Retrospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jan 16, 2019; 11(1): 41-53
Published online Jan 16, 2019. doi: 10.4253/wjge.v11.i1.41
Early vs late endoscopic retrograde cholangiopancreatography in patients with acute cholangitis: A nationwide analysis
Ramzi Mulki, Rushikesh Shah, Emad Qayed
Ramzi Mulki, Rushikesh Shah, Emad Qayed, Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30303, United States
Emad Qayed, Grady Memorial Hospital, Emory University, Atlanta, GA 30303, United States
Author contributions: Mulki R designed the research, drafted and revised the manuscript; Shah R designed the research and revised the manuscript for important intellectual content; Qayed E designed the research, interpreted the data, drafted and revised the manuscript; all authors read and approved the final version of the manuscript.
Institutional review board statement: This study was reviewed and deemed exempt from review by the Emory University Institutional Review Board because the database is publicly available and does not contain any identifiable information that can be linked to any specific subject.
Informed consent statement: Informed consent was not required as this research involves an administrative database and does not contain any identifiable information that can be linked to any specific subject.
Conflict-of-interest statement: The authors report no conflict of interest.
Open-Access: 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/
Corresponding author: Emad Qayed, MD, Assistant Professor, Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, 49 Jesse Hill Junior Drive, Atlanta, GA 30303, United States. eqayed@emory.edu
Telephone: +1-404-7781685 Fax: +1-404-7781681
Received: July 27, 2018
Peer-review started: July 30, 2018
First decision: October 5, 2018
Revised: October 12, 2018
Accepted: December 12, 2018
Article in press: December 13, 2018
Published online: January 16, 2019
Processing time: 173 Days and 20.2 Hours
Abstract
AIM

To assess the effect of early vs late endoscopic retrograde cholangiopancreatography (ERCP) on mortality and readmissions in acute cholangitis, using a nationally representative sample.

METHODS

We used the 2014 National Readmissions Database to identify adult patients hospitalized with acute cholangitis who underwent therapeutic ERCP within one week of admission. Early ERCP was defined as ERCP performed on the same day of admission or the next day (days 0 or 1, < 48 h), and late ERCP was performed on days 2 to 7 of admission. Patients with severe cholangitis had any of the following additional diagnoses: Severe sepsis, septic shock, acute renal failure, acute respiratory failure, or thrombocytopenia. Multivariate logistic regression was used to calculate the adjusted odds of association of ERCP timing with in-hospital mortality, 30-d mortality, and 30-d readmissions, controlling for age, sex, severe disease and comorbidities.

RESULTS

Four thousand five hundred and seventy patients satisfied the inclusion criteria; with a mean age of 64.1 years. Of these, 66.6% had early ERCP, while 33.4% had late ERCP. Early ERCP was associated with lower in-hospital mortality [1.2% vs 2.4%, adjusted odds ratio (aOR) = 0.50, 95%CI: 0.76-0.83, P = 0.001] and lower 30-d mortality (1.5% vs 3.3%, aOR = 0.48, 95%CI: 0.33-0.69, P < 0.0001) compared to the late ERCP group. Similarly, early ERCP was associated with lower 30-d readmissions (9.7% vs 15.1%, aOR = 0.58, 95%CI: 0.49-0.7, P < 0.0001). When stratified by severity of cholangitis, there was a similar benefit of early ERCP on all outcomes in those with and without severe cholangitis. The mean length of stay was higher in the late ERCP group compared to the early ERCP group (6.9 d vs 4.5 d, P < 0.0001). The mean hospitalization cost was higher in the late ERCP group ($21459 vs $16939, P < 0.0001).

CONCLUSION

Early ERCP is associated with lower in-hospital and 30-d mortality in those with or without severe cholangitis. Regardless of severity, we suggest performing early ERCP.

Keywords: Cholangitis; Endoscopic retrograde cholangiopancreatography; Mortality; Readmissions; Severity cholangitis; Length of stay; Nationwide analysis

Core tip: The impact of the timing of endoscopic retrograde cholangiopancreatography (ERCP) on outcomes in patients with acute cholangitis is unclear. Aim of this study is to assess the effect of early vs late ERCP on mortality and readmissions in acute cholangitis, using a nationally representative sample. Early ERCP was associated with a statistically significant lower in-hospital mortality, 30-d mortality, and 30-d readmission rate; adjusted odds ratio 0.5, 0.48, 0.58 respectively, compared to late ERCP. When stratified by severity, a similar benefit was observed. Early ERCP may improve outcomes in patients with acute cholangitis regardless of severity.