**5.3 Emergency ERCP in acute biliary patients with cholangitis or persistent cholestasis**

Certainly, biliopancreatic obstruction should be resolved immediately in patients with cholangitis or persistent cholestasis. The most effective method of this is undoubtedly the removal of stone or sludge that caused the obstruction by performing ERCP and ES [59]. The first study in this area was performed by Neoptolemos et al. and it demonstrated that E-ERCP and ES was the most useful method in acute biliary pancreatitis with cholangitis and cholangitis without pancreatitis [60]. Van Santvoort et al. [56] performed a study about the efficiency of ERCP in acute pancreatitis patient with or without cholestasis and findings as follows: 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).

Tse et al. [1] performed a meta-analysis which included 5 randomized controlled trials with 644 participants with cholangitis and reported mortality rates, comprising a total of 200 participants in the early routine ERCP strategy and 215 in the early conservative management strategy. Unweighted pooled mortality rates for participants were 1.0% for the early routine ERCP strategy and 6.9% in the early conservative management strategy. In the trials that included participants with cholangitis, the early routine ERCP strategy significantly reduced mortality compared to the early conservative management strategy (RR 0.20, 95% CI 0.06 to 0.68; P = 0.010).

### **5.4 U-ERCP or E-ERCP in acute biliary pancreatitis with cholangitis or persistent cholestasis?**

There is no consensus on timing of ERCP in the literature. In most publications, the ERCP preformed within 72 hours after the symptom onset is called emergency ERCP, but the emergency ERCP timing could be defined as within 48 hours in some other publications. Additionally, the ERCP which is performed within 72 hours named as U-ERCP in some publications. The only trial that compares the timing of ERCP (within 24 hours versus within 24–72 hours) in acute biliary pancreatitis is performed by Lee et al. [2]. Patients with acute biliary pancreatitis but without cholangitis was excluded retrospectively in this study, and they compared U-ERCP and E-ERCP in acute biliary pancreatitis. No significant difference was found in the total length of hospitalization or procedural-related complications, in patients with biliary pancreatitis and a bile duct obstruction without cholangitis, according to the timing of ERCP (< 24 h vs. 24–72 h). Although the definition is not U-ERCP, in one of Fan et al.'s studies [45] the ERCP which is performed within 24 hours is defined as E-ERCP and there was no significant difference between the ERCP group and the conservative treatment group in terms of local and systemic complications of pancreatitis whereas hospitalization time was a little shorter in the E-ERCP group. With these results, it was demonstrated that performing U-ERCP within 24 hours did not change the pancreatitis course, supporting the study of Lee et al. [2]. When considering the course of acute biliary pancreatitis, naming the ERCP performed within 24 hours as "URGENT" and the ERCP within 24–72 hours as "EARLY" by

*Endoscopic Retrograde Cholangiopancreatography in Acute Biliary Pancreatitis DOI: http://dx.doi.org/10.5772/intechopen.96545*

Lee et al. is the most appropriate definition [2]. When the literature and international guidelines are reviewed, ERCP is recommended to the acute biliary pancreatitis within 24 hours if the cholangitis is present and within 72 hours if the biliary obstruction is present, instead of this definition.

Although the naming does not resemble, recommendation of ESGE in this respect is as follows: "*ESGE recommends urgent (≤ 24 hours) ERCP and biliary drainage in patients with acute biliary pancreatitis combined with cholangitis. Strong recommendation, high quality of evidence. ERCP should be performed within 72 hours in patients with ongoing biliary obstruction. Weak recommendation, moderate quality evidence. It should not be performed in patients with acute biliary pancreatitis and neither cholangitis or ongoing bile duct obstruction. Weak recommendation, moderate quality evidence"* [33]. According to our clinical experience; although there is a need for randomized prospective trials on this subject, the absence of difference between performing the ERCP within 24 hours or within 24–72 hours leads to escape gastroenterologist or endoscopists from the regression of performing ERCP within 24 hours in a rush and off-duty, which is believed to be the reason of high rates of complications such as aggrevation of pancreatitis, possible bilioportal reflux in patients with cholangitis during ERCP, bacteriemia or systemic complications (i.e., organ failure) by depriving the patient's opportunity to receive extensive fluid therapy and broad-spectrum antibiotics within the most important 24 hours for the complications.

