Introduction

Early drainage of the biliary tract is significant in managing patients with acute cholangitis. In cases where endoscopic retrograde cholangiopancreatography (ERCP) is not feasible, percutaneous transhepatic gallbladder drainage (PTGBD) is considered as an alternative treatment. Several studies indicate that PTGBD is a well-established treatment as well as ERCP, however there is limited literature of evaluation and comparison of these procedures in elderly people.

Aims & Methods

This study aimed to compare the clinical outcomes of ERCP and PTGBD in elderly patients with acute cholangitis. We retrospectively compared patients aged 70 years or older who underwent ERCP or PTGBD between 2019 and 2022.

Results

Among 129 cases of acute cholangitis, 101 patients underwent ERCP, while 28 patients underwent PTGBD. Benign and malignant biliary obstruction were present in 76% (98/129) and 24% (31/129), respectively. The mean age was 84.2 years in ERCP and 84.5 years in PTGBD. Main reasons for performing PTGBD were postoperative stomach in 21% (6/28), unstable vital signs in 46% (13/28), full-stomach in 25% (7/28), and failure to perform ERCP in 14% (4/28). The overall technical success rate was 91% (92/101) in ERCP and 100% (28/28) in PTGBD. Senior residents performed the entire PTGBD procedure, while only 63% (64/101) of ERCP cases were performed by senior residents. Both ERCP and PTGBD showed improvement in jaundice (T-Bil -0.72 vs. -0.45, P>0.05), liver dysfunction (AST -178.7 vs. -206.6, P>0.05; ALT -57.4 vs. -77.4, P>0.05), and inflammatory response (white blood cell count -5.4x103 vs. -7.4x103, P>0.05) in blood tests after the procedure. However, acute pancreatitis occurred in 5% (5/101) after ERCP, leading to mortality in 2% (2/101). Other complications were observed in 19% (19/101), including bleeding after endoscopic sphincterotomy (EST) in 4% (4/101). In contrast, PTGBD caused no major complications or drainage failure, although tube dislocation occurred in 18% (5/28). The median length of stay was longer in PTGBD (25 days) compared to ERCP (15.2 days).

Conclusion

Both ERCP and PTGBD are effective treatments for acute cholangitis in elderly patients. Besides, PTGBD has an advantage of a higher technical success rate and fewer procedure-related complications compared to ERCP.

References

1. Li YL, Wong KH, Chiu KW, Cheng AK, Cheung RK, Yam MK, Chan AL, Chan VS, Law MW, Lee PS. Percutaneous cholecystostomy for high-risk patients with acute cholangitis. Medicine (Baltimore). 2018 May;97(19):e0735. doi: 10.1097/MD.0000000000010735. PMID: 29742738; PMCID: PMC5959387.
2. Kiriyama S, Kozaka K, Takada T, et al.Tokyo guidelines 2018: Diagnostic criteria and severity grading of acute cholangitis (with videos).J Hepatobiliary Pancreat Sci2018;25:17–30.

Introduction

Acute cholangitis (AC) is an important clinical problem which is associated with mortality upto 10%. The association between timing of ERCP and clinical outcomes of AC are not well studied. The current study is aimed to evaluate whether ERCP within 48 hours is associated with improved clinical outcomes.

Aims & Methods

This is single center retrospective analysis of prospectively maintained database. All patients who admitted with AC at AIG Hospitals, Hyderabad between January 2022 to December 2022 were included in study if they underwent ERCP. Patients satisfying diagnostic criteria of AC according to Tokyo Guidelines and stratified according to severity of AC. We evaluated association between ERCP within 48 hours and length of hospital stay, need for reintervention and re-admissions, mortality in-hospital and at 3 months follow.

