Optimal Timing of Single-Stage Retrograde Endoscopic Common Bile Duct Stone Removal in Mild and Moderate Acute Cholangitis: A Prospective Trial

Background: In this study, we aimed to compare the efficacy and safety of removing a single-stage, retrograde, endoscopic common bile duct stone in patients with mild and moderate acute cholangitis associated with choledocholithiasis.Methods: We enrolled 196 endoscopic retrograde cholangiopancreatography (ERCP)-naïve patients diagnosed with acute cholangitis and choledocholithiasis between September 2018 and February 2020 at a single hospital. For eligible patients, single-stage treatment involved stone removal at initial ERCP. Early ERCP was defined as ERCP performed ≤ 72 hours following diagnosis in the emergency room.Results: The final analysis included 138 patients. The success rate of complete stone extraction was similar in patients with mild and moderate cholangitis (88.5% vs. 91.7%; p = 0. 536). Complication rates were also comparable between the two groups. In the moderate cholangitis group, the length of hospitalization declined significantly among patients who underwent early single-stage ERCP (10.6 ± 6.1 vs. 18.7 ± 12.5 days; p = 0.001) compared with patients treated with delayed ERCP. In the multivariate analysis, early ERCP indicated shorter hospitalization times (≤ 10 days) (odds ratio (OR), 7.689; p = 0.030), while endoscopic retrograde biliary drainage, for acute cholangitis only, indicated longer hospitalization times (OR, 0.358; p = 0.030). A stone size larger than 1.5 cm was an independent risk factor for stone extraction failure (OR, 24.507; p = 0.009).Conclusions: Single-stage, retrograde, endoscopic common bile duct stone removal may be safe and effective for patients with mild and moderate cholangitis. The benefit of early single-stage ERCP (≤ 72 hours) was reflected mainly by reduced hospitalization time and costs.Trial registration: ClinicalTrials.gov: NCT03754491.