### **5.5 Elective ERCP to prevent pancreatitis recurrence**

Early laparoscopic or open cholecystectomy as soon as AP recovers completely is the only proven treatment modality to prevent recurrence of ABP. Index cholecystectomy is defined as cholecystectomy applied during the same hospitalization period of ABP and interval cholcystectonmy is cholecystectomy performed 6 weeks after patient's recovery from AP [61].

Sinha and colleagues [61] reported that index cholecystectomy in a case suitable for surgery has similar results with elective cholecystectomy in a patient without AP and they also reported significant difficulty to do dissection during interval cholecystectomy. In 2019, Fu-ping Zhung and colleagues [62] published a meta-analysis of 19 studies enrolling 2639 who underwent index or interval cholecystectomy. They noted that there was no differences with ragard to intraoperative and postoperative complications, duration of operation and the rates of open cholecystectomy. However, index cholecystectomy cases had lesser hospitalization period, lower biliary complications due to surgery and lesser rates of ERCP.

In cases with severe pancreatitis, most of the time it is impracticable to perform index cholcystectomy. Therefore, interval cholcystectomy is obligatory in these cases. Infortunately, these patients reamit with AP attacks and ot biliary complications during this 6 weeks period. Thus some authors offer ERCP and endoscopic sphincteratomy to prevent AP recurrences and or biliary complications to ocur during this time period [63, 64].

In a retrospective study comparing index cholecystectomy and post ERCP/ES plus interval cholecystectomy, both group of patients did not reveal mortality. Only 2 patients (%5) developed AP recurrences and acute cholecystitis and hospitalized. The authors suggested that ERCP/ES is highly successful to prevent recurrences in patients with severe ABP who can not undergo index cholecystectomy. ES and interval cholecystectomy in severe ABP is considered a reasonable alternative to an index cholecystectomy in patients with severe ABP [64].

Another report by Dedemadi and his colleagues [65] published in 2016 noted that ERCP and ES in cases with AP who can not undergo cholecystectomy developed biliary events 0%–28.6%, recurrent pancreatitis 0%–8.2%, mortality 3%–4.7%. Other cases under conservative treatment had biliary events 9.4%–14.3%, recurrent pancreatitis 12%–23%, mortality 3.9%. Statistical evaluation showed that ERCP and ES group had significanly less biliary complications and less recurrent pancreatitis with no difference in mortality compared to conservative treatment group. The conservative group consisted of patients who were elderly persons with multiple comorbidites and complications of AP. These conditions may be responsible for similar mortality rates in both groups. Nevertheless, because of high rates of biliary events and pancreatitis in the ERPC/ES group, this approach should be reserved only for patients not suitaable for cholecystectomy.

The advice of IAP/APA about timing od cholecystectomy in a case with ABP is as follows [31]:

	- 1.*Cholecystectomy during index admission for mild biliary pancreatitis appears safe and is recommended. Interval cholecystectomy after mild biliary pancreatitis isassociated with a substantial risk of readmission for recurrent biliary events, especially recurrent biliary pancreatitis.(GRADE 1C, strong agreement).*
	- 2.*Cholecystectomy should be delayed in patients with peripancreatic collections until the collections either resolve or if they persist beyond 6 weeks, at which time cholecystectomy can be performed safely.(GRADE 2C, strong agreement).*
	- 3.*In patients with biliary pancreatitis who have undergone sphincterotomy and are fit for surgery, cholecystectomy is advised, because ERCP and sphincterotomy prevent recurrence of biliary pancreatitis but not gallstone related gallbladder disease, i.e. biliary colic and cholecystitis.(GRADE 2B, strong agreement)".*

Moreover, If we consider surgery for pancreatic cystic collections, pseudocysyt and or walled off necrosis, it should be performed at the same time with cholecystectomy [65].
