Early Endoscopic Retrograde Cholangiopancreatography Research Articles

Early Endoscopic Retrograde Cholangiopancreatography in Gallstone Pancreatitis Is Safe: Results From A Large Single Center Retrospective Study

Abstract Objectives There is concern that performing early endoscopic retrograde cholangiopancreatography (ERCP) in the setting of gallstone pancreatitis (GSP) with choledocholithiasis can worsen underlying pancreatitis. This study was designed to assess outcomes of early versus delayed ERCP in patients with gallstone pancreatitis with choledocholithiasis in the absence of cholangitis. Methods In this single center retrospective study, we identified 124 patients who underwent ERCP for choledocholithiasis in the setting of GSP without cholangitis between 2012 and 2022. Timing of ERCP was categorized as early (<48 hours after time of diagnosis) versus delayed (>48 hours). Data on patient demographics, complications, length of stay (LOS), and mortality were collected. Results Cannulation success rates were similar for early and delayed ERCP (97% vs. 100%). The adverse event rate for early ERCP was 15% compared to 29% for delayed ERCP. LOS for patients with predicted mild pancreatitis was shorter for early versus delayed ERCP (4.2 vs. 7.1 days, p = 0.007). There were no deaths in either group. Conclusion There was a trend toward fewer adverse events and there was a shorter LOS among patients with GSP with choledocholithiasis undergoing early versus delayed ERCP. Early ERCP should be considered, particularly in patients with predicted mild pancreatitis.

Comparison of the results of early and elective endoscopic retrograde cholangiopancreatography in patients with mild cholangitis

Aims: The optimal duration of endoscopic retrograde cholangiopancreatography (ERCP) in patients with mild cholangitis and when it should be performed is unclear. This study aimed to compare the results of patients with mild cholangitis who underwent early and elective ERCP. Methods: This study was designed as a retrospective study to compare the results of elective (time from admission to ERCP>72 h) and early (time from admission to ERCP≤72 h) ERCP in patients with mild cholangitis according to the Tocyo 18 (TC18) guideline. The study included patients with naive papillae and mild cholangitis who underwent ERCP between February 2019 and 2023 at a single tertiary center’s gastroenterology clinic. Results: A total of 432 mild cholangitis patients were included in our study. The mean age and ASA score of the elective ERCP group was slightly higher than the other group (respectively, p=0.039 and p=0.025). No significant difference was found between the two groups in terms of technical and clinical success, mortality, ERCP-related adverse events, organ failure and intensive care unit admission. Length of hospital stay (LHS) was significantly (p

American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.

Utility of Urgent Endoscopic Retrograde Cholangiopancreatography in Patients with Predicted Mild Acute Pancreatitis and Cholestasis.

Endoscopic retrograde cholangiopancreatography (ERCP) within 72h is suggested for patients presenting with acute biliary pancreatitis (ABP) and biliary obstruction without cholangitis. This study aimed to identify if urgent ERCP (within 24h) improved outcomes compared to early ERCP (24-72h) in patients admitted with predicted mild ABP. Patients admitted for predicted mild ABP defined as a bedside index of severity in acute pancreatitis score < 3 and underwent ERCP for biliary obstruction within 72h of presentation during the study period were included. Patients with prior biliary sphincterotomy or surgically altered anatomy preventing conventional ERCP were excluded. The primary outcome was the development of moderately severe or severe pancreatitis based on the revised Atlanta classification. Secondary outcomes were the length of hospital stay, the need for ICU admission, and ERCP-related adverse events (AEs). Of the identified 166 patients, baseline characteristics were similar between both the groups except for the WBC count (9.4 vs. 8.3/µL; p < 0.044) and serum bilirubin level (3.0 vs. 1.6mg/dL; p < 0.0039). Biliary cannulation rate and technical success were both high in the overall cohort (98.8%). Urgent ERCP was not associated with increased development of moderately severe pancreatitis (10.4% vs. 15.7%; p = 0.3115). The urgent ERCP group had a significantly shorter length of hospital stay [median 3 (IQR 2-3) vs. 3days (IQR 3-4), p < 0.01]. Urgent ERCP did not impact the rate of developing more severe pancreatitis in patients with predicted mild ABP but was associated with a shorter length of hospital stay and a lower rate of hospital readmission.

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

We sought to determine whether race/ethnicity is associated with hospitalization outcomes among patients admitted with acute cholangitis. Few studies have evaluated the association between race and outcomes in patients with acute cholangitis. 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 (<48h from admission), length of stay (LOS), and in-hospital mortality. 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). 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.

