Early vs late endoscopic retrograde cholangiopancreatography in patients with acute cholangitis: A nationwide analysis

Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event

BACKGROUND

Gallstone disease will affect 15% of the adult population with concomitant common bile duct stone (CBDS) occurring in up to 30%. Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for removal of CBDS, as cholecystectomy for the prevention of recurrent biliary event (RBE). RBE occurs in up to 47% if cholecystectomy is not done. The goal of this study was to evaluate the timing of occurrence of RBE after common bile duct clearance with ERCP and associated outcomes.

METHODS

The records of all patients who underwent ERCP for gallstone disease followed by cholecystectomy, in a single center from 2010 to 2022, were reviewed. All RBE were identified. Actuarial incidence of RBE was built. Patients with and without RBE were compared.

RESULTS

The study population is composed of 529 patients. Mean age was 58.0 (18-95). There were 221 RBE in 151 patients (28.5%), 39/151 (25.8%) having more than one episode. The most frequent RBE was acute cholecystitis (n = 104) followed by recurrent CBDS (n = 95). Median time for first RBE was 34 days. Actuarial incidence of RBE started from 2.5% at 7 days to reach 53.3% at 1 year. Incidence-rate of RBE was 2.9 per 100 person-months. Patients with RBE had significant longer hospitalisation time (11.7 vs 6.4 days; P < 0.0001), longer operative time (66 vs 48 min; P < 0.0001), longer postoperative stay (2.9 vs 0.9 days; P < 0.0001), higher open surgery rate (7.9% vs 1.3%; P < 0.0001), and more complicated pathology (23.8% vs 5.8%; P < 0.0001) and cholecystitis (64.2% vs 25.9%; P < 0.0001) as final diagnoses.

CONCLUSIONS

RBE occurred in 28.5% of the subjects at a median time of 34 days, with an incidence of 2.5% as early as 1 week. Cholecystectomy should be done preferably within 7 days after common bile duct clearance in order to prevent RBE and adverse outcomes.

Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the clinical presentation and outcomes?

BACKGROUND

Whether clinical outcomes of acute cholangitis (AC) vary by etiology is unclear.

AIM

To compare outcomes in AC caused by malignant biliary obstruction (MBO) and common bile duct stones (CBDS).

METHODS

This retrospective study included 516 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) due to AC caused by MBO (MBO group, n = 56) and CBDS (CBDS group, n = 460). Clinical and laboratory parameters were compared between the groups. Propensity score matching (PSM) created 55 matched pairs. Confounders used in the PSM analysis were age, sex, time to ERCP, and technical success of ERCP. The primary outcome comparison was 30-d mortality. The secondary outcome comparisons were intensive care unit (ICU) admission rate, length of hospital stay (LOHS), and 30-d readmission rate.

RESULTS

Compared with the CBDS group, the MBO group had significantly lower body temperature, percentage of abnormal white blood cell counts, and serum levels of aspartate aminotransferase, alanine aminotransferase, and creatinine. Body temperature, percent abnormal white blood cell count, and serum aspartate aminotransferase levels remained significantly lower in the MBO group in the PSM analysis. Platelet count, prothrombin time/international normalized ratio, and serum levels of alkaline phosphatase and total bilirubin were significantly higher in the MBO group. The MBO group had a significantly higher percentage of severe AC (33.9% vs 22.0%, P = 0.045) and received ERCP later (median, 92.5 h vs 47.4 h, P < 0.001). However, the two differences were not found in the PSM analysis. The 30-d mortality (5.4% vs 0.7%, P = 0.019), ICU admission rates (12.5% vs 4.8%, P = 0.028), 30-d readmission rates (23.2% vs 8.0%, P < 0.001), and LOHS (median, 16.5 d vs 7.0 d, P < 0.001) were significantly higher or longer in the MBO group. However, only LOHS remained significant in the PSM analysis. Multivariate analysis revealed that time to ERCP and multiple organ dysfunction were independent factors associated with 30-d mortality.

CONCLUSION

MBO patients underwent ERCP later and thus had a worse prognosis than CBDS patients. Therefore, clinicians should remain vigilant in MBO patients with clinically suspected AC, and perform ERCP for biliary drainage as soon as possible.

Cholecystectomy following endoscopic clearance of common bile duct during the same admission

BACKGROUND

The recurrence of common bile duct stones and other biliary events after endoscopic retrograde cholangiopancreatography (ERCP) is frequent. Despite recommendations for early cholecystectomy, intervention during the same admission is carried out inconsistently.

METHODS

We reviewed the records of patients who underwent ERCP for gallstone disease and common bile duct clearance followed by cholecystectomy between July 2012 and June 2022. Patients were divided into 2 groups: the index group underwent cholecystectomy during the same admission and the delayed group was discharged and had their cholecystectomy postponed. Data on demographics and prognosis factors were collected and analyzed.

