Timing of endoscopic retrograde cholangiopancreatography for management of bile leaks after cholecystectomy: A systematic review

Background: The optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) for managing bile leaks after cholecystectomy remains unclear. This systematic review evaluates how ERCP timing affects clinical outcomes in adults with post-cholecystectomy bile leaks. Methods: We included randomized controlled trials and cohort or case-control studies of adults (≥18 years) undergoing ERCP for bile leaks after cholecystectomy, comparing outcomes by timing of intervention. Exclusion criteria were case series (<10 patients), non-English articles, and studies not stratifying outcomes by ERCP timing. PubMed, Embase, Scopus, Web of Science, and Cochrane Library were searched from inception to May 2025. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Newcastle-Ottawa Scale. Results were synthesized narratively due to heterogeneity in timing definitions and outcomes. Results: Nine retrospective cohort studies (n = 2306) were included. Definitions of “early” ERCP ranged from ≤ 1 to 3 days to ≤ 3 weeks post-diagnosis. Overall leak-closure rates were high (81%–100%). Early ERCP (≤3 weeks) was associated with higher leak closure (92% vs 75%) and lower biliary-stricture rates (18% vs 46%). Complication rates ranged from 6.9% to 24%; 1 large study reported fewer adverse events with delayed ERCP (>3 days: 16.7%) compared to emergent/urgent (<3 days: 30%). Mortality was low (0%–7.7%), with higher rates in emergent cases. 4 studies followed patients for 6 to 24 months post-ERCP. All studies were retrospective, and only 2 had low risk of bias. Retrospective design, inconsistent timing definitions, and limited reporting of secondary outcomes restrict generalizability. Conclusion: Early ERCP (within 72 hours to 3 weeks) generally improves leak closure and reduces strictures, but emergent procedures in unstable patients may increase risk. Individualized timing based on clinical context is recommended.