Impact of ERCP simulator training on early ERCP learning curves of novice trainees: a cohort study.

Background and study aim Simulator-based training has been extensively studied in training gastroduodenoscopy and colonoscopy and shown to significantly improve learning curves of novices. Data on simulator-based training in endoscopic retrograde cholangiopancreatography (ERCP) are scarce. We aimed to determine the impact of 2-day intensive hands-on simulator training on the course of the learning curve of novice trainees. Methods We conducted a prospective cohort study using a validated mechanical ERCP simulator (Boškoski-Costamagna ERCP Trainer). Six trainees were allocated to the simulation course program (SG). Each of these trainees were paired with an endoscopy trainee starting regular ERCP training at the same center who had no exposure to a simulation course program (control group; CG). The course included lectures, live ERCP demonstrations, and hands-on ERCP training to educate trainees in basic techniques related to cannulation, stent placement, stone extraction and stricture management. After the course, both the SG and CG started formal ERCP training in their respective centers. The Rotterdam Assessment Form for ERCP was used to register each performed ERCP. Simple moving average was applied to create learning curves based on successful common bile duct (CBD) cannulation. Outcomes were plotted against a historical cohort (HC). Results Thirteen trainees were included, six trainees in the SG and seven trainees in the CG, with a total of 717 ERCPs. Mean successful ERCP cannulation rate was higher for the simulator group at baseline compared to both CG and HC, 64% versus 43% and 42%, respectively. Differences became less explicit after 40 ERCPs, but persisted until a median of 75 ERCPs. Conclusions We demonstrate that 2-day hands-on simulator-based ERCP training course has a positive effect on the learning curves of ERCP trainees and should be considered an integral part of the training curricula for ERCP to develop skills prior to patient-based training.

Early is Not Superior to Late Endoscopic Intervention for Acute Cholangitis.

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. We retrospectively evaluated patients diagnosed with AC from June 2016 to May 2021. According to the time of ERCP, patients were divided into urgent (≤24h), early (24-48h), and late (≥48h) 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. 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 (13.93days vs 8.82days vs 14.20days, respectively; P = .02). There was no difference between groups for ERCP-related adverse events and 30-day readmission rates. 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.

Association between smoking status and inpatient outcomes of acute cholangitis in the United States: a propensity matched analysis.

Acute cholangitis (AC) is an infection of the biliary tract superimposed on stasis. This study aimed to investigate the effects of smoking on inpatient outcomes of AC. We identified primary AC hospitalizations using the National Inpatient Sample database (2017-2020). Using a 1:1 matching method, we created a matched comparison cohort of AC patients who were non-smokers, based on demographics, hospital characteristics and comorbidities. We matched 3960 smoker patients with 3960 non-smoker patients within the AC population. Non-smokers were older than smokers (70 vs. 59 years, P<0.001). Smokers had a stronger association with bile duct calculi (74.37% vs. 69.29%, P<0.001) and other bile duct disorders (clots, parasites, extrinsic compression and other rare disorders) (6.82% vs. 5.05%, P=0.011). No significant difference in inpatient mortality, median length of stay (LOS), or median inpatient cost (MIC) was found between the matched cohorts (P>0.05). However, smoking was associated with higher odds of complications, including sepsis without shock (0.88% vs. 0.51%, P=0.042), sepsis with shock (1.26% vs. 0.51%, P<0.001), biliary pancreatitis (6.57% vs. 4.42%, P<0.001) and myocardial infarction (6.19% vs. 3.54%, P<0.001), as well as a greater need for inpatient endoscopic retrograde cholangiopancreatography (ERCP) (72.85% vs. 63.76%, P<0.001) and early ERCP (50.76% vs. 42.32%, P<0.001) compared to non-smokers. This study found no difference in mortality, LOS, or MIC in acute cholangitis-related hospitalizations associated with smoking. However, smoking was associated with a higher risk of complications and a greater need for ERCP and early ERCP.

