ArticleSurgical endoscopy2026
Index-admission versus referred elective endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis in a resource-limited referral center: a real-world retrospective cohort study.
Article in Surgical endoscopy, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundThe optimal timing of ERCP in acute cholangitis remains controversial. Prior studies comparing early versus delayed ERCP have evaluated timing within the same admission. In resource-limited settings, patients are often initially managed at hospitals without ERCP capability and referred for elective ERCP, potentially delaying definitive biliary drainage. This study compared clinical outcomes between index-admission ERCP and referred elective ERCP.
methodsThis single-center retrospective cohort study included adult patients with acute cholangitis due to common bile duct (CBD) stones who underwent ERCP between August 2024 and November 2025. Patients were classified into index-admission ERCP and referred elective ERCP groups. Propensity score matching (PSM) was performed adjusting for age, sex, Charlson Comorbidity Index (CCI), and cholangitis severity according to the Tokyo Guidelines 2018. The primary outcome was 90-day recurrent cholangitis. Secondary outcomes included 90-day mortality, ICU admission, persistent organ failure at 72 h, need for rescue percutaneous transhepatic biliary drainage (PTBD), post-ERCP complications, and total length of hospital stay (LOS).
resultsAmong 283 eligible patients, 114 matched pairs were analyzed after matching. 90-day recurrent cholangitis occurred more frequently in the referred elective ERCP than in the index-admission group (21.9% vs 10.5%, p = 0.03), with lower 90-day recurrence-free survival (78.1% vs 89.5%, log rank p = 0.01). Referred elective ERCP was independently associated with recurrence (adjusted HR 2.69, 95% CI 1.27-5.70; p = 0.01). Additionally, total LOS was longer in the referred elective ERCP group (12.85 ± 4.66 vs 7.11 ± 4.98 days, p = 0.01). No differences were observed in 90-day mortality, ICU admission, organ failure, or post-ERCP complications.
conclusionIn a resource-limited setting, referred elective ERCP was associated with higher 90-day recurrent cholangitis and longer hospitalization without affecting short-term mortality. Strategies prioritizing index-admission ERCP for high-risk patients and ensuring a 30-day safety window for elective cases are essential to optimize clinical outcomes and resource management. (Thaiclinicaltrials.org number TCTR20260303001).
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