RESULTS

The study population was composed of 268 patients, with 71 (26.6%) having undergone cholecystectomy during the same admission after common bile duct clearance with ERCP. A greater proportion of patients aged 80 years and older were in the index group than in the delayed group. The American Society of Anesthesiologists score was significantly higher in the index group. There was no significant difference between groups regarding surgical complications, open cholecystectomy and death. The operative time was significantly longer in the delayed group. Among patients with delayed cholecystectomy, 18.3% had at least 1 recurrence of common bile duct stones (CBDS) and 38.6% had recurrence of any gallstone-related events before cholecystectomy. None of these events occurred in the the index group. There was no difference in the recurrence of CBDS and other biliary events after initial diagnosis associated with stone disease.

CONCLUSION

Cholecystectomy during the same admission after common bile duct clearance is safe, even in older adults with comorbidities. Compared with delayed cholecystectomy, it was not associated with adverse outcomes and may have prevented recurrence of biliary events.

Racial and Ethnic Disparities Among Patients Hospitalized for Acute Cholangitis in the United States

GOALS

We sought to determine whether race/ethnicity is associated with hospitalization outcomes among patients admitted with acute cholangitis.

BACKGROUND

Few studies have evaluated the association between race and outcomes in patients with acute cholangitis.

STUDY

We analyzed United States hospitalizations from 2009 to 2018 using the Nationwide Inpatient Sample (NIS). We included patients 18 years old or above admitted with an ICD9/10 diagnosis of cholangitis. Race/ethnicity was categorized as White, Black, Hispanic, or Other. We used multivariable regression to determine the association between race/ethnicity and in-hospital outcomes of interest, including endoscopic retrograde cholangiopancreatography (ERCP), early ERCP (<48 h from admission), length of stay (LOS), and in-hospital mortality.

RESULTS

Of 116,889 hospitalizations for acute cholangitis, 70% identified as White, 10% identified as Black, 11% identified as Hispanic, and 9% identified as Other. The proportion of non-White patients increased over time. On multivariate analysis controlling for clinical and sociodemographic variables, compared with White patients, Black patients had higher in-hospital mortality (adjusted odds ratio: 1.4, 95% confidence interval: 1.2-1.6, P <0.001). Black patients were also less likely to undergo ERCP, more likely to undergo delayed ERCP, and had longer LOS ( P <0.001 for all).

CONCLUSIONS

In this contemporary cohort of hospitalized patients with cholangitis, Black race was independently associated with fewer and delayed ERCP procedures, longer LOS, and higher mortality rates. Future studies with more granular social determinants of health data should further explore the underlying reasons for these disparities to develop interventions aimed at reducing racial disparities in outcomes among patients with acute cholangitis.

The Impact of the COVID-19 Pandemic on Outcomes in Acute Pancreatitis: A Propensity Score Matched Study Comparing before and during the Pandemic

We aimed to evaluate the outcomes and survival of patients with acute pancreatitis who shared the same clinical form, age, and sex before the pandemic, during the pandemic, and among those with confirmed COVID-19 infection upon hospital admission. This consideration used the sparse data in the existing literature on the influence of the pandemic and COVID-19 infection on patients with acute pancreatitis. To accomplish this, we conducted a multicentric, retrospective case-control study using propensity score matching with a 2:1 match of 28 patients with SARS-CoV-2 infection and acute pancreatitis, with 56 patients with acute pancreatitis pre-pandemic, and 56 patients with acute pancreatitis during the pandemic. The study outcome demonstrated a six-fold relative risk of death in patients with acute pancreatitis and SARS-CoV-2 infection compared to those with acute pancreatitis before the pandemic. Furthermore, restrictive measures implemented during the pandemic period led to a partial delay in the care of patients with acute pancreatitis, which likely resulted in an impairment of their immune state. This, in certain circumstances, resulted in a restriction of surgical treatment indications, leading to a three-fold relative risk of death in patients with acute pancreatitis during the pandemic compared to those with acute pancreatitis before the pandemic.

Incidence and outcomes in patients with acute cholangitis: a population-based study

OBJECTIVE

The importance of early ERCP (endoscopic retrograde cholangiopancreatography) in patients with acute cholangitis (AC) is controversial. The aims were to compare outcomes in those who had early ERCP within 24 h from diagnosis and those who had ERCP undertaken later and examine the general prognosis of AC patients.

METHODS

A prospective endoscopic database was used to identify all patients who underwent ERCP 2010-2021 at Landspitali University Hospital, diagnosed with cholangitis (k83.0) or calculus of bile duct with cholangitis (k80.3) according to ICD-10 diagnostic codes. Tokyo guidelines were used to verify the diagnosis and severity. Sepsis was analyzed by the Sepsis-3 criteria.