Outcomes of delayed versus early endoscopic intervention for acute biliary pancreatitis with non-severe acute cholangitis

BackgroundDespite previous studies on endoscopic interventions in patients with acute biliary pancreatitis (ABP), the optimal time to perform endoscopic retrograde cholangiopancreatography (ERCP) for ABP with non-severe acute cholangitis (AC) remains controversial.MethodsWe performed a retrospective cohort analysis of patients with concurrent ABP and non-severe AC. The patients were divided into two groups: those who underwent ERCP ≤ 72 h after admission (early ERCP group) and those who underwent ERCP > 72 h after admission (delayed ERCP group). The primary outcomes were the technical success rate and ERCP-related complications.ResultsThe study involved 164 patients (early ERCP, n = 70; delayed ERCP, n = 94) who were treated from 1 December 2 to 2016 to 12 December 2021. The patients’ baseline characteristics were not significantly different between the two groups. The technical success rate of ERCP was similar between the two groups (94.29% vs. 97.87%, p = 0.43). Morbidity was also similar between the two groups (p = 0.83). There was no significant difference in the total hospital stay (p = 0.13). However, the early ERCP group had a longer post-ERCP hospital stay (p < 0.001).ConclusionThis retrospective analysis showed that delayed ERCP performed > 72 h after admission has economic and safety outcomes similar to those of early ERCP for patients with concurrent ABP and non-severe AC.

Early and Direct Endoscopic Stone Removal in the Moderate Grade of Acute Cholangitis with Choledocholithiasis Was Safe and Effective: A Prospective Study.

Evidence supporting the feasibility of single-stage stone removal in patients with a moderate grade of acute cholangitis remains insufficient. The maximal size of a common bile-duct stone suitable for removal during a single-stage ERCP in a moderate grade of acute cholangitis is unknown. We prospectively enrolled 196 endoscopic retrograde cholangiopancreatography (ERCP)-naïve patients diagnosed with acute cholangitis and choledocholithiasis. For eligible patients, single-stage treatment involved stone removal at initial ERCP. A total of 123 patients were included in the final analysis. The success rate of complete stone extraction was similar between patients with mild and moderate grades of acute cholangitis (89.2% vs. 95.9%; p = 0. 181). Complication rates were comparable between the two groups. In the moderate grade of the cholangitis group, among patients who underwent early single-stage ERCP, the length of hospitalization declined as short as the patients in the mild grade of cholangitis (10.6 ± 6.2 vs. 10.1 ± 5.1 days; p = 0.408). In the multivariate analysis, early ERCP indicated shorter hospitalization times (≤10 days) (odds ratio (OR), 3.981; p = 0.001). A stone size less than 1.5 cm presented a high success rate (98.0%) for complete stone removal. Single-stage retrograde endoscopic stone removal in mild and moderate grades of acute cholangitis may be safe and effective, which can obviate the requirement for a second session, thus reducing medical expenses. gov: NCT03754491.

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.

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. 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). 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. 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.

Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity.

BACKGROUNDThe optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis (AC) is uncertain, especially in patients with AC of varying severity.AIMTo report whether the timing of ERCP is associated with outcomes in AC patients with different severities.METHODSAccording to the 2018 Tokyo guidelines, 683 patients who met the definite diagnostic criteria for AC were retrospectively identified. The results were first compared between patients receiving ERCP ≤ 24 h and > 24 h and then between patients receiving ERCP ≤ 48 h and > 48 h. Subgroup analyses were performed in patients with grade I, II or III AC. The primary outcome was 30-d mortality. Secondary outcomes were intensive care unit (ICU) admission rate, length of hospital stay (LOHS) and 30-d readmission rate.RESULTSTaking 24 h as the critical value, compared with ERCP > 24 h, malignant biliary obstruction as a cause of AC was significantly less common in the ERCP ≤ 24 h group (5.2% vs 11.5%). The proportion of cardiovascular dysfunction (11.2% vs 2.6%), respiratory dysfunction (14.2% vs 5.3%), and ICU admission (11.2% vs 4%) in the ERCP ≤ 24 h group was significantly higher, while the LOHS was significantly shorter (median, 6 d vs 7 d). Stratified by the severity of AC, higher ICU admission was only observed in grade III AC and shorter LOHS was only observed in grade I and II AC. There were no significant differences in 30-d mortality between groups, either in the overall population or in patients with grade I, II or III AC. With 48 h as the critical value, compared with ERCP > 48 h, the proportion of choledocholithiasis as the cause of AC was significantly higher in the ERCP ≤ 48 h group (81.5% vs 68.3%). The ERCP ≤ 48 h group had significantly lower 30-d mortality (0 vs 1.9%) and shorter LOHS (6 d vs 8 d). Stratified by AC severity, lower 30-d mortality (0 vs 6.1%) and higher ICU admission rates (22.2% vs 10.2%) were only observed in grade III AC, and shorter LOHS was only observed in grade I and II AC. In the multivariate analysis, cardiovascular dysfunction and time to ERCP were two independent factors associated with 30-d mortality.CONCLUSIONERCP ≤ 48 h conferred a survival benefit in patients with grade III AC. Early ERCP shortened the LOHS in patients with grade I and II AC.

