Optimal timing of biliary drainage based on the severity of acute cholangitis: A single-center retrospective cohort study

Abstract

BACKGROUND Biliary decompression is well known to greatly decrease the risks of mortality in acute cholangitis (AC). Although early biliary drainage is recommended by the treatment guidelines for AC, the best time for performing this procedure is yet to be established. Furthermore, since the clinical outcomes of patients with severe AC vary dramatically, screening for patients that could benefit the most from early drainage would be more beneficial than the drainage performed based on the severity grade criteria. AIM To investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction. METHODS In this retrospective monocenter cohort analysis, we reviewed 1305 patients who were diagnosed with AC according to the Tokyo guidelines 2018 at a Chinese tertiary hospital between July 2016 and December 2020. Demographic characteristics including age and sex, clinical and laboratory characteristics, and imaging findings of each patient were obtained from electronic medical records. We investigated the all-cause in-hospital mortality (IHM), hospital length of stay (LOS), and hospitalization costs associated with the timing of biliary drainage according to the severity grading and different dysfunctioning organs and predictors [age, white blood cell (WBC) count, total bilirubin, albumin, lactate, malignant obstruction, and Charlton comorbidity index (CCI)]. RESULTS Biliary drainage within 24 or 48 h in Grade III AC patients could dramatically decrease IHM (3.9% vs 9.0%, P = 0.041; 4% vs 9.9%, P = 0.018, respectively), while increasing LOS and hospitalization costs. Multivariate logistic analysis revealed that neurological, respiratory, renal, and cardiovascular dysfunctions, hypoalbuminemia, and malignant obstruction were significantly associated with IHM (odds ratio = 5.32, 2.541, 6.356, 4.021, 5.655, and 7.522; P < 0.001, P = 0.016, P < 0.001, P = 0.012, P < 0.001, and P < 0.001; respectively). Biliary decompression performed within 12 h of admission significantly decreased the IHM in AC patients with neurological dysfunction (0% vs 17.3%, P = 0.041) or with serum lactate > 2 mmol/L (0% vs 5.4%, P = 0.016). In the subgroup of AC patients with renal dysfunction, abnormal WBC count, hyperbilirubinemia, or hypoalbuminemia, early drainage (< 24 h) reduced the IHM (3.6% vs 33.3%, P = 0.004; 1.9% vs 5.8%, P = 0.031; 1.7% vs 5.0%, P = 0.019; 0% ...

Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the clinical presentation and outcomes?

“…In the literature, few studies reported only MBO-associated AC[ 17 ], some gave an account of only CBDS-associated AC[ 11 , 18 ], and most reported mixed results for AC of different etiologies[ 3 , 13 - 15 ]. Although the etiology of AC varies, studies explicitly comparing the clinical presentations and outcomes of AC of distinct etiologies are rare.…”

“…However, to our knowledge, such studies are limited in the literature[ 3 ]. Most studies based their findings and conclusions on populations with heterogeneous etiologies of AC[ 13 - 15 ]. Therefore, based on the TG18/TG13 diagnostic criteria, we conducted this study to elucidate the differences between AC caused by the two main etiologies, MBO and CBDS.…”

Timing of biliary decompression for acute cholangitis

“…Second, recent clinical studies have produced controversial results in terms of early implementation of BD for patients with grade III AC. In addition to the study by Huang et al [ 3 ] discussed herein (BD at ≤ 48 but not ≤ 24 h), another retrospective study by Lu et al [ 7 ] showed that BD is recommended at 24 h of admission for patients with grade III AC and within 12 h for those with AC accompanied by neurological or cardiovascular dysfunction. However, a study by Becq et al [ 8 ] using a propensity score matching approach indicated that the use of BD within 6h or 12 h of AC onset was not associated with better clinical outcomes, but possibly reduced readmission rates.…”

Effect of Delayed Endoscopic Retrograde Cholangiopancreatography after Diagnosis of Acute Cholangitis; A Real-life Experience

“…9 On the other hand, another retrospective study showed that biliary drainage within 12 hours was beneficial for patients with neurological or cardiovascular dysfunction, and the authors recommended complete biliary decompression within 24 hours of admission for severe acute cholangitis. 10 However, ERCP, which is the method of choice for biliary drainage, requires special equipment and advanced technical skill on the part of the physician. In limited-resource situations, patients who are diagnosed with acute cholangitis need to be transferred to a center where ERCP is available; hence, the waiting time for this procedure might be different from that recommended in the treatment guidelines.…”