Published online Aug 7, 2022. doi: 10.3748/wjg.v28.i29.3934
Peer-review started: March 17, 2022
First decision: April 11, 2022
Revised: April 25, 2022
Accepted: July 5, 2022
Article in press: July 5, 2022
Published online: August 7, 2022
Processing time: 138 Days and 21.7 Hours
Acute cholangitis (AC) is a life-threatening condition that occurs in the presence of biliary obstruction. Biliary decompression is well known to greatly decrease the risks of mortality in AC. Although early biliary drainage is recommended by the treatment guidelines for AC, the exact timeframe is yet to be established.
We have observed that the clinical outcomes of severe AC patients vary dramatically. So, we first attempted to study whether AC patients with different organ dysfunction should undergo biliary drainage at distinct times and try to screen out patients that could benefit the most from earlier drainage.
To investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction.
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 for four years. 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 critical predictors [age, white blood cell (WBC) count, total bilirubin, albumin, lactate, malignant obstruction, and Charlton comorbidity index (CCI)].
Biliary drainage within 24 h in Grade III AC patients had the greatest benefit, which could significantly reduce the all-cause IHM, 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. Furthermore, AC patients complicated with neurological dysfunction or with serum lactate > 2 mmol/L should be drained as early as possible (< 12 h) for it could significantly decrease the IHM. In the subgroup of AC patients with renal dysfunction, abnormal WBC count, hyperbilirubinemia, or hypoalbuminemia, drainage within 24 h reduced the IHM, while in the subgroup of AC patients with hepatic dysfunction, malignant obstruction, or a CCI > 3, biliary drainage should be performed within 48 h.
Biliary drainage within 12 h is beneficial for AC patients with neurological or cardiovascular dysfunction, while complete biliary decompression within 24 h of admission is recommended for treating patients with Grade III AC.
A further multicenter prospective cohort study will be conducted to verify the result and investigate whether the optimal timing of drainage based on different organ dysfunctions can increase the 30-d mortality rates and decrease the readmission rate.