The role and timing of endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis without cholangitis: A nationwide analysis

Abstract

Background/Purpose The role and optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis without cholangitis (ABPwoC) remains unclear. Using a large national database, we aimed to examine hospitalization outcomes of patients with ABPwoC as a function of the performance and timing of ERCP. Methods This was a retrospective study of adult patients with ABPwoC utilizing the National Inpatient Sample from 2016–2017. Patients who underwent inpatient ERCP were stratified into performance: within 24, 24–48, 48–72, and >72 h of hospital admission. The primary outcome was all‐cause inpatient mortality as a function of the performance and timing of ERCP; secondary outcomes, including healthcare utilization, were assessed. Multivariate modeling was used to adjust for potential confounders. Statistical analyses were conducted using STATA, version 16.0. Results Of the 70 030 patients with ABPwoC, 31.37% underwent inpatient ERCP. Performance (aOR: 0.6, p < .05), but not timing (aOR: 0.98, p = .9), of inpatient ERCP was associated with significantly lower all‐cause inpatient mortality. Urgent ERCP (within 24 h) was associated with shorter hospital length of stay, lower charges and cost, and less need for pancreatic drainage procedures, while ERCP within 72 h was associated with less frequent intensive care unit admission (all p < .05). Discussion Based on this large, nationwide analysis, inpatient ERCP for ABPwoC is associated with lower all‐cause mortality. ERCP within 24 and 72 h, though not associated with lower mortality, are associated with multiple improved clinical outcomes, including lower healthcare charges and costs.

Precision Medicine in Pancreatitis: The Future of Acute Pancreatitis Care

“… 88–92 RCTs in specific patient subpopulations showed that ERCP with endoscopic sphincterotomy performed early (within 24 h) was beneficial in biliary AP associated with cholangitis, 93 , 94 but it was not advantageous generally in any biliary cases. 95 Although a recent retrospective study challenged this concept by showing that early ERCP was associated with lower mortality rates in a large, nationwide analysis of patients with biliary AP without cholangitis, 96 the findings of a well-designed, multicenter RCT support the initiative that ERCP in AP is indicated only in patients with cholangitis or persistent cholestasis. 97 The contradictions regarding the use of ERCP in AP lead to adjustments of study protocols, which resulted in identification of specific subpopulation of patients (ie, those with cholangitis), who can benefit the most from the intervention if it is performed in a timely manner.…”

“… 97 The contradictions regarding the use of ERCP in AP lead to adjustments of study protocols, which resulted in identification of specific subpopulation of patients (ie, those with cholangitis), who can benefit the most from the intervention if it is performed in a timely manner. Since some results still question these recommendations, 96 further studies are warranted for fine-tuning the best target population, and, thereby, to further increase the efficacy of early ERCP in AP. The successful completion of such fine-tuning could serve as a pursuable model for establishing personalized (precision) treatment in AP.…”