Timing of intervention: Assessing early vs late endoscopic and surgical interventions in acute cholangitis

Table 1 Demographics and clinical characteristics endoscopic retrograde cholangiopancreatography vs laparoscopic common bile duct exploration

Demographics (unweighted n = 31817)	Endoscopic retrograde cholangiopancreatography only (n = 30330, 95.3%)	Laparoscopic common bile duct exploration only (n = 1487, 4.67%)	P value1
Age, years (mean, SE)	64.5 (0.097)	59.7 (0.49)	< 0.001
Sex, female (%, SE)	51.5 (0.31)	54.0 (1.39)	0.028
Income quartile (%, 95%CI)			0.24
1	25.6 (0.27)	23.9 (1.20)
2	27.6 (0.28)	26.7 (1.25)
3	25.8 (0.28)	26.2 (1.28)
4	20.9 (0.24)	23.0 (1.15)
Primary payer (%, SE)			< 0.001
Medicare	56.1 (0.31)	48.1 (1.40)
Medicaid	9.81 (0.18)	12.5 (0.92)
Private	28.9 (0.28)	34.5 (1.34)
Self-pay	2.41 (0.098)	2.82 (0.47)
Other	2.69 (0.10)	2.17 (0.42)
Elective admission (%, SE)	11.7 (0.21)	19.6 (1.13)	< 0.001
Weekend admission (%, SE)	19.1 (0.25)	18.8 (1.11)	0.83
Hospital location (%, SE)			< 0.001
Urban/non-teaching	14.7 (0.048)	16.3 (0.96)
Urban/teaching	82.9 (0.052)	79.5 (1.05)
Rural	2.44 (0.024)	4.19 (0.48)
Hospital bed size (%, SE)			0.29
Small	10.9 (0.04)	11.7 (0.82)
Medium	21.1 (0.06)	22.3 (1.16)
Large	68.0 (0.065)	66.0 (1.29)
Charlson Comorbidity Index (mean, SE)	3.35 (0.02)	2.53 (0.086)	< 0.001
Septic shock (%, SE)	0.57 (0.044)	0.95 (0.24)	0.056
Severe sepsis (%, SE)	0.46 (0.041)	0.86 (0.28)	0.054
SIRS with organ failure (%, SE)	0.064 (0.014)	0.052 (0.051)	0.83
SIRS without organ failure (%, SE)	0.91 (0.056)	0.76 (0.22)	0.54
Respiratory failure (%, SE)	2.34 (0.094)	3.34 (0.52)	0.026
Kidney failure (%, SE)	13.0 (0.20)	12.2 (0.91)	0.39
Thrombocytopenia (%, SE)	3.89 (0.12)	3.94 (0.53)	0.92
Altered mental status (%, SE)	0.19 (0.026)	0.27 (0.12)	0.41
Abnormal coagulation (%, SE)	1.51 (0.079)	0.83 (0.24)	0.04
Bile duct perforation (%, SE)	0.64 (0.05)	1.55 (0.36)	< 0.001
Post procedural bleeding (%, SE)	0.36 (0.039)	0.19 (0.11)	0.28
Chronic pancreatitis (%, SE)	5.58 (0.15)	2.89 (0.50)	< 0.001
Acute pancreatitis (%, SE)	7.52 (0.16)	3.12 (0.48)	< 0.001
Abdominal pain (%, SE)	3.48 (0.12)	4.45 (0.58)	0.069
Jaundice (%, SE)	5.85 (0.14)	3.75 (0.52)	0.002
Cholelithiasis	6.01 (0.15)	18.1 (1.10)	< 0.001
Choledocholithiasis (%, SE)	1.89 (0.083)	1.34 (0.31)	0.15
Biliary obstruction (%, SE)	85.1 (0.23)	53.9 (1.40)	< 0.001
Carcinoma of intrahepatic bile duct (%, SE)	5.10 (0.14)	3.59 (0.47)	0.008
Malignant neoplasm of pancreas (%, SE)	17.2 (0.23)	7.45 (0.69)	< 0.001
Inflation-adjusted total cost (mean, SE)	16968.87 (80.2)	20011.85 (446.7)	< 0.001
Length of stay (mean, SE)	4.89 (0.027)	5.80 (0.14)	< 0.001
In-hospital mortality (%, SE)	2	2	2
30-day readmission (%, SE)	25.6 (0.27)	21.8 (1.15)	0.002
30-day mortality (%, SE) (n = 5354)	5.27 (0.26)	2.93 (0.96)	0.072

¹Continuous variables compared using weighted linear regression. Categorical variables compared using χ² analysis.

²Not shown due to Healthcare Cost and Utilization Project regulations regarding 10 or fewer observed observations.

SIRS: Systemic inflammatory response syndrome.

