Early endoscopic retrograde cholangiopancreatography in predicted severe acute biliary pancreatitis: a prospective multicenter study.
BACKGROUND
The role of early endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis (ABP) remains controversial. Previous studies have included only a relatively small number of patients with predicted severe ABP. We investigated the clinical effects of early ERCP in these patients.


METHODS
We performed a prospective, observational multicenter study in 8 university medical centers and 7 major teaching hospitals. One hundred fifty-three patients with predicted severe ABP without cholangitis enrolled in a randomized multicenter trial on probiotic prophylaxis in acute pancreatitis were prospectively followed. Conservative treatment or ERCP within 72 hours after symptom onset (at discretion of the treating physician) were compared for complications and mortality. Patients without and with cholestasis (bilirubin: >2.3 mg/dL [40 mumol/L] and/or dilated common bile duct) were analyzed separately.


RESULTS
Of the 153 patients, 81 (53%) underwent ERCP and 72 (47%) conservative treatment. Groups were highly comparable at baseline. Seventy-eight patients (51%) had cholestasis. In patients with cholestasis, ERCP (52/78 patients: 67%), as compared with conservative treatment, was associated with fewer complications (25% vs. 54%, P = 0.020, multivariate adjusted odds ratio [OR]: 0.35, 95% confidence interval [CI]: 0.13-0.99, P= 0.049). This included fewer patients with >30% pancreatic necrosis (8% vs. 31%, P = 0.010). Mortality was nonsignificantly lower after ERCP (6% vs. 15%, P = 0.213, multivariate adjusted OR: 0.44, 95% CI: 0.08-2.28, P = 0.330). In patients without cholestasis, ERCP (29/75 patients: 39%) was not associated with reduced complications (45% vs. 41%, P = 0.814, multivariate adjusted OR: 1.36; 95% CI: 0.49-3.76; P = 0.554) or mortality (14% vs. 17%, P = 0.754, multivariate adjusted OR: 0.78; 95% CI: 0.19-3.12, P = 0.734).


CONCLUSIONS
Early ERCP is associated with fewer complications in predicted severe ABP if cholestasis is present.
van Santvoort
Hjalmar C
HC
Department of Surgery, University Medical Center Utrecht, Utrecht 3508 GA, The Netherlands.
Besselink
Marc G
MG
de Vries
Annemarie C
AC
Boermeester
Marja A
MA
Fischer
Kathelijn
K
Bollen
Thomas L
TL
Cirkel
Geert A
GA
Schaapherder
Alexander F
AF
Nieuwenhuijs
Vincent B
VB
van Goor
Harry
H
Dejong
Cees H
CH
van Eijck
Casper H
CH
Witteman
Ben J
BJ
Weusten
Bas L
BL
van Laarhoven
Cees J
CJ
Wahab
Peter J
PJ
Tan
Adriaan C
AC
Schwartz
Matthijs P
MP
van der Harst
Erwin
E
Cuesta
Miguel A
MA
Siersema
Peter D
PD
Gooszen
Hein G
HG
van Erpecum
Karel J
KJ
D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D001660:Biliary Tract Diseases / Q000150:complications*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002779:Cholestasis / Q000209:etiology; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D011183:Postoperative Complications; D011446:Prospective Studies