Mulki R, Shah R, Qayed E. Early vs late endoscopic retrograde cholangiopancreatography in patients with acute cholangitis: A nationwide analysis. World J Gastrointest Endosc 2019; 11(1): 41-53 [PMID: 30705731 DOI: 10.4253/wjge.v11.i1.41]
Corresponding Author of This Article
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
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective 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 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
ARTICLE HIGHLIGHTS
Research background
Acute cholangitis is associated with a high mortality when the diagnosis and treatment is delayed. After the diagnosis is made, the most common method for source control is endoscopic retrograde cholangiopancreatography (ERCP). The exact timing of ERCP and its outcomes remains unclear.
Research motivation
The recent 2018 Tokyo guidelines suggest “early” ERCP for mild cholangitis, and “urgent” ERCP for severe cholangitis with no clear defining parameters.
Research objectives
The objectives of this study was to determine the effect of early ERCP vs late ERCP on mortality and readmissions in a large nationally representative sample with acute cholangitis. This could help determine the optimal timing for ERCP as a guide to practicing clinicians.
Research methods
We used the 2014 National Readmissions Database to identify patients hospitalized with acute cholangitis. Early ERCP was defined as ERCP performed < 48 h from admission, and late ERCP was defined as ERCP performed > 48 h. 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.
Research results
Four thousand five hundred and ninety-two patients satisfied the inclusion criteria; 65.9% had early ERCP, while 34.1% had late ERCP. Early ERCP was associated with lower in-hospital mortality (1.2% vs 2.4%) adjusted odds ratio (aOR), lower 30-d mortality (1.5% vs 3.3%), and a lower 30-d readmission rate (9.7% vs 15.1%). When stratified by severity of cholangitis, there was a similar benefit.
Research conclusion
There is a clear benefit from performing an early ERCP, specifically < 48 h from admission, for biliary drainage in patients with acute cholangitis regardless of severity. The benefits include, lower in-hospital mortality, 30-d mortality, 30-d readmission and reduced hospitalization costs.
Research prospective
Early ERCP seems to offer a mortality benefit compared to later ERCP. This data adds to the body of evidence from other studies about the benefit of early ERCP. Therefore hospitals should have the resources to perform ERCP early in patients with cholangitis, regardless of severity.
