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

Table 1 Characteristics data for all patients

Characteristics, n (%)	Total (n = 1305)	Grade I (n = 433)	Grade II (n = 405)	Grade III (n = 467)	P value
Age (yr)-median (IQR)	74 (63-82)	66 (59-72.5)	79 (69-84)	77 (66-83)	< 0.001
Male, n (%)	783 (60)	276 (63.7)	240 (59.3)	267 (57.2)	0.123
CCI- median (IQR)	2 (1-4)	2 (1-3)	2 (1-4)	3 (1-5)	< 0.001
Etiology, n (%)					< 0.001
Choledocholithiasis	906 (69.4)	315 (72.7)	252 (62.2)	339 (72.6)
Malignant obstruction	242 (18.5)	73 (16.9)	97 (24.0)	72 (15.4)
Benign stenosis	94 (7.2)	27 (6.2)	42 (10.4)	25 (5.4)
Others	63 (4.8)	18 (4.2)	14 (3.5)	31 (6.6)
Biliary drainage, n (%)	915 (70.1)	302 (69.7)	306 (75.6)	307 (65.7)	0.006
LOS (d)-median (IQR)	11 (8-14)	11 (8-14)	11 (7.5-14)	12 (7-15)	0.110
Hospitalization cost (CNY)-median (IQR)	38784.37 (22744.31-53278.63)	36536.36 (20851.37-47274.77)	38308.33 (23452.14-52847.29)	41832.19 (23355.98-58145.52)	< 0.001
IHM, n (%)	41 (3.1)	1 (0.2)	7 (1.7)	33 (7.1)	< 0.001
Survival time of dead (d)-median (IQR)	8 (3-23.5)	9	23 (13-46)	6 (3-17)	0.024
Organ dysfunction
Neurological dysfunction	126	0	0	126	< 0.001
Respiratory dysfunction	227	0	0	227	< 0.001
Renal dysfunction	64	0	0	64	< 0.001
Cardiovascular dysfunction	39	0	0	39	< 0.001
Hematological dysfunction	149	0	0	149	< 0.001
Hepatic dysfunction	83	0	0	83	< 0.001
Temperature (℃)-median (IQR)	37.0 (36.6-38)	36.8 (36.6-37.8)	37 (36.6-38.25)	37.2 (36.6-38.3)	0.001
Laboratory values
WBC (/mm3)-median (IQR)	10560 (7705-14305)	9120 (7160-11165)	12700 (8897-18441)	11140 (7870-15810)	< 0.001
T-Bil (mg/dL)-median (IQR)	99.81 (62.43-155.76)	69.28 (49.625-120.975)	121.74 (88.97-184.41)	1041.2 (67.74-156.31)	< 0.001
Albumin (g/L)-median (IQR)	35.4 (31.2-39.2)	37.5 (34.2-40.4)	34.9 (30.8-38.1)	33.6 (29.2-37.8)	< 0.001
Lactate (mmol/L)-median (IQR)	2.15 (1.6-3.4)	1.8 (1.4-2.7)	2.1 (1.5-2.8)	2.4 (1.7-4.1)	< 0.001

IQR: Interquartile range; CCI: Charlton Comorbidity Index; LOS: Length of stay; CNY: Chinese Yuan; IHM: In-hospital mortality; WBC: White blood cell count; T-Bil: Total bilirubin.

Table 2 Characteristics data for patients with drainage

Characteristics, n (%)	Total (n = 915)	Grade I (n = 302)	Grade II (n = 306)	Grade III (n = 307)	P value
Drainage method, n (%)					0.001
ERCP	830 (90.7)	289 (95.7)	269 (87.9)	272 (88.6)
PTBD	85 (9.3)	13 (4.3)	37 (12.1)	35 (11.4)
Timing of drainage (hours)- median (IQR), n (%)	24.0 (60.0)	26.4 (62.4)	26.4 (62.4)	21.6 (45.6)	0.001
Biliary drainage within, n (%)					0.001
12 h	212 (23.2)	54 (17.9)	69 (22.5)	89 (29.0)
12-24 h	233 (25.5)	74 (24.5)	70 (22.9)	89 (29.0)
24-48 h	172 (18.8)	71 (23.5)	54 (17.6)	47 (15.3)
> 48 h	298 (32.6)	103 (34.1)	113 (36.9)	82 (26.7)
Second intervention, n (%)	478 (52.2)	159 (52.6)	154 (50.3)	165 (53.7)	0.688
Drainage outside working hours, n (%)	207 (22.6)	49 (16.2)	60 (19.6)	98 (31.9)	< 0.001
Adverse events, n (%)
Pancreatitis	75 (8.2)	23 (7.6)	23 (7.5)	29 (9.4)	0.643
Cholangitis	8 (0.9)	2 (0.7)	2 (0.7)	4 (1.3)	0.742
Perforation	7 (0.8)	1 (0.3)	2 (0.7)	0 (0)	0.440
Bile leak	4 (0.4)	2 (0.7)	1 (0.3)	1 (0.3)	0.701
Myocardial infarction	5 (0.5)	0 (0)	3 (1.0)	2 (0.7)	0.339

IQR: Interquartile range; ERCP: Endoscopic retrograde cholangiopancreatography; PTBD: Percutaneous transhepatic biliary drainage.