Results

A total of consecutive 301 patients underwent ERCP during study period; of which 217 patients (31.3% females; mean age 54.02 ± 14.9 years) underwent ERCP within 48 hours of admission. Remaining 84 (32.1% females; mean age 56.56 ± 13.9 years) underwent ERCP after 48 hours. 58 (26.7%) and 22 (26.2%) patients with severe cholangitis (grade 3 as per Tokyo Guidelines) underwent ERCP within 48hours and beyond 48 hours respectively. The proportion of patients with malignant biliary obstruction was 34.1% (74/217) and 46.6% (39/84) in ERCP within 48 hours and beyond respectively. There was no statistically significant difference for overall mortality (6.45%vs7.14%, p 0.83); need for reinterventions (46.1% versus 54.8%, p 0.53) and readmissions (62.2% versus 58.33%; p 0.18). The length of hospital stay during 1^st admission was significantly higher in ERCP beyond 48hours group (9.48 ± 6.50 versus 12.86 ± 7.25 days; p 0.0001).

Conclusion

The current study indicates that ERCP within 48 hours for AC is associated with decreased length of hospital stay while overall mortality, need for reinterventions, readmissions are comparable. There is unmet need to confirm these findings by randomized controlled study.

Introduction

Acute cholangitis is an important cause of mortality and morbidity, especially in elderly patients and those with multiple comorbidities. However, the appropriate duration of antibiotic therapy after biliary drainage remains controversial. The aim of this study is to evaluate the efficacy of a short versus a long course of antibiotics after biliary drainage in patients with acute cholangitis.

Aims & Methods

Retrospective analytical cohort study of patients with acute cholangitis treated at a fourth level hospital in Bogotá, Colombia, from 2014 to 2022. Short antibiotic therapy was defined as ≤ 4 days after successful post-ERCP drainage. The primary outcome was a composite of in-hospital mortality, ICU admission, and hospital readmission 30 days after discharge. A univariate and multivariate logistic regression model was performed to assess the association between duration of antibiotic therapy and the primary composite outcome.

Results

317 patients were included. E. coli was the most commonly isolated microorganism regardless of severity, and 54% proved 100% antimicrobial susceptibility. 59 patients received short therapy and 258 received long therapy. There were no statistically significant differences in the primary outcome (p=1), but a longer hospital stay was observed in the long-term treatment group (p<0.001). The presence of Tokyo III severity and carbapenem resistance were risk factors for the primary outcome (OR 32.07; 95% CI 11.84-113.16, p<0.001) and (OR 4.07; 95% CI 1.02-16.96, p=0.04) respectively.

Univariate and multivariate analysis of clinical factors associated with mortality, ICU admission or hospital readmission at 30 days in patients with acute cholangitis undergoing ERCP

Conclusion

Shorter courses of antibiotics after ERCP drainage can be considered a therapeutic option for patients with acute cholangitis. However, the methodological limitations of this study should be considered.

References

[1] M. Ahmed, “Acute cholangitis - an update,” World J Gastrointest Pathophysiol, vol. 9, no. 1, pp. 1–7, Feb. 2018, doi: 10.4291/wjgp.v9.i1.1.

[2] S. Kiriyama et al., “Clinical application and verification of the TG13 diagnostic and severity grading criteria for acute cholangitis: an international multicenter observational study,” J Hepatobiliary Pancreat Sci, vol. 24, no. 6, pp. 329–337, Jun. 2017, doi: 10.1002/jhbp.458.

[3] R. Mohan et al., “Validation of Tokyo Guidelines 2007 and Tokyo Guidelines 2013/2018 Criteria for Acute Cholangitis and Predictors of In-Hospital Mortality,” Visceral Medicine, vol. 37, no. 5. S. Karger AG, pp. 434–442, Oct. 01, 2021. doi: 10.1159/000516424.

[4] R. Mohan, S. W. L. Goh, G. W. Tan, S. P. Junnarkar, C. W. Huey, and V. G. Shelat, “Validation of TG07 and TG13/TG18 criteria for acute cholangitis and predictors of in-hospital mortality in patients over 80 years old,” Clin Exp Hepatol, vol. 7, no. 4, pp. 396–405, 2021, doi: 10.5114/ceh.2021.110996.

[5] P. A. Lipsett and H. A. Pitt, “Acute Cholangitis.”

[6] Z. An, A. L. Braseth, and N. Sahar, “Acute Cholangitis: Causes, Diagnosis, and Management,” Gastroenterology Clinics of North America, vol. 50, no. 2. W.B. Saunders, pp. 403–414, Jun. 01, 2021. doi: 10.1016/j.gtc.2021.02.005.

