EFFICACY OF EARLY ERCP IN PRIMARY AND SECONDARY DISTAL MALIGNANT BILIARY OBSTRUCTION

Aims Early endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute cholangitis, mainly from biliary stones, is known to improve outcomes. Currently, there is a lack of studies regarding optimal timing of ERCP in patients with malignant biliary obstruction (MBO).

Methods From January 2005 to June 2018, 1872 patients who visited emergency room (ER) and underwent ERCP for suspected biliary obstruction at Seoul National University Hospital were analyzed. In total, 567 patients with distal MBO were included and further classified as primary and secondary distal MBO groups, according to the tumor origin and status. Early ERCP was defined as ERCP performed within 48 hours after ER arrival. The primary outcomes were 30-day and 180-day mortality in the overall cohort. Secondary outcomes were differences in 30-day and 180-day mortality between patients with primary and secondary distal MBO.

Results ERCP was performed within 48 hours of ER arrival in 477 (84.1%) patients. Biliary drainage via ERCP was successful in 444 patients (78.3%), and clinical success rate was 90.8% (403/444). In total cohort, 30-day mortality (2.1% and 12.7%; P< 0.001) and 180-day mortality (36.5% and 50.8%; P=0.043) were significantly lower in patients who underwent ERCP within 48 hours than those who did not. In primary distal MBO group, there was positive tendency toward ERCP within 48 hours in 30-day mortality (1.4% vs 7.1%; P=0.066) and 180-day mortality (27.2% vs 42.9%; P=0.057). In patients with secondary distal MBO, 30-day mortality was significantly lower in patients who underwent ERCP within 48 hours than those who did not (4.3% vs 23.8%; P=0.010), while there was no significant difference in 180-day mortality (64.9% vs 66.7%; P>0.999).

Conclusions Early ERCP clearly improves clinical outcomes in distal MBO patients regardless of the tumor origin, especially short-term outcomes including 30-day mortality.