Table 2 Demographics and clinical characteristics by endoscopic retrograde cholangiopancreatography timing

Demographics (unweighted n = 31817)	None (n = 1487, 4.74%)	Urgent ERCP (n = 5833, 18.6%)	Early ERCP (n = 16645, 53.1%)	Late ERCP (n = 7380, 23.5%)	P value1
Age, years (mean, SE)	59.7 (0.49)	63.4 (0.23)2	64.7 (0.13)3,5	65.1 (0.19)4,6	< 0.001
Sex, female (%, SE)	54.6 (1.39)	57.6 (0.71)	49.9 (0.42)3,5	50.4 (0.63)4,6	< 0.001
Income quartile (%, 95%CI)					< 0.001
1	23.9 (1.20)	24.3 (0.64)	25.2 (0.37)5	28.4 (0.57)4,6,7
2	26.7 (1.25)	28.1 (0.67)	27.5 (0.38)	26.9 (0.57)
3	26.2 (1.28)	26.4 (0.65)	25.8 (0.67)	24.7 (0.55)
4	23.0 (1.15)	21.2 (0.56)	21.4 (0.33)	19.9 (0.48)
Primary payer (%, SE)					< 0.001
Medicare	48.1 (1.40)	55.3 (0.72)2	55.3 (0.42)3,5	57.9 (0.63)4,6,7
Medicaid	12.5 (0.92)	9.91 (0.39)	9.78 (0.24)	11.1 (0.38)
Private	34.5 (1.34)	31.1 (0.67)	29.5 (0.39)	25.9 (0.56)
Self-pay	2.82 (0.47)	2.02 (0.23)	2.62 (0.14)	2.36 (0.19)
Other	2.17 (0.42)	2.72 (0.23)	2.79 (0.14)	2.70 (0.20)
Elective admission (%, SE)	19.6 (1.13)	32.6 (0.69)2	6.51 (0.23)3,5	5.86 (0.31)4,6	< 0.001
Weekend admission (%, SE)	18.8 (1.11)	12.9 (0.50)2	20.4 (0.34)	21.3 (0.52)6	< 0.001
Hospital location (%, SE)					< 0.001
Urban/non-teaching	16.3 (0.96)	12.5 (0.38)2	15.8 (0.19)3,5	13.9 (0.36)4,7
Urban/teaching	79.5 (1.05)	85.2 (0.42)	81.8 (0.20)	83.6 (0.39)
Rural	4.19 (0.48)	2.27 (0.19)	2.47 (0.089)	2.39 (0.17)
Hospital bed size (%, SE)					< 0.001
Small	11.7 (0.82)	9.31 (0.35)2	11.3 (0.17)	9.72 (0.32)7
Medium	22.3 (1.16)	19.0 (0.51)	21.7 (0.23)	20.9 (0.46)
Large	66.0 (1.29)	71.6 (0.57)	67.1 (0.27)	69.3 (0.51)
Charlson Comorbidity Index (mean, SE)	2.53 (0.086)	2.65 (0.043)2	3.33 (0.027)3,5	4.02 (0.045)4,6,7	< 0.001
Septic shock (%, SE)	0.95 (0.24)	0.36 (0.077)	0.36 (0.047)3	1.23 (0.13)6,7	< 0.001
Severe sepsis (%, SE)	0.86 (0.28)	0.41 (0.10)	0.28 (0.039)3	0.93 (0.12)6,7	< 0.001
SIRS with organ failure (%, SE)	8	8	8	0.17 (0.049)	8
SIRS without organ failure (%, SE)	0.76 (0.22)	0.81 (0.11)	0.90 (0.077)	1.06 (0.13)6	0.43
Respiratory failure (%, SE)	3.35 (0.52)	2.00 (0.21)2	1.82 (0.11)3,5	3.80 (0.24)6,7	< 0.001
Kidney failure (%, SE)	12.2 (0.91)	8.07 (0.37)2	11.9 (0.27)	19.2 (0.48)4,6,7	< 0.001
Thrombocytopenia (%, SE)	3.94 (0.53)	2.83 (0.24)	3.84 (0.16)	4.75 (0.26)6,7	< 0.001
Altered mental status (%, SE)	8	8	0.17 (0.031)	0.32 (0.07)	0.049
Abnormal coagulation (%, SE)	0.84 (0.24)	0.73 (0.12)	1.33 (0.098)	2.50 (0.19)4,6,7	< 0.001
Bile duct perforation (%, SE)	1.55 (0.36)	0.66 (0.11) 2	0.52 (0.062)3,5	0.93 (0.13)7	< 0.001
Post procedural bleeding (%, SE)	8	0.37 (0.088)	0.28 (0.048)	0.56 (0.094)7	0.004
Chronic pancreatitis (%, SE)	2.89 (0.50)	7.64 (0.42)2	4.56 (0.18)5	6.19 (0.32)4,6,7	< 0.001
Acute pancreatitis (%, SE)	3.12 (0.48)	7.72 (0.37)2	7.07 (0.21)3	8.43 (0.34)4,7	< 0.001
Abdominal pain (%, SE)	4.45 (0.58)	4.13 (0.29)	3.23 (0.15)	3.62 (0.24)	0.008
Jaundice (%, SE)	3.76 (0.52)	3.81 (0.25)	6.17 (0.19)3,5	7.01 (0.32)4,6	< 0.001
Cholelithiasis (%, SE)	18.1 (1.10)	4.83 (0.29)2	5.54 (0.19)3,5	7.79 (0.34)4,6,7	< 0.001
Choledocholithiasis (%, SE)	1.34 (0.31)	1.89 (0.19)	1.62 (0.10)	2.38 (0.19)7	0.001
Biliary obstruction (%, SE)	53.9 (1.41)	82.2 (0.52)2	85.7 (0.29)3,5	86.4 (0.44)4,6	< 0.001
Carcinoma of intrahepatic bile duct (%, SE)	3.58 (0.47)	4.36 (0.31)	4.92 (0.18)	5.71 (0.30)4,6	0.001
Malignant neoplasm of pancreas (%, SE)	7.45 (0.69)	14.4 (0.49)2	18.5 (0.33)3,5	17.1 (0.46)4,6	< 0.001