S110 Racial Differences in the Performance of Endoscopic Retrograde Cholangiopancreatography (ERCP) in Acute Cholangitis: A Nationwide Time Trend Analysis, 2008-2018

Introduction: Black race was shown to have high mortality from acute cholangitis (AC) previously (1998-2009) and to undergo less endoscopic retrograde cholangiopancreatography (ERCP) (2009-2012). We conducted a longitudinal racial breakdown of ERCP performed in AC in the USA over 11 years (2008-2018). Methods: This is a retrospective longitudinal trend analysis using National Inpatient Sample. Adult patients (≥18 years old) with AC were identified. Multivariate linear or logistic regression was performed when appropriate. To control for the severity of AC, we also included severe sepsis, septic shock, systemic inflammatory response syndrome with acute organ dysfunction, acute renal failure, acute respiratory failure, thrombocytopenia, altered mental status, and abnormal coagulation in the regression model. Stata (v.14.2) was used to perform analyses considering a 2-sided P-value< 0.05 as statistically significant. Results: A total of 312,849 patients with AC were included in the analysis. Before 2015, the longitudinal trend for the overall total and early ERCPs performed in Whites and Hispanics was increasing (P< 0.01) (Table). The trend was stable in Asians but in Blacks, even though the trend for early ERCP was increasing (P< 0.01) but the overall ERCPs performed for AC remained the same (P=0.07). After 2015, the trends for both early and total ERCPs remained stable for all races (P >0.05). However, upon examining the proportion of early ERCPs among total ERCPs performed, Blacks represented the racial category with the lowest numbers (Figure). Even though the trend of proportions for all racial categories was increasing (P< 0.01) however, the rate of increase was lowest for Blacks (per year increase for Whites was 1.37%, Blacks 1.18%, Hispanics 1.47%, and 1.37 for Asians). Racial mortality comparison showed that compared to Whites, Blacks had the highest odds of mortality (for Blacks, adjusted odds ratio (aOR) 1.86, P< 0.01, Hispanics aOR 1.29, P< 0.01, Asians aOR 1.30, P=0.01). Conclusion: The modification in International Classification of Diseases (ICD) coding in 2015 resulted in an apparent sharp change in the proportion of ERCPs performed due to coding change. Even though the trend for the performance of early ERCP for AC is on the rise in all races, there still exists a racial disparity in the use of early ERCP. The black population was at risk of receiving lower rates of early ERCP (calculated as a fraction of total ERCP), which may impart higher mortality.Figure 1.: Trend for the proportion of early ERCP comparing to total ERCP (ERCP: endoscopic retrograde cholangiopancreatography, AC: acute cholangitis, %: percentage, ICD: International Classification of Diseases) Table 1. - Trends for early and total ERCP performance in acute cholangitis Year 2008 2010 2012 2014 P value a,b 2016 2018 P value a,b White Total ERCP, % 47.58 48.75 50.21 50.55 < 0.01 33.42 32.55 0.37 Early ERCP, % 24.43 25.60 28.38 29.01 < 0.01 18.89 18.90 0.99 Black Total ERCP, % 41.20 39.75 43.59 43.45 0.07 30.97 30.21 0.72 Early ERCP, % 17.34 18.09 22.58 21.93 < 0.01 13.96 14.72 0.66 Hispanic Total ERCP, % 53.87 53.85 56.36 58.14 < 0.01 35.61 35.51 0.96 Early ERCP, % 28.70 27.64 31.94 34.36 < 0.01 17.64 20.28 0.13 Asians Total ERCP, % 54.34 52.86 55.28 53.04 0.84 35.08 37.58 0.39 Early ERCP, % 31.69 27.32 33.45 33.18 0.31 17.16 22.33 0.27 ERCP: endoscopic retrograde cholangiopancreatography.aLinear P trend values.bTime-interrupted trends (before and after 2015) were obtained due to International Classification of Diseases (ICD) coding change from ICD-9 to ICD-10 in 2015.

