Emergency surgery for severe acute cholangitis. The high-risk patients.

Emergency surgery for patients with severe acute cholangitis carries formidable postoperative morbidity and mortality rates. A retrospective study was conducted on 86 consecutive patients who had exploration for the calculous obstructions to identify the high-risk population to guide better management. Septicemic shock was present in 55 patients before surgery. All patients had ductal exploration under general anesthesia. Additional procedures included cholecystectomy (n = 55), cholecystostomy (n = 5), and transhepatic intubation (n = 2). Complications and deaths occurred in 43 (50%) and 17 (20%) patients, respectively. Multivariate analysis on the 25 clinical (n = 14) and biochemical (n = 11) parameters evaluated yield the following five predictive factors (relative risk): the presence of concomitant medical problems (4.5); pH less than 7.4 (3.5); total bilirubin more than 90 mumol/l (3.1); platelet less than 150 x 10(9)/l (2.9), and serum albumin less than 30 g/L (2.9). In the presence of three or more albumin less than 30 g/L (2.9). In the presence of three or more risk factors, postoperative morbidity and mortality rates were 91% and 55%, respectively, which were significantly higher than those with two or less risk factors (34% and 6%, respectively). As thrombocytopenia developed even with transient hypotension, timely ductal decompression would improve outcome of these patients after surgery. For the high-risk population, application of nonoperative biliary drainage might be considered.