RESULTS

A total of 240 patients met the inclusion criteria, 107 women (45%), median age 74 years, mostly due to gallstones (75%) and malignancy (19%), 61 (25%) underwent ERCP early. Overall 30-day mortality was 3.3% and was not significantly different between the early and late ERCP groups (4.9% vs 2.5% respectively). Patients who underwent early ERCP were more likely to have severe cholangitis according to the Tokyo guidelines criteria than those who underwent ERCP later (31% vs 18%, p = 0.047) but had a shorter median hospital stay (4 vs. 6 days, p = 0.006). Sepsis was more common among those who had ERCP early than those who had late ERCP (33% vs 19%, p = 0.033).

CONCLUSIONS

The results indicate that for patients with AC the timing of ERCP is an important factor influencing the hospital stay, with shorter hospital stay for patients receiveing ERCP within 24 h, despite more severe cholangitis at diagnosis.

Identification of Microbial Species and Analysis of Antimicrobial Resistance Patterns in Acute Cholangitis Patients with Malignant and Benign Biliary Obstructions: A Comparative Study

Background and Objectives: Acute cholangitis (AC) is still lethal if not treated promptly and effectively. Biliary drainage, also known as source control, has been acknowledged as the backbone treatment for patients with AC; nonetheless, antimicrobial therapy allows these patients to undergo non-emergent drainage procedures. This retrospective study aims to observe the bacterial species involved in AC and analyze the antimicrobial resistance patterns. Materials and Methods: Data were collected for four years, comparing patients with benign and malignant bile duct obstruction as an etiology for AC. A total of 262 patients were included in the study, with 124 cases of malignant obstruction and 138 cases of benign obstruction. Results: Positive bile culture was obtained in 192 (73.3%) patients with AC, with a higher rate among the benign group compared with malignant etiologies (55.7%.vs 44.3%). There was no significant difference between the Tokyo severity scores in the two study groups, identifying 34.7% cases of malignant obstruction with Tokyo Grade 1 (TG1) and 43.5% cases of TG1 among patients with benign obstruction. Similarly, there were no significant differences between the number of bacteria types identified in bile, most of them being monobacterial infections (19% in the TG1 group, 17% in the TG2 group, and 10% in the TG3 group). The most commonly identified microorganism in blood and bile cultures among both study groups was E. coli (46.7%), followed by Klebsiella spp. (36.0%) and Pseudomonas spp. (8.0%). Regarding antimicrobial resistance, it was observed that significantly more patients with malignant bile duct obstruction had a higher percentage of bacterial resistance for cefepime (33.3% vs. 11.7%, p-value = 0.0003), ceftazidime (36.5% vs. 14.5%, p-value = 0.0006), meropenem (15.4% vs. 3.6%, p-value = 0.0047), and imipenem (20.2% vs. 2.6%, p-value < 0.0001). Conclusions: The positive rate of biliary cultures is higher among patients with benign biliary obstruction, while the malignant etiology correlates with increased resistance to cefepime, ceftazidime, meropenem, and imipenem.

Early is Not Superior to Late Endoscopic Intervention for Acute Cholangitis

BACKGROUND

Acute cholangitis (AC) is a common emergency with a significant mortality risk. This study aimed to compare urgent, early, and late endoscopic retrograde cholangiopancreatography (ERCP) for AC.

METHOD

We retrospectively evaluated patients diagnosed with AC from June 2016 to May 2021. According to the time of ERCP, patients were divided into urgent (≤24 h), early (24-48 h), and late (≥48 h) groups. Primary outcomes were technical success, in-hospital mortality, and 30-day mortality. Secondary outcomes were the length of hospital stay (LOS), ERCP-related adverse events, and 30-day readmission.

RESULTS

We divided 121 patients who underwent ERCP into urgent (N = 15), early (N = 19), and late groups (N = 87). There was no in-hospital mortality and no significant difference in technical success (93.3% (urgent) vs 89.5% (early) vs 96.6% (late); P = .41) and 30-day mortality (P = .82). LOS in the urgent and early groups was shorter than that in the late group (13.93 days vs 8.82 days vs 14.20 days, respectively; P = .02). There was no difference between groups for ERCP-related adverse events and 30-day readmission rates.

CONCLUSIONS

Urgent or early ERCP was not superior to late ERCP for technical success and 30-day mortality. However, urgent or early ERCP was associated with shorter LOS than late ERCP.

Can endoscopic retrograde cholangiopancreatography-related procedures for resolving acute cholangitis be effectively and safely performed in patients with surgically altered anatomy? Comparison study to evaluate the timing of short-type single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography

OBJECTIVES

Balloon enteroscopy (BE)-assisted endoscopic retrograde cholangiopancreatography (ERCP)-related procedures to resolve acute cholangitis (AC) in patients with surgically altered anatomy (SAA) are limited. There is a lack of evidence on whether the timing of BE-assisted ERCP affects clinical outcomes in patients with AC. This study aimed to evaluate the clinical outcomes of short-type single-balloon enteroscopy (short SBE)-assisted ERCP in patients with SAA and AC.

