Safety and efficacy of single-stage endoscopic stone removal and the timing of ERCP for acute cholangitis: a multicenter study.

backgroundAcute cholangitis (AC) is a medical emergency, often caused by common bile duct (CBD) stone obstruction. The 2018 Tokyo Guidelines (TG18) recommend early drainage with selective stone removal. When stone removal is performed simultaneously with drainage, it is referred to as single-stage stone removal, which theoretically can reduce the number of endoscopic retrograde cholangiopancreatography (ERCP) procedures, hospital stay, and hospital costs. The safety and efficacy of single-stage stone removal for mild AC has been validated. However, there is insufficient evidence-based medicine regarding single-stage treatment for moderate and severe AC. Additionally, the optimal timing for ERCP remains unclear.

methodsWe conducted a multicenter, retrospective study of 263 patients who underwent single-stage endoscopic treatment for AC between January 2017 and June 2025. AC was classified according to the 2018 Tokyo Guidelines (TG18). The complete stone removal rate, complication rate (post-ERCP pancreatitis (PEP), bleeding, perforation), length of hospital stay, 30-day pneumonia, and 30-day mortality were compared between moderate and mild AC groups, and between severe and mild AC groups undergoing single-stage stone removal.

resultsThe complete stone removal rate was similar between the mild and moderate AC groups (92.4% vs. 83.8%; p = 0.058), and the complication rate were comparable between the two groups (PEP 10.2% vs. 6.3%, p = 0.334; bleeding, 3.4% vs. 2.5%, p = 1.000; perforation 0% vs. 0%; p = -). The complete stone removal rate was also similar between the mild and severe AC groups (92.4% vs. 87.7%; p = 0.297), with comparable complication rates (PEP 10.2% vs. 9.2%, p = 0.838; bleeding, 3.4% vs. 3.1%, p = 1.000; perforation 0% vs. 0%; p = -). A total of two patient deaths occurred, both in the moderate AC group, and the comparison with the mild AC group showed no statistically significant difference (0% vs. 2.5%; p = 0.162). A subgroup analysis showed the early ERCP group (≤ 72 h) had shorter hospital stays (7.0(6.5–12) days vs. 10.0(8.0–13) days; P = 0.034) in patients with severe AC. Multivariate analysis revealed that a stone size ≥ 1.5 cm was an independent risk factor associated with failed stone removal (OR, 2.942, 95% CI: 1.012–8.548; p = 0.047). The complete stone removal rate was significantly lower in the stone size ≥ 1.5 cm group compared to the < 1.5 cm group (90.6% vs. 80.4%; p = 0.040).

conclusionSingle-stage stone removal is safe and effective for moderate to severe AC, but the impact of patient comorbidities on clinical outcomes must be considered. Early single-stage stone removal significantly reduces the hospital stay for patients with severe AC. The rate of complete stone removal decreases in patients with stone size ≥ 1.5 cm.