Elshaarawy O, Ramesh J. Letter to the Editor: Omission of key predictors of sepsis undermines the validity of risk modelling for post-endoscopic retrograde cholangiopancreatography biliary infection. World J Gastroenterol 2026; 32(30): 116606 [DOI: 10.3748/wjg.116606]
Corresponding Author of This Article
Omar Elshaarawy, MD, Doctor, Department of Gastroenterology, University of Liverpool Hospitals, Mount Vernon Street, Liverpool L7 8YE, Merseyside, United Kingdom. oelshaarawy@outlook.com
Research Domain of This Article
Gastroenterology & Hepatology
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letter
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Elshaarawy O, Ramesh J. Letter to the Editor: Omission of key predictors of sepsis undermines the validity of risk modelling for post-endoscopic retrograde cholangiopancreatography biliary infection. World J Gastroenterol 2026; 32(30): 116606 [DOI: 10.3748/wjg.116606]
World J Gastroenterol. Aug 14, 2026; 32(30): 116606 Published online Aug 14, 2026. doi: 10.3748/wjg.116606
Letter to the Editor: Omission of key predictors of sepsis undermines the validity of risk modelling for post-endoscopic retrograde cholangiopancreatography biliary infection
Omar Elshaarawy, Jayapal Ramesh
Omar Elshaarawy, Jayapal Ramesh, Department of Gastroenterology, University of Liverpool Hospitals, Liverpool L7 8YE, Merseyside, United Kingdom
Jayapal Ramesh, Centre for Advanced Endoscopy Research and Education, Orlando Health Digestive Health Institute, Orlando, FL 32806, United States
Co-corresponding authors: Omar Elshaarawy and Jayapal Ramesh.
Author contributions: Elshaarawy O and Ramesh J conceived and designed the manuscript; Elshaarawy O drafted the manuscript; Ramesh J critically revised the manuscript for important intellectual content.
AI contribution statement: Grammarly for language polishing of Abstract. The authors confirm that no AI tools were used for study design, analysis, image generation or data interpretation. Grammarly was only used for language polishing of the abstract to ensure clarity.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Corresponding author: Omar Elshaarawy, MD, Doctor, Department of Gastroenterology, University of Liverpool Hospitals, Mount Vernon Street, Liverpool L7 8YE, Merseyside, United Kingdom. oelshaarawy@outlook.com
Received: November 17, 2025 Revised: January 18, 2026 Accepted: February 26, 2026 Published online: August 14, 2026 Processing time: 250 Days and 5.2 Hours
Abstract
Post-endoscopic retrograde cholangiopancreatography biliary infection remains a significant cause of morbidity in malignant perihilar biliary obstruction. A recent model by Wang et al, published in the recent issue of the World Journal of Gastroenterology, which identified hypokalaemia, Bismuth-Corlette classification, and aspartate aminotransferase as predictors, yet omitted critical sepsis determinants. The absence of key variables, including baseline inflammatory biomarkers, biliary colonization, stent characteristics, antibiotic protocols, and particularly the degree of biliary drainage, such as hepatic volume decompressed and undrained ducts after failed cannulation, significantly limits validity. Drainage adequacy is central to infection pathogenesis and outcome. Comprehensive models incorporating these parameters are essential for accurate risk prediction and meaningful clinical application.
Core Tip: Post-endoscopic retrograde cholangiopancreatography biliary infection is a significant risk in malignant obstruction. Current risk models are incomplete, omitting critical factors like drainage adequacy (hepatic volume decompressed) and inflammatory biomarkers. Comprehensive models are essential for accurate postoperative biliary infection risk prediction and better clinical outcomes.