METHODS

Patients with AC who underwent short SBE-assisted ERCP procedures between September 2011 and April 2022 were retrospectively reviewed. The outcomes of procedures undergone at ≤24 h and >24 h were compared. The primary outcome was the length of stay (LOS).

RESULTS

Overall, 56 patients underwent procedures at ≤24 h, and 58 patients at >24 h. The procedural success and adverse event rates of short SBE-assisted ERCP were 87.7% (95% confidence interval [CI] 80.3-93.1%) and 4.4% (95% CI 1.4-9.9%), respectively. Patients with severe (Grade III) AC and systemic inflammatory response syndrome were more in early (at ≤24 h) ERCP groups. LOS and median time from ERCP procedures to discharge were shorter in the early group. Procedural success and adverse event rates between both groups had no significant differences. Multivariable linear regression analysis showed that ERCP performed at ≤24 h was associated with shorter LOS, while severe cholangitis and malignant biliary obstruction were associated with longer LOS.

CONCLUSIONS

Short SBE-assisted ERCP is effective and safe in patients with SAA and AC. Early procedures seemed to attribute early improvement of general condition, thus shortening the LOS.

Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis

Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.

Impact of the Timing of Endoscopic Retrograde Cholangiopancreatography for the Treatment of Acute Cholangitis: A Meta-analysis and Systematic Review

BACKGROUND

The optimal timing for endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis (AC) has not been unequivocally established.

AIMS

To perform a meta-analysis of the outcomes associated with particular timings of ERCP for AC.

METHODS

A systematic literature search was conducted for studies of ERCP for AC, and then a meta-analysis of the in-hospital mortality (IHM), 30-day mortality, and length of hospital stay (LHS) was performed.

RESULTS

Seven non-randomized studies of 88,562 patients were considered appropriate for inclusion. Compared with performing ERCP more than 24 hours after admission, ERCP within 24 hours was associated with lower IHM ( P <0.0004), but no difference in 30-day mortality ( P =0.38) was found between the 2 groups. ERCP performed <48 hours after admission was associated with a lower IHM and 30-day mortality ( P <0.00001 and P =0.03) than ERCP performed >48 hours after admission. In addition, ERCP performed within 24 or 48 hours was associated with a shorter LHS ( P <0.00001 and P <0.00001, respectively).

CONCLUSION

ERCP within 48 hours of admission is superior to subsequent ERCP with respect to IHM, 30-day mortality, and LHS, and ERCP performed within 24 hours is associated with lower IHM and LHS.

Optimal timing of biliary drainage based on the severity of acute cholangitis: A single-center retrospective cohort study

BACKGROUND

Biliary decompression is well known to greatly decrease the risks of mortality in acute cholangitis (AC). Although early biliary drainage is recommended by the treatment guidelines for AC, the best time for performing this procedure is yet to be established. Furthermore, since the clinical outcomes of patients with severe AC vary dramatically, screening for patients that could benefit the most from early drainage would be more beneficial than the drainage performed based on the severity grade criteria.

AIM

To investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction.

METHODS

In this retrospective monocenter cohort analysis, we reviewed 1305 patients who were diagnosed with AC according to the Tokyo guidelines 2018 at a Chinese tertiary hospital between July 2016 and December 2020. Demographic characteristics including age and sex, clinical and laboratory characteristics, and imaging findings of each patient were obtained from electronic medical records. We investigated the all-cause in-hospital mortality (IHM), hospital length of stay (LOS), and hospitalization costs associated with the timing of biliary drainage according to the severity grading and different dysfunctioning organs and predictors [age, white blood cell (WBC) count, total bilirubin, albumin, lactate, malignant obstruction, and Charlton comorbidity index (CCI)].

RESULTS

Biliary drainage within 24 or 48 h in Grade III AC patients could dramatically decrease IHM (3.9% vs 9.0%, P = 0.041; 4% vs 9.9%, P = 0.018, respectively), while increasing LOS and hospitalization costs. Multivariate logistic analysis revealed that neurological, respiratory, renal, and cardiovascular dysfunctions, hypoalbuminemia, and malignant obstruction were significantly associated with IHM (odds ratio = 5.32, 2.541, 6.356, 4.021, 5.655, and 7.522; P < 0.001, P = 0.016, P < 0.001, P = 0.012, P < 0.001, and P < 0.001; respectively). Biliary decompression performed within 12 h of admission significantly decreased the IHM in AC patients with neurological dysfunction (0% vs 17.3%, P = 0.041) or with serum lactate > 2 mmol/L (0% vs 5.4%, P = 0.016). In the subgroup of AC patients with renal dysfunction, abnormal WBC count, hyperbilirubinemia, or hypoalbuminemia, early drainage (< 24 h) reduced the IHM (3.6% vs 33.3%, P = 0.004; 1.9% vs 5.8%, P = 0.031; 1.7% vs 5.0%, P = 0.019; 0% vs 27%, P = 0.026; respectively). The IHM was lower in patients with AC combined with hepatic dysfunction, malignant obstruction, or a CCI > 3 who had undergone biliary drainage within 48 h (2.6% vs 20.5%, P = 0.016; 3.0% vs 13.5%, P = 0.006; 3.4% vs 9.6%, P = 0.021; respectively).