Table 3 Association of the clinical outcomes in relation to the timing of biliary drainage and severity grading by Tokyo guidelines 2018

Severity of AC	Characteristic-median (IQR)	Drainage	Absence of drainage	P value	Drainage < 12 h	Drainage > 12 h or absence	P value	Drainage < 24 h	Drainage > 24 h or absence	P value		Drainage < 48 h	Drainage > 48 h or absence	P value
Grade I	IHM	0/302	1/131	0.303	0/54	1/379	1.000	0/128	1/305		1.000	0/199	1/234	1.000
	LOS (d)	11 (9-15)	7 (4-10)	< 0.001	11 (8-13.25)	10 (8-14)	0.778	11 (8-14)	10 (7-14)		0.004	11 (8-14)	10 (6-14)	0.002
	Survivors’ LOS (d) (n = 387)	12 (9-15)	8 (5-11)	< 0.001	11 (8-13.25)	11 (8-14)	0.794	11 (9-14)	11 (8-14)		0.065	11 (9-14)	10 (8-14)	0.101
	Hospitalization cost (CNY)	42845.67 (33734.18-52209.23)	15763.10 (7737.32-23680.31)	< 0.001	43328.59 (32863.61-49384.19)	35317.71 (18848.59-46850.08	0.001	44154.19 (35638.76-52219.56)	31292.68 (16269.75-44599.67)		< 0.001	42908.34 (33358.44-50564.68)	25519.43 (12347.06-42424.96)	< 0.001
	Survivors’ hospitalization cost (CNY) (n = 387)	42957.18 (33973.58-52224.73)	16596.85 (9096.73-24755.65	< 0.001	43462.72 (36174.00-49384.19)	36604.86 (21962.98-47554.27)	0.003	44443.3 (35988.02-52237.14)	33492.6 (46019.17-18880.26)		< 0.001	43264.07 (34606.54-51093.62)	29762.32 (16376.75-44463.21)	< 0.001
Grade II	IHM	2/306	5/99	0.011	0/69	7/336	0.608	0/139	7/266		0.101	1/193	6/212	0.125
	LOS (d)	11 (9-15)	7 (4-12)	< 0.001	11 (8-14)	11 (7-14)	0.684	11 (9-14)	10 (7-14)		0.122	11 (8-14)	10 (7-14.8)	0.190
	Survivors’ LOS (d) (n = 349)	12 (9-15)	7.5 (4.75-11.25)	< 0.001	11.5 (9-14)	11 (8-14)	0.367	12 (10-14)	11 (7-14)		0.024	12 (9-14)	11 (7-14)	0.050
	Hospitalization cost (CNY)	44033.13 (31071.05-56134.72)	17626.20 (10037.69-25587.43)	< 0.001	45832.44 (36061.53-56949.37)	36132.93 (21795.89-51453.62)	< 0.001	46789.09 (35989.59-57723.15)	31505.72 (19948.31-47463.61)		< 0.001	45489.74 (33858.99-57600.43)	29275.30 (16928.45-46255.47)	< 0.001
	Survivors’ hospitalization cost (CNY) (n = 349)	45004.20 (32631.09-56660.62)	16342.15 (10300.68-25017.80)	< 0.001	47938.00 (37937.29-58046.02)	36629.15 (22828.93-51509.37)	< 0.001	48254.61 (37937.29-58929.51)	31589.96 (20386.80-47062.76)		< 0.001	46564.37 (36191.07-57998.63)	29338.38 (17687.02-45685.12)	< 0.001
Grade III	IHM	11/307	22/160	< 0.001	3/89	30/378	0.168	7/178	26/289		0.041	9/225	24/242	0.018
	LOS (d)	13 (9-17)	8 (3-12)	< 0.001	13 (11-19)	11 (6-15)	< 0.001	13 (10-17)	10 (6-14)		< 0.001	13 (9-17)	9.5 (5-14)	< 0.001
	Survivors’ LOS (d) (n = 351)	13 (11-18)	9.5 (7-13.25)	<0.001	13 (12-19)	12 (9-16)	0.001	13 (11-17.75)	12 (9-15)		< 0.001	13 (11-17.75)	11 (8-15)	< 0.001
	Hospitalization cost	51583.64 (38985.47-64886.01)	20183.58 (11317.37-29525.99)	< 0.001	56599.94 (43260.73-70300.00)	38527.58 (21034.79-55279.53)	< 0.001	55121.49 (40428.29-67707.01)	31832.99 (17933.81-50037.89)		< 0.001	54295.52 (39252.57-65638.57)	28165.23 (15708.29-45478.26)	< 0.001
	Survivors’ hospitalization cost (CNY) (n = 351)	53507.33 (41027.94-65312.29)	22909.77 (15594.93-31845.39)	< 0.001	57976.4 (50131.44-70333.71)	43241.54 (28347.56-57860.29)	< 0.001	55873.84 (46654.40-69946.73)	38973.06 (24292.41-53090.85)		< 0.001	55782.38 (43994.26-66493.67)	34748.29 (21379.37-50147.24)	< 0.001