Disclosure

Nothing to disclose

Introduction

Malignant distal biliary obstruction is a common complication in the progression of pancreatic tumors. Endoscopic ultrasound (EUS) guided drainage can provide effective biliary drainage when not achieved by endoscopic retrograde cholangiopancreatography (ERCP) and can be performed by hepaticogastrostomy or choledocoduodenostomy (CDD). Gallbladder drainage by cholecystogastrostomy (GBD) has been described in small uncontrolled series and could be effective. The objective of this study was to compare the clinical efficacy of CGD vs CDD in distal biliary tract obstruction (DBTO).

Aims & Methods

This was a retrospective, multicenter study (four tertiary centers) including all consecutive patients with DBTO and jaundice who underwent CDD or GBD with a lumen-apposing metal stent (LAMS). The primary outcome was to compare the clinical success rate defined as a decrease of total bilirubin by 50% in 14 days and/or a decrease in total bilirubin below 51 µmol/L after 30 days. Secondary outcomes were technical success, overall survival, survival without biliary reintervention, immediate (within 24 hours) and delayed (>24 hours) morbidity.

Results

78 patients were included between July 2018 and September 2022, 41 GBD and 37 CDD. The mean age was 71 years, and 82% had pancreatic adenocarcinoma, 55% had metastatic disease at diagnosis, and 45% had duodenal stenosis. Most patients (N=59; 76%) had undergone EUS-guided drainage after ERCP failure. The mean diameter of the main bile duct was significantly smaller in the CGD group (13 mm vs. 18 mm; p=0.001). The total bilirubin mean was 196 µmol/L in the GBD group vs. 241 µmol/L in the CDD group; p=0.149. Clinical success was comparable between the two groups: 88% (36/41 - CGD) vs. 89.2% (33/37 - CDD); p=0.848. There was no difference in overall survival (log-rank p=0.727) or survival without biliary obstruction (log-rank p=0.725) between the two groups. Immediate morbidity was comparable: 7% (3/41 - GBD) vs. 13% (5/37 - CDD); p=0.368. The rate of significant immediate complications tended to be lower in the GBD group (5% (2/41 - CGD) vs. 8% (3/37 - CDD); p=0.093). Delayed morbidity (mainly LAMS obstruction) (>24 hours) was lower in the GBD group 7.3% (3/41 - CGD) vs. 27% (10/37 - CDD); p=0.022. There were no biliary complications after the 26th day in the GBD group. The LAMS dimensions did not have an impact on biliary complications in the CGD group (6x8mm vs. 10x10mm vs. 15x10mm).

Conclusion

Biliary drainage of tumoral obstruction of the distal biliary tract by GBD had comparable clinical efficacy and was associated with reduced delayed morbidity compared to CDD. This type of drainage is feasible, especially when the main bile duct is not dilated enough to consider CDD.

References

Maire F, Hammel P, Ponsot P, Aubert A, O’Toole D, Hentic O, et al. Long-term outcome of biliary and duodenal stents in palliative treatment of patients with unresectable adenocarcinoma of the head of pancreas. Am J Gastroenterol. 2006 Apr;101(4):735–42.
van der Merwe SW, van Wanrooij RLJ, Bronswijk M, Everett S, Lakhtakia S, Rimbas M, et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022 Feb;54(2):185–205.
Issa D, Irani S, Law R, Shah S, Bhalla S, Mahadev S, et al. Endoscopic ultrasound-guided gallbladder drainage as a rescue therapy for unresectable malignant biliary obstruction: a multicenter experience. Endoscopy. 2021 Aug;53(8):827–31.

Introduction

ERCP is effective for common bile duct stone treatment but carries post-op risks like pancreatitis and cholangitis. Biliary drainage post-surgery is vital, with methods like ENBD and ERBD being common. ENBD allows monitoring but has drawbacks like infection and inconvenience. ERBD mitigates these but can cause complications. A new solution, Detachable biliary plastic stents without flanges, uses soft materials for self-expulsion, reducing the need for further procedures and patient burden.