CONCLUSION

Biliary drainage within 12 h is beneficial for AC patients with neurological or cardiovascular dysfunction, while complete biliary decompression within 24 h of admission is recommended for treating patients with Grade III AC.

Cost-effectiveness analysis of optimal diagnostic strategy for patients with symptomatic cholelithiasis with intermediate probability for choledocholithiasis

BACKGROUND AND AIMS

EUS, MRCP, and intraoperative cholangiogram (IOC) are the recommended diagnostic modalities for patients with intermediate probability for choledocholithiasis (IPC). The relative cost-effectiveness of these modalities in patients with cholelithiasis and IPC is understudied.

METHODS

We developed a decision tree for diagnosing IPC (base-case probability, 50%; range, 10%-70%); patients with a positive test were modeled to undergo therapeutic ERCP. The strategies tested were laparoscopic cholecystectomy with IOC (LC-IOC), MRCP, single-session EUS + ERCP, and separate-session EUS + ERCP. Costs and probabilities were extracted from the published literature. Effectiveness was assessed by assigning utility scores to health states, average proportion of true-positive diagnosis of IPC, and the mean length of stay (LOS) per strategy. Cost-effectiveness was assessed by extrapolating a net-monetary benefit (NMB) and average cost per true-positive diagnosis.

RESULTS

LC-IOC was the most cost-effective strategy to diagnose IPC (base-case probability of 50%) among patients with cholelithiasis in health state-based effectiveness analysis (NMB of $34,612), diagnostic test accuracy-based effectiveness analysis (average cost of $13,260 per true-positive diagnosis), and LOS-based effectiveness analysis (mean LOS of 4.13) compared with strategies 2 (MRCP), 3 (single-session EUS + ERCP), and 4 (separate-session EUS + ERCP). These findings were robust on deterministic and probabilistic sensitivity analyses.

CONCLUSIONS

For patients with cholelithiasis with IPC, LC-IOC is a cost-effective approach that should limit preoperative testing and may shorten hospital LOS. Our findings may be used to design institutional and organizational management protocols.

ASGE guideline on the management of cholangitis

Cholangitis is a GI emergency requiring prompt recognition and treatment. The purpose of this document from the American Society for Gastrointestinal Endoscopy's (ASGE) Standards of Practice Committee is to provide an evidence-based approach for management of cholangitis. This document addresses the modality of drainage (endoscopic vs percutaneous), timing of intervention (<48 hours vs >48 hours), and extent of initial intervention (comprehensive therapy vs decompression alone). Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to formulate recommendations on these topics. The ASGE suggests endoscopic rather than percutaneous drainage and biliary decompression within 48 hours. Additionally, the panel suggests that sphincterotomy and stone removal be combined with drainage rather than decompression alone, unless patients are too unstable to tolerate more extensive endoscopic treatment.

Timing of Performing Endoscopic Retrograde Cholangiopancreatography and Inpatient Mortality in Acute Cholangitis: A Systematic Review and Meta-Analysis

Although early biliary drainage improves outcomes in patients with acute cholangitis, the optimal time to perform endoscopic retrograde cholangiopancreatography (ERCP) is controversial. Our aim was to evaluate the impact of timing of ERCP on mortality in hospitalized patients with acute cholangitis.

ERCP within 6 or 12 h for acute cholangitis: a propensity score-matched analysis

BACKGROUND

The optimal timing of biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute cholangitis remains controversial. The aim of our study was to determine if ERCP performed within 6 or 12 h of presentation was associated with improved clinical outcomes.

METHODS

Medical records for all patients with acute cholangitis who underwent ERCP at our institution between 2009 and 2018 were reviewed. Outcomes were compared between those who underwent ERCP within or after 12 h using propensity score framework. Our primary outcome was length of hospitalization. Secondary outcomes included in-hospital mortality, adverse events, ERCP failure, length of ICU stay, organ failure, recurrent cholangitis, and 30-day readmission. In secondary analysis, outcomes for ERCP done within or after 6 h were also compared.

