Comment on Article “Effect of Urgent ERCP on Clinical Outcomes in Acute Cholangitis With Concurrent Acute Gallstone Pancreatitis: A Propensity Score Matching Analysis”

To the Editor,

The study by Comoglu et al. has been found to be quite fascinating. In a way, the study was doing the same thing but in a different manner because of the good choice of a clinical situation that the authors highlighted and the effective implementation of propensity score matching to enhance group similarity [1]. The authors did a commendable job by bringing up a complex clinical dilemma and then applying propensity score matching to improve group similarity and strengthen their analysis. However, several methodological issues need attention when interpreting the findings.

First, important baseline metabolic factors, such as body mass index (BMI), were not included in the matching variables. Obesity is a known risk factor for gallstone disease and can affect the severity of pancreatitis, inflammation, and clinical course. A mismatch in these metabolic traits could confound outcome comparisons [2].

Second, the details on peri‐procedural medical management were not clear. Prompt and appropriate antibiotic therapy is essential for managing acute cholangitis and can greatly affect clinical stabilization, inflammatory markers, and the urgency of biliary drainage. Additionally, if corticosteroids were used for other reasons, they might reduce inflammation and mask disease severity. These unmeasured factors introduce potential confusion that propensity score matching cannot resolve [3].

Third, propensity score matching reduced the effective sample size even though it enhanced baseline balance. The matched analysis included just 62 patients, and even fewer had urgent ERCP. This decline may reduce statistical power and increase the likelihood of a type II error, which could conceal significant group differences [4].

Finally, the severity of cholangitis was not explicitly accounted for in the analysis. Emergency ERCP is required for those with severe (Grade III) cholangitis, and this is supported by the Tokyo Guidelines, which emphasize the importance of treating according to severity. Without stratification by severity, the conclusions risk oversimplification [5].

In summary, while the study provides valuable insights, these methodological limitations suggest caution in interpreting the findings. Larger, multicenter studies with comprehensive covariate adjustment and stratified analyzes are needed to clarify the role of urgent ERCP in patients with concurrent acute cholangitis and gallstone.

Conflicts of Interest

The author declares no conflicts of interest.

Data Availability Statement

The author has nothing to report.