On-Site ERCP Availability Does Not Impact Cholangitis Outcomes: A Retrospective Cohort Study

Introduction: ERCP is a key component acute cholangitis (AC) management but is not available at all hospitals. The impact of on-site ERCP availability on cholangitis outcomes unknown. Methods: In this cohort study, we included adults diagnosed with acute cholangitis at 27 hospitals in Ontario through the GEMINI collaborative. We collected data on demographics, clinical and laboratory values, and interventions. The primary outcome was in-hospital mortality. Secondary outcomes were length of stay, intensive care unit (ICU) admission, readmission rates, and requirement for percutaneous or surgical decompression. We used multivariable regression analyses to assess the impact of on-site ERCP availability on the primary and secondary outcomes, adjusting for demographics, comorbidities, severity of initial disease, and underlying hepatopancreaticobiliary (HPB) malignancy. We performed subgroup analyses on patients with HPB malignancy and severe cholangitis (Figure 1). Results: There were 4943 patients in our cohort (3942 at ERCP site, 1001 at non-ERCP site). The median age was 74, 15% had underlying HPB malignancy, and 19% had severe cholangitis. In hospital mortality was 4%. On-site ERCP availability did not impact in-hospital mortality (odds ratio (OR)=1.08,95%CI=0.73-1.59) or any secondary outcomes. In the subgroup analysis, severe AC patients at ERCP-sites had lower odds of ICU admission (OR=0.36,95% CI=0.14-0.94) and 7-day readmission (OR=0.46,95%CI=0.23-0.92) (Table 1). Conclusion: On-site ERCP availability did not impact in-hospital mortality. For patients with severe cholangitis, on-site ERCP availability was associated with lower odds of ICU admission and 7-day readmission. While these results should be interpreted cautiously, patients with severe AC may warrant early consultation with a hepatobiliary endoscopist.Figure 1.: (A) percentage of patients with cholangitis at ERCP and non-ERCP centers who underwent ERCP during the hospitalization. (B) Among patients who underwent ERCP, percentage who underwent ERCP in <24h, between 24-48h, and >48h after admission. Table 1. - Unadjusted Estimates and Adjusted Effects Comparing ERCP-Sites to Non-ERCP Sites for Primary and Secondary Outcomes Outcome Unadjusted estimates Adjusted effect In-hospital mortality 4% (ERCP site) vs 5% (non-ERCP site) OR 1.08 (95% CI 0.73-1.59) Length of stay 5.25 days vs 5.90 days RR 0.93 (95% CI 0.83-1.05) 7-day readmission 5% vs 3% OR 0.74 (95% CI 0.54-1.06) 30-day readmission 13% vs 11% OR 0.88 (95% CI 0.69–1.13) ICU admission 11% vs 13% OR 0.68 (95% CI 0.29-1.64) Percutaneous intervention 8% vs 5% OR 1.30 (95% CI 0.57-2.93) ICU – intensive care unit; ERCP – endoscopic retrograde cholangiopancreatography; OR – odds ratio; CI – confidence interval; RR – risk ratio.