RESULTS

During study period, 487 patients with cholangitis were identified, of whom 147 had ERCP within 12 h of presentation. Using propensity score matching, we selected 145 pairs of patients with similar characteristics. Length of hospitalization was similar between ERCP within or after 12 h (135.9 vs 122.1 h, p 0.094). No difference was noted in mortality, ERCP failure, adverse events, need and length of ICU stay, and recurrent cholangitis. However, 30-day readmission rates were lower when ERCP within 12 h (7.6 vs 15.2, p 0.042). No significant difference was noted in aforementioned outcomes between ERCP performed within or after 6 h.

CONCLUSIONS

ERCP performed within 6 h or 12 h of presentation was not associated with superior clinical outcomes, however, may result in reduced re-hospitalization.

Very urgent endoscopic retrograde cholangiopancreatography is associated with early discharge in patients with non-severe acute cholangitis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a first-line procedure for biliary drainage in patients with acute cholangitis, and no study focused very urgent ERCP within several hours of hospital arrival. We aimed to elucidate the utility of very urgent ERCP for non-severe acute cholangitis.

METHODS

This retrospective observational study included patients with non-severe acute cholangitis who underwent ERCP between April 2011 and June 2020 in the study institution. Patients were stratified into three groups based on the time to ERCP after hospital arrival: very urgent (≤3hours), urgent (3-24hours), and elective (>24hours). The primary outcome was length of hospital stay (LOS).

RESULTS

In the study cohort of 291 patients, including 168 males (57.7%), with a median age of 76 (interquartile range, 70-83) years, 47, 196, and 48 patients underwent very urgent, urgent, and elective ERCP, respectively. The median LOSs in the very urgent, urgent, and elective groups were 12, 14, and, 15 days, respectively (Kaplan-Meier method). A shorter LOS was associated with earlier ERCP (log-rank trend test, P=0.04). The rates of readmission within 30 days of discharge and adverse events were not significantly different among the three groups. By multivariate analysis, very urgent ERCP was associated with a significantly earlier discharge than urgent and elective ERCP (HR 0.71, P=0.04 and HR 0.47, P<0.01, respectively). In addition, age≥75years, pancreatitis, albumin≤2.8g/dL, and two or more ERCP procedures were associated with significantly longer LOS (HRs <1, P<0.05).

CONCLUSIONS

Very urgent ERCP for non-severe acute cholangitis was associated with early discharge.

Optimal timing of endoscopic retrograde cholangiopancreatography for acute cholangitis associated with distal malignant biliary obstruction

BACKGROUND

There is a lack of studies regarding the optimal timing for endoscopic retrograde cholangiopancreatography (ERCP) in patients with cholangitis caused by distal malignant biliary obstruction (MBO). This study aims to investigate the optimal timing of ERCP in patients with acute cholangitis associated with distal MBO with a naïve papilla.

METHODS

A total of 421 patients with acute cholangitis, associated with distal MBO, were enrolled for this study. An urgent ERCP was defined as being an ERCP performed within 24 h following emergency room (ER) arrival, and early ERCP was defined as an ERCP performed between 24 and 48 h following ER arrival. We evaluated both 30-day and 180-day mortality as primary outcomes, according to the timing of the ERCP.

RESULTS

The urgent ERCP group showed the lowest 30-day mortality rate (2.2%), as compared to the early and delayed ERCP groups (4.3% and 13.5%) (P < 0.001). The 180-day mortality rate was lowest in the urgent ERCP group, followed by early ERCP and delayed ERCP groups (39.4%, 44.8%, 60.8%; P = 0.006). A subgroup analysis showed that in both the primary distal MBO group, as well as in the moderate-to-severe cholangitis group, the urgent ERCP had significantly improved in both 30-day and 180-day mortality rates. However, in the secondary MBO and mild cholangitis groups, the difference in mortality rate between urgent, early, and delayed ERCP groups was not significant.

CONCLUSIONS

In patients with acute cholangitis associated with distal MBO, urgent ERCP might be helpful in improving the prognosis, especially in patients with primary distal MBO or moderate-to-severe cholangitis.

Factors Associated with Mortality in Severe Acute Cholangitis in a Moroccan Intensive Care Unit: A Retrospective Analysis of 140 Cases

BACKGROUND

Severe acute cholangitis is a life-threatening biliary infection, leading to organ dysfunction, septic shock, and naturally death. Mortality has dropped significantly in the past years through improving resuscitation and biliary drainage techniques. The aim of our study is to analyze our daily practice and the factors associated with mortality.

METHODS

A retrospective study including severe acute cholangitis patients admitted to our unit from January 2009 to December 2018. Variables analyzed (univariate then multivariate analysis) were age, sex, history, origin, evolution time, bilirubin, etiology, organ dysfunction, qSOFA, SOFA, TOKYO, biliary drainage timing and technique, shock, antibiotherapy, and resuscitation.

