Association of Timing of Biliary Drainage with Clinical Outcomes in Severe Acute Cholangitis: A Retrospective Cohort Study

Abstract

Purpose

The guidelines recommend urgent biliary drainage (BD) for severe acute cholangitis, without a clear definition of “urgent”. To explore the optimal time, we identified the impact of timing of BD on clinical outcomes in severe acute cholangitis.

Patients and Methods

A retrospective study of patients with severe acute cholangitis was conducted based on the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) database. Multivariable regressions were used to identified the effect of timing of BD on in-hospital mortality, 30-day mortality, and the length of stay (LOS) in hospital and the intensive care unit (ICU) with adjustment for confounding factors.

Results

A total of 106 severe acute cholangitis patients underwent BD with a median time of 14.14 hours (IQR: 7.60–32.59). Among them, 67.9% were performed within 24 hours and 80.2% within 48 hours. Median length of stay was 2.65 days (IQR: 1.70–5.12) in the ICU and 7.54 days (IQR: 4.49–17.17) in hospital. The in-hospital and 30-day mortality rates were 13.2% and 14.2%, respectively. On multivariate analysis, every 1-day delay of BD increased 1.49 days of stay in hospital (P<0.0001). Delayed BD (>48 hours) was linked with 5.56 days longer ICU LOS (P = 0.0096), while urgent BD (<24 hours) did not significantly shorten the ICU stay (P = 0.0997). No significant increase was observed on in-hospital mortality (OR = 1.03; 95% CI 0.93–1.13) nor 30-day mortality (OR=1.01; 95% CI 0.87–1.14) with BD delay in this population.

Conclusion

In severe acute cholangitis patients, delay in BD increased in-hospital LOS. BD after 48 hours was associated with longer ICU LOS. Yet, BD within 24 hours did not significantly reduce the mortality nor shortened the ICU LOS.

Keywords:

• acute cholangitis
• biliary drainage
• endoscopic retrograde cholangiopancreatography
• ERCP
• length of stay LOS
• mortality

Abbreviations

BD, biliary drainage; MIMIC-III, Multiparameter Intelligent Monitoring in Intensive Care III; LOS, length of stay; ICU, intensive care unit; AC, acute cholangitis; TG18, Tokyo Guidelines 2018; BUN, blood urea nitrogen; WBC, white blood cell; INR, international normalized ratio; AST, aspartate aminotransferase; ALT, alanine aminotransferase; ALP, alkaline phosphatase; SOFA, Sequential Organ Failure Assessment; ECI, (vanWalRaven) Elixhauser comorbidity index; ERCP, endoscopic retrograde cholangiopancreatography; PBD, percutaneous biliary drainage.

Data Sharing Statement

The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics Statement

The studies involving human participants were reviewed and approved by The Massachusetts Institute of Technology and Beth Israel Deaconess Medical Center. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.

Acknowledgments

I would extend my sincere gratitude to professor Jiyong Jing for his constant guidance, valuable suggestions and inspiring advice of the thesis. I am also deeply indebted to all group members of our research team for their patience and serious practical discussion for every reading through of the draft. Last but not least, special thanks should go to my beloved husband for his continuous support and encouragement.

Disclosure

The authors declare that they have no conflicts of interest.

Additional information

Funding

This study was supported by the Medical Health Science and Technology Project of Zhejiang Provincial Health Commission. (No. 2021440354).