Delay to ERCP for Patients with Cholangitis Requiring Inter-hospital Transfer Does Not Worsen Patient Outcome

Abstract

Purpose: The Tokyo Guidelines 2018 recommend early biliary decompression in acute cholangitis. Transferring patients to a centre where ERCP is available may result in delayed ERCP. No studies describe the consequence of patient transfer on outcomes in cholangitis. We offer a surgeon-led referral service for ERCP in Melbourne, Australia, receiving patients with cholangitis from rural and smaller metropolitan hospitals. Our study characterises the time to ERCP in patients requiring transfer, and impact on outcomes in patients with cholangitis. Method: A retrospective review of patients undergoing emergency ERCP for cholangitis in calendar years 2016-19 was performed. Demographics, Tokyo guidelines criteria, time to ERCP and admission/ICU data were collected. Groups were compared based on where patients initially presented – 1) presenting to our primary hospital 2) transferred from a smaller metropolitan hospital 3) transferred from a rural hospital. Data was compared using Fisher’s and T-tests. Results: 380 patients underwent ERCP for cholangitis over four years - 202 (53%) presented to our primary hospital, 133 (35%) were transferred from smaller metropolitan hospitals and 45 (12%) from rural hospitals. Early ERCP (<48hrs from index admission) occurred less commonly if patients had required transfer (26% vs 40%, p=0.005), but by 72 hours differences between groups were insignificant. In-hospital mortality (<2%), length of stay (mean 8.7 days) and ICU admissions (mean 14%) were equivalent between groups. Conclusion: The small delay to ERCP in patients presenting to other hospitals likely reflects the logistics of transfer. The impact of this delay was clinically insignificant - mortality and length of stay were unchanged. We demonstrate that a centralised ERCP service with appropriate referral and transfer pathways can provide effective treatment for acute cholangitis.FP16.022016-2019: ERCP for CholangitisTotal - n= 380Primary Hospital - n=202 (53%)Metro Transfer - n=133 (35%)Rural Transfer - n=45 (12%)Age (median)72.4(sd 16.7)78.5(sd 16.0)74.5(sd 16.7)74(sd 18.9)M/F (Male %)182/19848%100/10249%65/6849%17/2838%Grade (TG)17019%3316.%2317%1431%222960%12261%8363%2453%38021%4723%2620%716%Mean day of ERCP2.87(sd 2.6)2.63(sd 2.5)3.13(sd 2.6)3.2(sd 2.7)In Hospital Mortality71.8%42%21.5%12%Length of Stay (d)8.7d8.8d8.7d8.3dICU # / Mean LOS (d)523.5d244.4d202.7d82.7d Open table in a new tab