Aims & Methods

This study aimed to investigate the efficacy and safety of using detachable biliary plastic stents without flanges for the prevention of cholangitis following endoscopic retrograde cholangiopancreatography (ERCP) in patients with common bile duct stones.
The study cohort comprised patients diagnosed with common bile duct stones and treated at the First People's Hospital affiliated with West Lake University School of Medicine between January 2019 and January 2024. Participants were randomly assigned to either the group receiving detachable biliary plastic stents without flanges or the nasobiliary drainage group. In the former group, the stents were deployed for biliary drainage following the clearance of stones during ERCP. The latter group received nasobiliary drains for similar purposes. Comprehensive clinical data were gathered, encompassing preoperative and postoperative details, including laboratory investigations, endoscopic procedures, complications, hospital stay, and comfort levels assessed using the Visual Analogue Scale (VAS). Additionally, the incidence of cholangitis, the rate of spontaneous drain removal, and stent detachment were compared between the two groups.

Results

1. The study included 820 patients who underwent ERCP for common bile duct stones. After accounting for 10 patients lost to follow-up, a total of 810 patients were analyzed, with equal distribution across both study groups. The incidence of postoperative cholangitis was 2.0% in the stent group and 3.0% in the nasobiliary drainage group, showing no significant difference (P=0.365). Pancreatitis occurred in 2.7% of patients in the stent group and 4.2% in the drainage group, also not statistically significant (P=0.248). No instances of perforation or bleeding were reported in either group.
2. The median postoperative hospital stay was significantly shorter in the stent group at 2.0 days (range: 1.0 to 4.0d) compared to 3.0 days (range: 2.0 to 5.0d) in the nasobiliary drainage group (P＜0.001).
3. The VAS scores for postoperative comfort were significantly lower in the stent group with a mean of 2.86±1.08 versus 5.13±2.19 in the nasobiliary drainage group (P＜0.001).
4. All 405 patients in the stent group returned for follow-up one month postoperatively. Stent detachment was confirmed in 373 patients (92.1%). Among the 32 patients with retained stents, two developed cholangitis, and two reported recurrent abdominal pain, resulting in a complication rate of 1.0%. In the nasobiliary drainage group, 10 patients (2.5%) spontaneously removed their drains, with an average age of 72.2±8.3 years.

Conclusion

The deployment of detachable biliary plastic stents without flanges following ERCP for common bile duct stones is as effective as traditional nasobiliary drainage in preventing postoperative cholangitis. This approach offers enhanced patient comfort, reduced hospital stay, and a high rate of spontaneous stent detachment, demonstrating its safety and efficacy in clinical practice.

Disclosure

The authors declare that there are no conflicts of interest.

Introduction

The cornerstone of acute cholangitis treatment is antibiotic therapy combined with biliary drainage. The Tokyo Guidelines 2018 provide severity grading criteria that help predict prognosis and identify patients requiring early biliary drainage. While mild cholangitis can often be managed initially with antibiotics alone, moderate and severe cases typically require early and emergent drainage, respectively. Our aim is to explore factors influencing the timing of ERCP in acute cholangitis and its impact on clinical outcomes.

Aims & Methods

This retrospective single-center cohort study included patients diagnosed with acute cholangitis who underwent ERCP between March 2022 and March 2023 in a tertiary hospital with ERCP. Diagnosis and severity grading were based on the Tokyo Guidelines 2018. Descriptive and statistical analyses were performed to evaluate patient characteristics, severity classification, timing to ERCP and related clinical outcomes.

