Department of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
World J Gastroenterol. 2022 Oct 14;28(38):5602-5613. doi: 10.3748/wjg.v28.i38.5602.
The optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis (AC) is uncertain, especially in patients with AC of varying severity.
To report whether the timing of ERCP is associated with outcomes in AC patients with different severities.
According 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.
Taking 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% 11.5%). The proportion of cardiovascular dysfunction (11.2% 2.6%), respiratory dysfunction (14.2% 5.3%), and ICU admission (11.2% 4%) in the ERCP ≤ 24 h group was significantly higher, while the LOHS was significantly shorter (median, 6 d 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% 68.3%). The ERCP ≤ 48 h group had significantly lower 30-d mortality (0 1.9%) and shorter LOHS (6 d 8 d). Stratified by AC severity, lower 30-d mortality (0 6.1%) and higher ICU admission rates (22.2% 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.
ERCP ≤ 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.
内镜逆行胰胆管造影术（ERCP）在急性胆管炎（AC）中的最佳时机尚不确定，尤其是在病情轻重不一的患者中。
报告 ERCP 时机与不同严重程度 AC 患者结局的关系。
根据 2018 年东京指南，回顾性确定了符合 AC 明确诊断标准的 683 例患者。首先比较了接受 ERCP≤24 小时和>24 小时的患者之间的结果，然后比较了接受 ERCP≤48 小时和>48 小时的患者之间的结果。在 I 级、II 级或 III 级 AC 患者中进行了亚组分析。主要结局为 30 天死亡率。次要结局为重症监护病房（ICU）入住率、住院时间（LOHS）和 30 天再入院率。
以 24 小时为临界值，与 ERCP>24 小时相比，ERCP≤24 小时组胆道恶性梗阻作为 AC 病因的比例明显较低（5.2%比 11.5%）。ERCP≤24 小时组心血管功能障碍（11.2%比 2.6%）、呼吸功能障碍（14.2%比 5.3%）和 ICU 入住率（11.2%比 4%）显著升高，而 LOHS 明显缩短（中位数，6 天比 7 天）。按 AC 严重程度分层，仅在 III 级 AC 中观察到更高的 ICU 入住率，仅在 I 级和 II 级 AC 中观察到更短的 LOHS。无论是在总体人群中还是在 I 级、II 级或 III 级 AC 患者中，两组之间的 30 天死亡率均无显著差异。以 48 小时为临界值，与 ERCP>48 小时相比，ERCP≤48 小时组胆管结石作为 AC 病因的比例明显较高（81.5%比 68.3%）。ERCP≤48 小时组的 30 天死亡率（0%比 1.9%）和 LOHS 明显更低（6 天比 8 天）。按 AC 严重程度分层，仅在 III 级 AC 中观察到较低的 30 天死亡率（0%比 6.1%）和更高的 ICU 入住率（22.2%比 10.2%），仅在 I 级和 II 级 AC 中观察到更短的 LOHS。多因素分析显示，心血管功能障碍和 ERCP 时间是与 30 天死亡率相关的两个独立因素。
ERCP≤48 小时可使 III 级 AC 患者获益生存。早期 ERCP 可缩短 I 级和 II 级 AC 患者的 LOHS。
