Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Endoscopic biliary drainage was safer and more effective than surgery for severe acute cholangitis

ACP J Club. 1992 Nov-Dec;117:70. doi:10.7326/ACPJC-1992-117-3-070


Source Citation

Lai EC, Mok FP, Tan ES, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med. 1992 Jun 11;326:1582-6.


Abstract

Objective

To compare endoscopic biliary drainage with emergency exploratory surgery as initial therapy for patients with severe acute cholangitis due to choledocholithiasis.

Design

Randomized controlled trial with follow-up to hospital discharge.

Setting

A surgery ward of a university hospital in Hong Kong.

Patients

82 of 96 consecutive adults with severe acute cholangitis were studied. Patients had fever (≥ 37.5 °C) and a history of chills with abdominal pain, jaundice, or both, along with either septicemic shock or evidence of progressive biliary sepsis despite appropriate antibiotic treatment. 14 patients were excluded because they were pregnant, moribund, had intrahepatic stones or gastroduodenal anatomy not amenable to endoscopic drainage, or declined to participate. Patient mean age was 69 years (range 35 to 97 y), and 42 were women. Follow-up was 100%.

Intervention

Before randomization all patients had emergency endoscopic retrograde cholangiopancreatography to delineate and cannulate the biliary tract. No attempt was made to extract any stones during endoscopy. After randomization the procedure was continued for 41 patients and drainage was done with a 7-French nasobiliary catheter placed proximal to the obstruction. For the remaining 41 patients, endoscopy was terminated, and exploratory surgery of the common bile duct was done. After the cholangitis subsided, all patients had surgery or endoscopic papillotomy, as needed.

Main outcome measures

In-hospital mortality and complications.

Main results

All patients had common bile duct calculi. 13 patients in the surgery group died compared with 4 in the endoscopy group (32% vs 10%, P < 0.05). {This absolute risk reduction (ARR) of 22% means that 5 patients would need to be treated (NNT) with endoscopy to prevent 1 additional death, 95% CI 3 to 21; the relative risk reduction (RRR) was 69%, CI 19% to 89%.}* Patients in the surgery group had more complications (66% vs 34%, P < 0.05) {ARR 32; NNT 4, CI 2 to 10; RRR 48%, CI 18% to 69%}*, more ventilatory support (63% vs 29%, P < 0.05) {ARR 34%, NNT 3, CI 2 to 8; RRR 54%, CI 24% to 73%}*, and a higher frequency of residual stones (29% vs 7%,P < 0.05) {ARR 22%, NNT 5, CI 3 to 18; RRR 75%, CI 25% to 92%}* than those in the endoscopy group. The groups did not differ for time to normalization of temperature or stabilization of blood pressure. The factors that independently predicted hospital mortality were mode of drainage, concomitant medical problems, low platelet count, low serum albumin level, and high serum urea nitrogen concentration (P < 0.03 for all factors).

Conclusion

Compared with surgery, endoscopic drainage was a safer and more effective initial therapy for severe acute cholangitis caused by choledocholithiasis and reduced the mortality associated with this condition.

Source of funding: Not stated.

For article reprint: Dr. E.C. Lai, Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong.

*Numbers calculated from data in article.


Commentary

The study by Lai and colleagues showed that endoscopic nasobiliary drainage for severe cholangitis caused by common bile duct stones was safer and more effective than emergency surgery. Fewer patients died in the endoscopy group compared with the surgery group, and the incidence of serious complications was decreased. 25 of 41 patients in the endoscopy group had subsequent elective endoscopic removal of stones as definitive treatment, whereas 16 required surgery. Fewer patients in the endoscopy group had residual stones. Although the mortality rate in the surgery group seems high, it is within the range of published mortality data (20% to 60%) for similar patients who have emergency surgery (1).

How should these results be interpreted? The results of this study appear definitive and confirm the experience of most physicians: Endoscopic drainage of the biliary tree is safer, more effective, and also less expensive than emergency surgery. In fact, the advantages of endoscopic drainage over emergency surgery seem so apparent that some clinicians have questioned the need for a randomized trial (2). The take-home message is clear. In medical centers where the services of a skilled endoscopist are available, endoscopic drainage for severe acute cholangitis is the preferred treatment.

Marshall M. Kaplan, MD
Tufts-New England Medical CenterBoston, Massachusetts, USA


References

1. Gigot JF, Leese T, Derome T, et al. Acute cholangitis: multivariate analysis of risk factors. Ann Surg. 1989;209:435-8.

2. Cotton PB. Endoscopic drainage for suppurative cholangitis. Lancet. 1989;2:213.