Results

A total of 104 patients underwent ERCP for acute cholangitis; 55 were female (52.9%) and the median age was 77 years. Based on the Tokyo 2018 criteria, 28 patients (26.9%) had grade III cholangitis, 52 (50%) grade II and 24 (23%) grade I. Only 5 patients (4.8%) underwent ERCP within 24 hours of admission—2 with grade III, 1 with grade II and 2 with grade I. Within 72 hours, 31 patients (29.8%) had undergone ERCP—9 with grade III, 16 with grade II and 6 with grade I. Notably, 70.8% of grade III cases were submitted to ERCP more than 72 hours after admission, with a median of 3 days of antibiotics before the procedure. There was no statistically significant association between ERCP timing and patient age, cholangitis severity, intensive/intermediate care admission or anticoagulant/antiplatelet use. However, admission on a Friday or Saturday was significantly associated with delayed ERCP (p=0.007), with 91% of these patients undergoing ERCP after 72 hours, compared to 56% for admissions on other days. Cholangitis severity correlated significantly with total hospital stay (grade I: 7 ± 3 days, grade II: 8 ± 3.8 days, grade III: 10.5 ± 9 days; p=0.001). ERCP timing was also associated with total antibiotic duration (<24h: 9 ± 2.6 days, 24–72h: 8 ± 3 days, >72h: 10 ± 4.8 days; p=0.043). The 30-day mortality rate was 4.8%, with no significant association with ERCP timing or severity grade.

Conclusion

In this real-world cohort, ERCP was frequently delayed beyond the recommended window, even in severe acute cholangitis. Weekend admission was a significant contributor to this delay. However, no association was found between ERCP timing and 30-day mortality, likely due to small sample size. These findings highlight the need for optimized access to biliary drainage, particularly during weekends, to better meet guideline recommendations.

Introduction

According to guidelines for acute cholangitis management (Tokyo 2018), urgent drainage of the biliary tract is indicated in moderate and severe cases. However, it does not consider factors such as bacteraemia or comorbidities. In addition, the availability of immediate biliary drainage may be limited in some centres.

Aims & Methods

Aims: To evaluate the clinical characteristics of acute cholangitis in our environment and to identify predictive factors of severity.
Methods: A retrospective study of clinical and analytical variables at admission of 331 patients diagnosed with acute cholangitis at Hospital del Mar (2018-2021). Analysis of predictive factors for mortality during admission and at 30 days from discharge. Severty was assessed as association of mortality with clinical, haemodynamic and analytical variables analyzed via logistic regression. Analysis of differences in mortality between early drainage (before 48 hours) and late drainage through Pearson Chi squared test.

Results

The average age was 78 years, 53% were men, 35% had a smoking habit and 17.5% had a Charlson index of high morbidity (>5p). As relevant antecedents they had: diabetes (32.1%), COPD (11.48%), heart failure (16.92%) and ischaemic heart disease (10.3%). The causes of cholangitis were: choledocholithiasis (48.33%) and both benign and malignant strictures (24.92%), 26.75% of cholangitis did not have a clear cause. Choledocholithiasis was diagnosed by endoscopic ultrasound (41.67%), CT scan (23.72%), magnetic ressonance (19.87%) or abdominal ultrasound (14.74%). 197 patients required biliary drainage, median time to drainage of 5 days. The median hospital stay was 9 days and 6.65% of patients needed intensive care unit (ICU) admission.
Mortality was 4.23% during admission and 3.34% at 30 days from discharge. Intra-hospital mortality was related to high morbidity (p<0,002), a malignant aetiology of the cholangitis (p<0,026), alkaline phosphatase (AP) >300UI/L (p<0,005), CRP (C reactive protein) >8mg/dl (p<0,006), low albumin <3,3g/dl (p<0,007) and high leukocytes >12x10^3/uL (p<0,022). Mortality at 30 days was associated with low levels of albumin, high levels of AP and CRP, high morbidity and a malignant origin of the cholangitis. In the multivariate analysis for intrahospital mortality, having high morbidity, AP>300 U/L and CRP>8mg/dl, were predictors of intra-hospital mortality (OR 2,34, IC 95% 1,19-4,16; OR 6,37 IC 95% 1,20-31,01; OR 5,10 IC95% 1,05-24,68; respectively). A malignant origin of a biliary stenosis was significantly associated with higher risk of mortality at 30 days after discharge (OR 12,57 IC 95% 1,58-100,17). There were no differences in mortality of moderate and severe cholangitis between those drained before 48h of admission and those drained after 48h (p=0,571). In those patients who had the risk factors for mortality we identified, no differences in mortality were found between drainage before and after 48h of admission.

Conclusion

Patients with a high Charlson score, initial PA >300 U/L or initial CRP >8 mg/dL have a higher risk of mortality and therefore, should be considered as useful factors to prioritize those patients who need urgent drainage.