RESULTS

140 patients were included in this study. Average age was 61. Sex ratio M/F was 0.59. Lithiasis etiology was dominant (69%). SOFA average score upon admission was 8. Ceftriaxone + metronidazole was the empirical antibiotic used in 87%. Average time to biliary drainage was 1.58 ± 0.89 days. Endoscopic unblocking was the technique used in 76%. Mean duration of ICU stay was 6 days. Mortality rate was 28%. Statistically significant factors for mortality (p < 0.05) were history of taking anticoagulant treatment, use of catecholamines and mechanical ventilation during ICU stay, and delay in consultation and administration of antibiotic therapy.

CONCLUSIONS

Early recognition, antibiotics, resuscitation, and minimally invasive biliary drainage have improved patient outcomes although there is still progress to be made. Moreover, as multiple organ failure is often associated with mortality in severe acute cholangitis, predictive risk factors of organ failure should be more investigated.

The influence of stone size on spontaneous passage of common bile duct stones in patients with acute cholangitis: A retrospective cohort study

Background

The common bile duct (CBD) stones passage in patients with cholangitis was unclear.

This study aimed to evaluate the effect on CBD stone sizes and predicting factors on spontaneous passage in patients with cholangitis.

Method

The medical records of cholangitis at Her Royal Highness Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University from January 2014 to December 2019 were retrospectively reviewed. Patients with acute cholangitis from CBD stones underwent ERCP in the same admission were enrolled.

Result

Of the 96 patients, The rate of spontaneous passage of CBD stones was 19.8%. By univariate analysis, factors significantly associated with a predictor of spontaneous CBD stone passage in patient with cholangitis were single CBD stone (p = 0.001), CBD stone diameter < 5 mm (p < 0.001), and clinical symptom improved before ERCP procedure (p = 0.004). Multivariate logistic regression analyses also revealed that these three factors were significantly associated with spontaneous passage. From ROC curve analysis, stone size of less than 4.85 mm was more likely to pass spontaneously with acceptable sensitivity (81.8%) and specificity (78.9%).

Conclusions

CBD stone diameter < 5 mm, single CBD stone and improved clinical symptom before ERCP procedure are key predictors of spontaneous CBD stone passage in cholangitis.

•

The rate of spontaneous passage of CBD stones in cholangitis was 19.8%.

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Stone size < 5 mm, single stone and improved clinical symptom before ERCP are predictors of spontaneous passage.

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Stone size < 4.85 mm was more likely to pass spontaneously with sensitivity (81.8%) and specificity (78.9%).

Impact of Preoperative Cholangitis on Short-term Outcomes Among Patients Undergoing Liver Resection

BACKGROUND

The impact of preoperative cholangitis (PC) on perioperative outcomes among patients undergoing liver resection remains poorly defined. We sought to characterize the prevalence of PC among patients undergoing hepatectomy and define the impact of PC on postoperative outcomes.

METHODS

Patients who underwent liver resection between 2013 and 2015 were identified using the Center for Medicare Services (CMS) 100% Limited Data Set (LDS) Standard Analytic Files (SAFs). Short-term outcomes after liver resection, stratified by the presence of PC, were examined. Subgroup analyses were performed to evaluate the relationship between the timing of liver resection relative to PC.

RESULTS

Among 7392 patients undergoing liver resection, 251 patients (3.4%) experienced PC. Patients with PC were more likely to be male (59.0% vs. 50.6%) and to have a benign diagnosis (34.3% vs. 19.8%) compared with patients without PC (both p<0.05). On multivariable analysis, PC was associated with increased odds of experiencing a complication (OR 1.54, 95%CI 1.17-2.03), extended LOS (OR 2.60, 95%CI 1.99-3.39), 90-day mortality (OR 2.31, 95%CI 1.64-3.26), and higher Medicare expenditures (OR 3.32, 95%CI 2.55-4.32). Among patients with PC, requirement of both endoscopic and percutaneous biliary drainage (OR 5.16, 95%CI 1.36-9.61), as well as liver resection < 2 weeks after PC (OR 2.92, 95%CI 1.13-7.57) were associated with higher odds of 90-day mortality.

CONCLUSION

Approximately 1 in 30 Medicare beneficiaries undergoing liver resection had a history of PC. PC was associated with an increased risk of adverse short-term outcomes and higher healthcare expenditures among patients undergoing hepatectomy.

Same-day endoscopic ultrasound, retrograde cholangiopancreatography and stone extraction, followed by cholecystectomy: A case report and literature review

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The risk of recurrence or complications is high after a common bile duct stone related event.

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Cholecystectomy should be carried out soon after extraction of a common bile duct stone.

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Same-day investigation, endoscopic stone extraction and cholecystectomy is feasible and safe.