¹Continuous variables compared using weighted linear regression. Categorical variables compared using χ² analysis.

²Statistical differences between no endoscopic retrograde cholangiopancreatography (ERCP) and urgent ERCP (Bonferroni P < 0.008).

³Statistical differences between no ERCP and early ERCP (Bonferroni P < 0.008).

⁴Statistical differences between no ERCP and late ERCP (Bonferroni P < 0.008).

⁵Statistical differences between urgent ERCP and early ERCP (Bonferroni P < 0.008).

⁶Statistical differences between urgent ERCP and late ERCP (Bonferroni P < 0.008).

⁷Statistical differences between Early ERCP and late ERCP (Bonferroni P < 0.008).

⁸Not shown due to Healthcare Cost and Utilization Project regulations regarding 10 or fewer observed observations. Group excluded from comparison.

ERCP: Endoscopic retrograde cholangiopancreatography; SIRS: Systemic inflammatory response syndrome.

Table 3 Demographics by 30-day admission status

Demographics (unweighted n = 31811)	No 30-day readmission (n = 24807, 77.9%)	30-day readmission (n = 7004, 22.0%)	P value1
Age, years (mean, SE)	54.5 (0.11)	63.9 (0.19)	0.032
Sex, female (%, SE)	52.6 (0.35)	47.9 (0.65)	< 0.001
Income quartile (%, 95%CI)			< 0.001
1	25.6 (0.30)	25.1 (0.58)
2	28.0 (0.32)	25.9 (0.58)
3	25.7 (0.31)	26.5 (0.59)
4	20.6 (0.26)	22.6 (0.52)
Primary payer (%, SE)			0.008
Medicare	55.9 (0.35)	54.9 (0.65)
Medicaid	9.62 (0.19)	11.1 (0.39)
Private	29.2 (0.31)	29.4 (0.59)
Self-pay	2.50 (0.11)	2.18 (0.19)
Other	27.5 (0.11)	2.41 (0.20)
Elective admission (%, SE)	13.0 (0.25)	8.96 (0.39)	< 0.001
Weekend admission (%, SE)	19.2 (0.27)	18.7 (0.52)	0.41
Hospital location (%, SE)			< 0.001
Urban/non-teaching	14.9 (0.10)	14.0 (0.37)
Urban/teaching	82.4 (0.11)	84.0 (0.40)
Rural	2.67 (0.045)	1.95 (0.16)
Hospital bed size (%, SE)			0.52
Small	10.9 (0.097)	10.7 (0.35)
Medium	21.3 (0.13)	20.7 (0.48)
Large	67.8 (0.15)	68.6 (0.55)
Charlson Comorbidity Index (mean, SE)	3.11 (0.022)	4.07 (0.044)	< 0.001
Septic shock (%, SE)	0.54 (0.048)	0.76 (0.10)	0.038
Severe sepsis (%, SE)	0.48 (0.046)	0.47 (0.091)	0.92
SIRS with organ failure (%, SE)	0.075 (0.017)	0.021 (0.015)	0.071
SIRS without organ failure (%, SE)	0.93 (0.063)	0.79 (0.11)	0.27
Respiratory failure (%, SE)	2.32 (0.11)	2.63 (0.21)	0.17
Kidney failure (%, SE)	12.7 (0.23)	13.9 (0.45)	0.024
Thrombocytopenia (%, SE)	3.72 (0.13)	4.51 (0.27)	0.006
Altered mental status (%, SE)	0.21 (0.028)	0.15 (0.051)	0.40
Abnormal coagulation (%, SE)	1.38 (0.082)	1.87 (0.19)	0.011
Bile duct perforation (%, SE)	0.73 (0.061)	0.51 (0.089)	0.054
Post procedural bleeding (%, SE)	0.37 (0.042)	0.32 (0.080)	0.62
Chronic pancreatitis (%, SE)	5.52 (0.17)	5.25 (0.32)	0.43
Acute pancreatitis (%, SE)	7.17 (0.17)	7.85 (0.34)	0.069
Abdominal pain (%, SE)	3.34 (0.13)	3.09 (0.22)	0.039
Jaundice (%, SE)	5.76 (0.16)	5.67 (0.29)	0.77
Cholelithiasis	6.75 (0.17)	5.87 (0.32)	0.019
Choledocholithiasis (%, SE)	2.03 (0.095)	1.28 (0.14)	< 0.001
Biliary obstruction (%, SE)	82.6 (0.26)	87.7 (0.45)	< 0.001
Carcinoma of intrahepatic bile duct (%, SE)	4.59 (0.15)	6.68 (0.34)	< 0.001
Malignant neoplasm of pancreas (%, SE)	16.5 (0.25)	17.9 (0.49)	< 0.001
Inflation-adjusted total cost (mean, SE)	16526.26 (83.9)	19234.87 (210.8)	< 0.001
Length of stay (mean, SE)	4.73 (0.029)	5.67 (0.067)	< 0.001