AC: Acute cholangitis; IQR: Interquartile range; IHM: In-hospital mortality; LOS: Length of stay; CNY: Chinese Yuan.

Table 4 Univariate and multivariate analysis of predictors of mortality, and relationship of mortality with the timing of drainage for each predictor

Predictors (n = 1305)	Univariate analysis		Multivariate analysis		Mortality to the timing of drainage
	OR (95%CI)	P value	OR (95%CI)	P value	< 12 h	> 12 h or absence	P value	< 24 h	> 24 h or absence	P value	< 48 h	> 48 h or absence	P value
Neurological dysfunction	8.377 (4.384-16.007)	< 0.001	5.32 (2.373-11.931)	< 0.001	0/22	18/104	0.041	3/42	15/84	0.175	5/51	13/75	0.304
Respiratory dysfunction	2.886 (1.491-5.497)	0.003	2.541 (1.189-5.43)	0.016	1/44	14/183	0.314	4/91	11/136	0.414	6/117	9/110	0.428
Renal dysfunction	11.043 (5.402-22.573)	< 0.001	6.356 (2.623-15.397)	< 0.001	1/15	12/49	0.269	1/28	12/36	0.004	1/31	12/33	0.001
Cardiovascular dysfunction	11.569 (5.078-26.357)	< 0.001	4.021 (1.361-11.88)	0.012	0/7	9/32	0.169	2/16	7/23	0.262	2/18	7/21	0.139
Hematological dysfunction	2.611 (1.253-5.441)	0.02	N/A		2/37	8/104	1	3/61	7/88	0.527	3/74	7/75	0.327
Hepatic dysfunction	5.263 (2.484-11.152)	< 0.001	N/A		0/15	10/68	0.196	1/30	9/53	0.086	1/39	9/44	0.016
Age (≥ 75 yr)	1.432 (0.765-2.680)	0.261	N/A		2/88	21/531	0.759	4/196	19/423	0.172	7/267	16/352	0.284
Temperature (≥ 39 ℃)	0.390 (0.093-1.631)	0.197	N/A		0/43	2/106	1	1/75	1/74	1	1/85	1/64	1
WBC (> 12000/mm3, < 4000/mm3)	1.962 (1.043-3.688)	0.036	N/A		1/107	23/445	0.063	4/207	20/342	0.031	6/278	18/275	0.012
T-Bil (≥ 5 mg/dL)	1.711 (0.865-3.385)	0.123	N/A		3/143	26/626	0.333	5/292	24/477	0.019	8/407	21/362	0.007
Albumin (< STD*0.7)	10.715 (5.147-22.303)	< 0.001	5.655 (2.398-13.335)	< 0.001	0/8	12/51	0.188	0/15	12/44	0.026	1/24	11/35	0.018
Lactate (≥ 2 mmol/L)	1.450 (0.766-2.747)	0.254	N/A		0/105	16/298	0.016	2/186	14/217	0.008	4/227	12/176	0.018
Malignant obstruction	5.495 (2.924-10.325)	< 0.001	7.522 (3.504-16.149)	< 0.001	1/26	21/216	0.483	2/59	20/183	0.116	3/101	19/141	0.006
CCI (> 3)	4.080 (2.153-7.7340)	< 0.001	N/A		2/57	23/318	0.397	4/127	21/248	0.052	6/177	19/198	0.021

WBC: White blood cell count; T-Bil: Total bilirubin; STD: Lower limit of normal value; CCI: Charlton Comorbidity Index; OR: Odds ratio; CI: Confidence interval; N/A: Not applicable.