Introduction

Common bile duct stone-related events and their recurrence are frequent even after endoscopic retrograde cholangiopancreatography and stone extraction. Cholecystectomy should be carried out as soon as possible after the initial episode to prevent complications.

Case presentation

We present a case of a patient who underwent endoscopic ultrasound, cholangiopancreatography with stone extraction and cholecystectomy on the same day.

Discussion

After a common bile duct stone-related event, investigation, and stone extraction, cholecystectomy should be carried out as soon as possible to avoid high rates of recurrence and complications. Rise in health care costs nowadays mandate such an approach as a pre-emptive measure to prevent health complications while lowering health costs.

Conclusion

Diagnosis of common bile duct stone followed by extraction with endoscopic cholangiopancreatography and cholecystectomy on the same day is feasible, safe, and has many potential advantages.

Emergent versus urgent ERCP in acute cholangitis: a systematic review and meta-analysis

BACKGROUND AND AIMS

Acute cholangitis is characterized by abdominal pain, fever, and jaundice. Most patients respond to medical management with intravenous hydration and antibiotics. About 20% to 30% require biliary drainage, and ERCP is the procedure of choice. We conducted a systematic review and meta-analysis to evaluate the impact of emergent biliary drainage on patient outcomes.

METHODS

A comprehensive literature review was conducted by searching the Embase and PubMed databases from inception to April 2019 to identify all studies that evaluated the impact of timing of ERCP on patient outcomes. Our primary outcome was in-hospital mortality (IHM), and secondary outcomes were length of stay (LOS), organ failure, and 30-day mortality. Fixed and random effects models were used to generate pooled measures of IHM, 30-day mortality, and LOS.

RESULTS

Nine observational studies involving 7534 patients were included in the primary meta-analysis. IHM was significantly lower in patients who underwent emergent biliary drainage within 48 hours (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.28-0.98). As a sensitivity analysis, we pooled the data from 2 population registry studies of 81,893 patients, which yielded consistent results for the main outcomes. LOS was also significantly lower in patients who underwent ERCP within 48 hours with a mean difference of 5.56 days (95% CI, 1.59-9.53). Patients who underwent emergent ERCP also had lower odds of 30-day mortality (OR, 0.39; 95% CI, 0.14-1.08) and organ failure (OR, 0.69; 95% CI, 0.33-1.46).

CONCLUSIONS

Our study reveals that performing emergent ERCP within 48 hours in patients with acute cholangitis is associated with lower IHM, 30-day mortality, organ failure, and shorter LOS.

Trends and risk factors for 30-day readmissions in patients with acute cholangitis: analysis from the national readmission database

INTRODUCTION

Acute cholangitis (AC) can be associated with significant mortality and high risk of readmissions, if not managed promptly. We used national readmission database (NRD) to identify trends and risk factors associated with 30-day readmissions in patients with AC.

METHODS

We conducted a retrospective cohort study of adult patients admitted with AC from 2010-2014 and Q1-Q3 of 2015 by extracting data from NRD. Initial admission with a primary diagnosis of acute cholangitis (ICD-9 code: 576.1) was considered as the index admission and any admission after index admission was considered a readmission regardless of the primary diagnosis. Multivariable regression analyses were performed to assess the association.

RESULTS

From 52,906 AC index admissions, overall 30-day readmission rate was 21.48% without significant differences in the readmission rates across the study period. There was significant increase in the overall hospital charges for readmissions, while a significant reduction in the death rate was observed during the first readmission. Recurrent cholangitis (14%), septicemia (6.4%), and mechanical complication of bile duct prosthesis (3%) were the most common reasons for readmissions. The risk of readmission was significantly higher in patients with pancreatic neoplasm (OR 1.6, 95% CI 1.4-1.8), those who underwent percutaneous biliary procedures (OR 1.4, 95% CI 1.2-1.6), and who had an acute respiratory failure (OR 1.2, 95% CI 1.0-1.15). Other factors contributing to increased risk of readmissions included patients with Charleston comorbidity index > 3, diabetes, and length of stay > 3 days. Readmission risk was significantly lower in patients who underwent ERCP (OR 0.80, 95% CI 0.73-0.88) or cholecystectomy (OR 0.54, 95% CI 0.43-0.69).

CONCLUSIONS

AC is associated with a high 30-day readmission rate of over 21%. Patients with malignant biliary obstruction, increased comorbidities, and those who undergo percutaneous drainage rather than ERCP seem to be at the highest risk.

A Memorable Moment During Laparoscopic Cholecystectomy: A Case Report

Common bile duct (CBD) stones are encountered in 14%-15% of patients with symptomatic gall stone disease. Endoscopic retrograde cholangiopancreatography (ERCP) is a primary modality for the management of pancreaticobiliary disorders. We present a case of unintentional stent placement into the gall bladder discovered during surgery.