¹Continuous variables compared using weighted linear regression. Categorical variables compared using χ² analysis.

Not shown due to Healthcare Cost and Utilization Project regulations regarding 10 or fewer observed observations. Group excluded from comparison. SIRS: Systemic inflammatory response syndrome.

Table 4 Outcomes by endoscopic retrograde cholangiopancreatography timing

Unweighted (n = 67738)	30-day readmission1 [% (SE)]	No ERCP as the reference group [odds ratio (95%CI)]	P value	Urgent ERCP as the reference group	P value
ERCP
None (n = 1487)	19.9 (1.11)	Reference
Urgent ERCP (n = 5833)	17.9 (0.54)	0.85 (072-0.99)	0.046	Reference
Early ERCP (n = 16645)	21.3 (0.35)	0.91 (0.78-1.06)	0.24	1.08 (0.99-1.18)	0.079
Late ERCP (n = 7380)	25.2 (0.54)	1.08 (0.92-1.26)	0.36	1.28 (1.15-1.41)	< 0.001
Unweighted (n = 7004)	30-day mortality1
ERCP
None (n = 302)	2.93 (0.96)	Reference
Urgent ERCP (n = 1118)	3.76 (0.58)	1.24 (0.58-2.65)	0.58	Reference
Early ERCP (n = 3586)	5.36 (0.36)	1.76 (0.85-3.59)	0.12	1.43 (0.99-2.05)	0.055
Late ERCP (n = 1896)	5.95 (0.54)	1.79 (0.87-3.69)	012	1.46 (0.97-2.15)	0.066
	Length of stay1 [mean (SE)]	β (95%CI)		β (95%CI)
ERCP
None (n = 1487)	5.81 (0.14)	Reference
Urgent ERCP (n = 5833)	2.98 (0.043)	-2.70 (-2.98 to -2.42)	< 0.001	Reference
Early ERCP (n = 16645)	4.20 (0.029)	-1.61 (-1.89 to -1.33)	< 0.001	1.12 (1.02-1.23)	< 0.001
Late ERCP (n = 7380)	8.17 (0.073)	1.82 (1.52-2.14)	< 0.001	4.58 (4.42-4.73)	< 0.001
	Inflation-adjusted total cost2 [mean (SE)]	β (95%CI)		β (95%CI)
ERCP
None (n = 1487)	20011.85 (446.7)	Reference
Urgent ERCP (n = 5833)	14024.95 (137.8)	-5433.6 (-6316.1 to -4551.0)	< 0.001	Reference
Early ERCP (n = 16645)	15164.99 (86.6)	-4826.5 (-5700.7 to -3952.2)	< 0.001	599.3 (263.8-934.7)	< 0.001
Late ERCP (n = 7380)	23509.59 (231.7)	1951.6 (972.5-2930.7)	< 0.001	7391.9 (6902.2-7881.7)	< 0.001

¹Multivariable linear regression adjusting for age, biological sex, income quartile, insurance status, hospital size and teaching status, Charlson Comorbidity index, complications associated with endoscopic retrograde cholangiopancreatography (ERCP), and the cycle year.

²Multivariable logistic regression adjusting for age, biological sex, income quartile, insurance status, hospital size and teaching status, Charlson Comorbidity index, complications associated with ERCP, and the cycle year.

ERCP: Endoscopic retrograde cholangiopancreatography.