	0.789
Multiple stones	-3.31 (-9.87 to 3.249)	0.316
CCI	1.466 (-0.713 to 3.644)	0.183
Age	-0.367 (-0.663 to -0.072)	0.016	-0.086 (-0.256 to 0.083)	0.312
Severity of AC	3.188 (-3.434 to 9.809)	0.338
Time to ERCP	0.051 (0.340 to 0.059)	< 0.001	0.044 (0.033 to 0.056)	< 0.001
Common bile duct width	-0.002 (-0.34 to 0.335)	0.988

OR: Odds ratio; CI: Confidence interval; CCI: Charlson Comorbidity Index; ERCP: Endoscopic retrograde cholangiopancreatography; WBC: White blood cell; CRP: C-reactive protein; NLR: Neutrophil-lymphocyte ratio; INR: International normalized ratio; TB: Total bilirubin; Cr: Creatinine; AST: Aspartate transaminase; ALT: Alanine transaminase; AC: Acute cholangitis.

Table 4 Outcomes of endoscopic retrograde cholangiopancreatography in the propensity matched population (Tokyo score 3 subgroup)

Patients with Grade III AC	Total, n = 58	ERCP ≤ 24 h, n = 35	ERCP > 24 h, n = 23	P value
Duration of antibiotic use (d)	8 (3-28)	7 (3-15)	11 (3-28)	0.004
In-hospital mortality, n (%)	1 (1.7)	0	1 (4.3)	0.213
30-d mortality, n (%)	4 (6.9)	2 (5.7)	2 (8.7)	0.661
Recurrent cholangitis, n (%)	4 (6.9)	2 (5.7)	2 (8.7)	0.661
LOHS, (d)	13 (6-71)	9 (6-17)	20 (14-71)	< 0.001
Required ICU stay, n (%)	32 (55.2)	21 (60)	11 (47.8)	0.362
ICU stay length, (d)	6 (1-71)	4 (1-15)	11 (1-71)	0.014
30 d readmission, n (%)	10 (17.2)	6 (17.1)	4 (17.4)	0.98
ERCP-related complications, n (%)	11 (19)	8 (22.9)	3 (13)	0.351
PEP	4 (6.9)	3 (8.6)	1 (4.3)	0.535
Cholangitis	3 (5.2)	3 (8.6)	0	0.149
Bleeding	2 (3.4)	1 (2.9)	1 (4.3)	0.761
Others	1 (1.7)	1 (2.9)	0	0.414

AC: Acute cholangitis; ERCP: Endoscopic retrograde cholangiopancreatography; LOHS: Length of hospital stay; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis; ICU: Intensive care unit.