Timing of intervention: Assessing early vs late endoscopic and surgical interventions in acute cholangitis

BACKGROUND Acute cholangitis (AC) is characterized by infection and inflammation of the biliary tree, often resulting from acute biliary obstruction. AIM To evaluate outcomes of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration (LCBDE) in the management of AC, focusing on timing, complications, and hospital resource utilization. METHODS Between 2016 and 2021, a total of 31817 patients were included, with 30330 (95.3%) undergoing ERCP and 1487 (4.67%) undergoing LCBDE. RESULTS ERCP patients were older (mean age 64.5 years vs 59.7 years; P < 0.001) with higher Medicare use (56.1% vs 48.1%) compared to LCBDE patients. LCBDE patients had more elective admissions (19.6% vs 11.7%; P < 0.001) and were treated more often in non-teaching hospitals (P < 0.001). Complication rates differed significantly: LCBDE patients had higher respiratory failure (3.34% vs 2.34%; P = 0.026) and bile duct perforation (1.55% vs 0.64%; P = 0.026), while ERCP patients had higher rates of pancreatitis (P < 0.001) and jaundice (P = 0.002). Late ERCP was associated with higher rates of septic shock (1.23%), respiratory failure (3.80%), and bile duct perforation (0.93%) compared to earlier timing. Patients undergoing late ERCP also had longer hospital stays and higher costs (P < 0.001). LCBDE patients experienced significantly longer hospital stays (mean 8.92 days vs 4.89 days) and higher costs, particularly in late interventions (P < 0.001). CONCLUSION ERCP remains the preferred intervention for AC, with earlier procedures resulting in better outcomes and lower resource utilization. LCBDE, while less common, is associated with longer hospital stays and higher costs, particularly when performed late. Optimizing timing for both ERCP and LCBDE is critical to improving patient outcomes and reducing healthcare expenditures.