Revised Clinical Practice Guideline of Korean Pancreatobiliary Association for Acute Pancreatitis: Diagnosis

There is general acceptance that a diagnosis of acute pancreatitis requires two of the following three features: 1) epigastric or upper abdominal pain characteristic of acute pancreatitis, 2) serum amylase and/or lipase ≥3 times the upper limit of normal, and 3) characteristic findings of acute pancreatitis on abdominal images such as ultrasonography, computed tomography (CT) or magnetic resonance imaging. Other pancreatic diseases and acute abdomen have been ruled out before making a diagnosis of acute pancreatitis. Serum lipase may be more useful than serum amylase because serum lipase is thought to be more sensitive and specific than serum amylase in the diagnosis of acute pancreatitis. Contrast-enhanced CT scan is the best imaging technique to rule out the conditions that masquerade as acute pancreatitis, to diagnose the severity of acute pancreatitis, and to identify complications of pancreatitis. The etiology of acute pancreatitis should be made clear as soon as possible to decide treatment policy of acute pancreatitis or to prevent the recurrence of pancreatitis. The etiology of acute pancreatitis in an emergency situation should be assessed by clinical history, laboratory tests such as serum liver function tests, measurement of serum calcium and serum triglycerides and ultrasonography. A differentiation of gallstone-induced acute pancreatitis should be given top priority in its etiologic diagnosis because early endoscopic retrograde cholangiopancreatography should be considered if a complication of cholangitis and a prolonged passage disorder of the biliary tract are suspected.

Urgent Endoscopic Retrograde Cholangiopancreatography (ERCP) vs. Conventional Approach in Acute Biliary Pancreatitis Without Cholangitis: An Updated Systematic Review and Meta-Analysis.

Gallstone disease is the common cause of acute pancreatitis. The role of early endoscopic retrograde cholangiopancreatography (ERCP) in biliary pancreatitis without cholangitis is not well-established. Thus, this study aims to compare the outcome of early ERCP with conservative management in patients with acute biliary pancreatitis without acute cholangitis. An online search of PubMed, PubMed Central, Embase, Scopus, and Clinicaltrials.gov databases was performed for relevant studies published till December 15, 2020. Statistical analysis was performed using RevMan v 5.4 (The Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen). Odds Ratio (OR) with a 95% confidence interval was used for outcome estimation. Among 2700 studies from the database search, we included four studies in the final analysis. Pooling of data showed no significant reduction in mortality (OR 0.59, 95% CI 0.32 to 1.09; p=0.09); overall complications (OR 0.56, 95% CI 0.30 to 1.01; p=0.05); new-onset organ failure (OR 1.06, 95% CI 0.65 to 1.75; p=0.81); pancreatic necrosis (OR 0.80, 95% CI 0.49 to 1.32; p=0.38); pancreatic pseudo-cyst (OR 0.44, 95% CI 0.16 to 1.24; p=0.12); ICU admission (OR 1.64, 95% CI 0.97 to 2.77; p=0.06); and pneumonia development (OR 0.81, 95% CI 0.40 to 1.65; p=0.56) by urgent ERCP comparing with conventional approach for acute biliary pancreatitis without cholangitis. Henceforth, early ERCP in acute biliary pancreatitis without cholangitis did not reduce mortality, complications, and other adverse outcomes compared to the conservative treatment.

Predictors of Early Repeat Endoscopic Retrograde Cholangiopancreatography After Liver Transplantation by Organ Donor Type

Background and AimsEndoscopic retrograde cholangiopancreatography (ERCP) is the first-line therapy for management of post-transplant biliary complications. We assess ERCP frequency and rate of early repeat ERCP and anastomotic stricture development across, living donor (LD), donation after cardiac death (DCD) and donation after brain death (DBD) liver transplant (LT) donor types. MethodsWe performed a single-center retrospective study of patients who underwent LT from January 2014 to December 2019. Proportion of patients requiring ERCP and number of ERCPs per patient were compared across donor types using analysis of variance and chi-squared methods. Logistic regression was used to assess the risk of early repeat ERCP, defined as ERCP within 28 days of preceding ERCP and anastomotic stricture development. ResultsA total of 509 LTs, 352 (69.2%) DBD, 101 (19.8%) DCD, and 56 (11.0%) LD were performed during the study period. A greater proportion of LD (51.8%) recipients required ERCP compared with DBD (28.7%) recipients (P ≤ 0.01). LD and DCD recipients required significantly greater number of median (interquartile range [IQR]) ERCPs compared with DBD recipients (8 [4, 12] vs 3 [2, 5], P < 0.01 and 4 [2, 6] vs 3 [2, 5], P = 0.05). Risk of early repeat ERCP was significantly higher in LD (odds ratio 9.2; 95% confidence interval 4.6-18.5) and DCD (OR 2.3; 95% confidence interval 1.2-4.5) recipients compared with DBD recipients. ConclusionLD and DCD recipients experience higher ERCP frequency and greater risk of early repeat ERCP compared with DBD recipients. Our results suggest the need to tailor ERCP management protocols for post-LT biliary complications based on donor type.

