Risk factors for post-ERCP pancreatitis in 527 patients with choledocholithiasis: A retrospective cohort study

BACKGROUND: Choledocholithiasis, a common cause for biliary obstruction and acute cholangitis, requires prompt treatment. Endoscopic retrograde cholangiopancreatography (ERCP) remains first-line therapy but carries a risk of post-ERCP pancreatitis (PEP), the most common serious adverse event. METHODS: This retrospective, single-center cohort study was conducted at Colentina Clinical Hospital. The aim was to identify patient and procedure-related factors associated with the development of post-ERCP pancreatitis (PEP) in patients with choledocholithiasis. The study also provides data from an eastern European tertiary center, a region currently under-represented in literature. Patients undergoing ERCP were identified from the institutional database and divided into cases who developed PEP and controls without PEP. Demographic, clinical, procedural and post-procedural data was collected and subjected to comprehensive statistical analyses, including univariate and multi-variate methods, to identify independent predictors of PEP. RESULTS: Among 527 patients with choledocholithiasis, 68 (12.9%) developed post-ERCP pancreatitis (PEP). Female sex was more frequent among patients with PEP (75.0% vs. 57.7%, p = 0.007) and the median age was 68 years. Previous cholecystectomy was less common in the PEP group (17.6% vs. 36.2%, p = 0.003), while median common bile duct (CBD) diameter was greater (15.8 mm [interquartile range (IQR) 12-18] vs. 14 mm [IQR 10-16]; p = 0.014). Pre-cut sphincterotomy (22.1% vs. 7.6%, p < 0.001), main pancreatic duct (MPD) cannulation (42.6% vs. 10.9%, p < 0.001) and contrast injection into the MPD (14.7% vs. 3.5%, p < 0.001) were more frequent in patients who developed PEP. In the multi-variable analysis, female sex, larger CBD diameter, MPD cannulation and intra-ductal lithotripsy were associated with PEP, while prior cholecystectomy was associated with a lower risk. Pre-cut sphincterotomy showed a borderline association. Post-ERCP bleeding occurred in 16 patients (3.0%), while no cases of perforation or post-ERCP cholangitis were observed. Overall mortality was 2.1%, without significant difference between the PEP and non-PEP groups (5.9% vs. 1.5%, p = 0.20). CONCLUSIONS: PEP continues to be one of the most important complications of ERCP, contributing substantially to patient morbidity and potential mortality. A greater focus on procedural risk awareness and prevention strategies may help reduce its occurrence and improve the overall safety of therapeutic ERCP.