Effect of Antibiotic Resistance of Pathogens on Initial Antibiotic Therapy for Patients With Cholangitis.

ObjectivesConsidering that pathogens resistant to initial antibiotic therapies for cholangitis can affect mortality rates, appropriate initial empiric antibiotic therapy is important. However, evidence regarding the influence of pathogens resistant to initial antibiotics in patients with cholangitis who have undergone early endoscopic retrograde cholangiopancreatography (ERCP) is limited, and the conditions in several cases can improve with early ERCP even when pathogens resistant to initial antibiotics are detected on time. Therefore, this study aimed to assess the influence of pathogens resistant to initial antibiotics on the course of cholangitis in patients undergoing early ERCP.Materials and methodsPatients (n=266) with positive blood or bile culture results treated with early ERCP were divided into those with cultures that were resistant to the initial antibiotics (antibiotic-resistant group; n=66; 24.8%) and those with cultures that were sensitive to the initial antibiotics (antibiotic-sensitive group; n=200; 75.2%). The duration of hospitalization, in-hospital mortality rates due to cholangitis, rates of increased disease severity, and complications during hospitalization were studied.ResultsEnterococcus, Enterobacter, Citrobacter, and Pseudomonas species showed high resistance to several antibiotics. No significant between-group differences were found in the duration of hospitalization, in-hospital mortality rates due to cholangitis, and rates of increased disease severity. However, the rate of post-ERCP cholecystitis was significantly higher in the antibiotic-resistant group than in the antibiotic-sensitive group (p=0.0245).ConclusionsEven if the initial antibiotics were ineffective, the rate of fatal outcomes did not increase among patients with cholangitis who had undergone early ERCP. However, when initial antibiotics were ineffective, the frequency of post-ERCP cholecystitis increased even after early bile duct decompression.

ERCP improves mortality in acute biliary pancreatitis without cholangitis.

Background and study aims Acute pancreatitis (AP) is an increasingly common indication for hospitalization in the United States. The necessity for endoscopic retrograde cholangiopancreatography (ERCP) and the timing of ERCP in acute gallstone-related pancreatitis without cholangitis (AGPNC) is controversial. The aim of this study was to evaluate the association of ERCP and its performance during admission with mortality and length of stay (LOS) in patients with AGPNC. Patients and methods We queried the Nationwide Inpatient Sample (NIS) from 2004 to 2014 to identify all patients with admissions for gallstone AP. We excluded patients with chronic pancreatitis or concurrent cholangitis, and those who were transferred from elsewhere for treatment. Our primary outcome measure was inpatient mortality. Our secondary outcome measure was hospital length of stay (LOS). Results We identified 491,011 records eligible for analysis. Of the patients, 30.6 % (150,101) had AGPNC. There were 1.34 deaths per 100 admissions in patients with AGPNC. The average LOS was 5.88 (± 6.38) days with a median stay of 4 days (range, 3–7). When adjusted for age, Elixhauser Comorbidity Index, and severe pancreatitis, patients with ERCP during admission were 43 % less likely to die. ERCP performed between Days 3 and 9 of hospitalization resulted in a significant mortality benefit. Among those who had ERCP, a shorter wait time for ERCP was associated with a shorter LOS after adjustment for demographics and severity of illness. Conclusion ERCP performed during inpatient admission for AGPNC was associated with decreased mortality. These data support early ERCP in patients with acute gallstone pancreatitis without cholangitis.

ID: 3526627 ERCP DURING INDEX ADMISSION REDUCES 30-DAY READMISSION RATE AFTER ACUTE BILIARY PANCREATITIS WITHOUT CHOLANGITIS. BUT DOES TIMING MATTER? : A NATIONWIDE STUDY

Acute biliary pancreatitis (ABP) may account for upto 60% of all acute pancreatitis cases. Early Endoscopic Retrograde Cholangiopancreatography (ERCP) is recommended in patients with cholangitis, but it is not clearly established in patients without cholangitis. Early readmissions add to the clinical and economic burden on the healthcare system. Strategies to reduce readmission are now a crucial aspect of management. Therefore, we conducted this study to investigate the impact of ERCP and timing of ERCP on 30-day readmission in patients with ABP without cholangitis.

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

BackgroundThere 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.MethodsA 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.ResultsThe 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.ConclusionsIn 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.