Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study

doi:10.1016/j.amjsurg.2013.08.019

The American Journal of Surgery

Volume 206, Issue 6, December 2013, Pages 935-941

https://doi.org/10.1016/j.amjsurg.2013.08.019 Get rights and content

Abstract

Background

Morbidity and mortality are very high for critically ill patients who develop acute acalculous cholecystitis (AAC). The aim of this study was to compare outcomes in extremely ill patients with AAC treated with percutaneous cholecystostomy (PC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC), which were also analyzed together in the LC-plus-OC (LO) group.

Methods

Discharge data from the University HealthSystem Consortium database were accessed using International Classification of Diseases codes. The University HealthSystem Consortium's Clinical Data Base/Resource Manager allows member hospitals to compare patient-level, risk-adjusted outcomes. Multivariate regression models for extremely ill patients undergoing PC or LO for the diagnosis of AAC were created and analyzed.

Results

A total of 1,725 extremely ill patients were diagnosed with AAC between October 2007 and June 2011. Patients undergoing PC (n = 704) compared with the LO group (n = 1,021) showed decreased morbidity (5.0% with PC vs 8.0% with LO, P < .05), fewer intensive care unit admissions (28.1% with PC vs 34.6% with LO, P < .05), decreased length of stay (7 days with PC vs 8 days with LO, P < .05), and lower costs ($40,516 with PC vs $53,011 with LO, P < .05). Although perioperative outcomes of PC compared with LC were statistically similar, PC had lower costs compared with LC ($40,516 vs 51,596, P < .005). Multivariate regression analysis showed that LC (n = 822), compared with OC (n = 199), had lower mortality (odds ratio [OR], .3; 95% confidence interval [CI], .1 to .6), lower morbidity (OR, .4; 95% CI, .2 to .7), reduced intensive care unit admission (OR, .3; 95% CI, .2 to .5), and similar 30-day readmission rates (OR, 1.0; 95% CI, .6 to 1.5). Also, decreased length of stay (7 days with LC vs 8 days with OC) and costs ($51,596 with LC vs $61,407 with OC) were observed, with a 26% conversion rate to an open procedure.

Conclusions

On the basis of this experience, extremely ill patients with AAC have superior outcomes with PC. LC should be performed in patients in whom the risk for conversion is low and in whom medical conditions allow. These results show PC to be a safe and cost-effective bridge treatment strategy with perioperative outcomes superior to those of OC.

Section snippets

Database description

The University HealthSystem Consortium (UHC) is an alliance of >100 academic medical centers and >250 of their affiliated hospitals, representing 90% of the nation's nonprofit academic medical centers. The UHC database is an administrative, clinical, and financial database that provides patient-level data for the purpose of comparative analysis between institutions. The UHC database contains discharge information on inpatient hospital stay, including patient characteristics, length of stay

Results

A total of 1,725 patients with major and extreme SOI were diagnosed with acalculous cholecystitis between October 2007 and June 2011. Of these, LC was attempted in 822 patients, OC in 199, and PC in 704.

Patients undergoing PC (n = 704) compared with LO (n = 1,021) showed decreased morbidity (5.0% with PC vs 8.0% with LO, P < .05), fewer ICU admissions (28.1% with PC vs 34.6% with LO, P < .05), decreased LOS (7 days with PC vs 8 days with LO, P < .05), and lower costs ($40,516 with PC vs $53,011

Comments

AAC in extremely ill patients poses significant challenges to their surgical management. Several procedural treatment options are available, making the need for evidence-based recommendation more critical.

In this study, we attempted to answer this question by looking at the perioperative outcomes of surgical management of AAC, available in a large retrospective administrative database, that of the UHC. As many studies have suggested before, LC is a safe and effective treatment for acute

Conclusions

On the basis of this experience, we conclude that extremely ill patients with AAC have superior outcomes with PC. For those patients in whom the risk for conversion is low and medical condition allows, LC should be performed. Our results show PC to be a safe and cost-effective bridge treatment strategy with superior perioperative outcomes compared with OC.

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Citation Excerpt :
This can be a temporary solution or a treatment option. As it has been suggested by a large retrospective study, for selected patients, PC can have a lower morbidity, fewer intensive care unit admissions, a decreased length of stay, and lower costs compared with open cholecystectomy [11] with a low overall rate of complications (around 2%) [27]. In addition, higher mortality rates could be linked to their conditions and not directly to the PC.
Acute acalculous cholecystitis (AAC) is an inflammation of the gallbladder with no evidence of gallstones. It occurs mostly in patients in intensive care units and is associated with several risk factors (fasting, parenteral nutrition, mechanical ventilation) leading to ischemia of the gallbladder wall.
This is a retrospective multiple cases study of five cases of AAC in patients hospitalized in the Medical Intensive Care Unit at Tahar Sfar Hospital in Mahdia over a 4-year period between January 2016 and December 2020.
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This study, in spite of its small sample size, gave us an idea of patients at risk of developing this disease, on the difficulty of diagnosis and on the importance of surgical treatment.
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Percutaneous cholecystostomy is a safe, minimally invasive and clinically effective therapeutic intervention in carefully selected patients. It is most appropriate in patients with severe (Grade III) acute cholecystitis who are not candidates for immediate surgical intervention and can be a definitive intervention in elderly or critically unwell patients. Percutaneous cholecystostomy is primarily utilized for the management of acute cholecystitis but can be employed as a means of access to the biliary system for therapeutic intervention. This chapter provides an overview of the indications and contraindications for the technique and provides detail about technical aspects of the procedure and follow-up after drainage tube insertion.
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Across the American population of approximately 330 million, 10–15% of adults have gallstones. Of these, 1–4% have symptomatic cholelithiasis, and of these 20% - an estimated 400,000 patients - develop acute complications.1–3 Cholecystectomy remains the standard of care for symptomatic or complicated cholelithiasis, with approximately 600,000 to 1.5 million cholecystectomies performed per year in the United States.
Percutaneous Cholecystostomy Tubes (PCT) have become an accepted and common modality of treating acute cholecystitis in patients that are not appropriate surgical candidates. As percutaneous gallbladder drainage has rapidly increased newer research suggests that the technique may be overused, and patients may be burdened with them for extended periods. We examined our experience with PCT placement to identify independent predictors of interval cholecystectomy versus destination PCT.
All patients with cholecystitis initially treated with PCT from 2014 to 2017 were stratified by whether they underwent subsequent interval cholecystectomy. Demographic data, initial laboratory values, Tokyo Grade, Charlson Comorbidity Index, ASA Class, complications related to PCT, complications related to cholecystectomy, and mortality data were retrospectively collected. Descriptive statistics, univariable, and multivariable Poisson regression were performed.
165 patients received an initial cholecystostomy tube to treat cholecystitis. 61 (37%) patients went on to have an interval cholecystectomy. There were 4 complications reported after cholecystectomy. A total of 46 (27.9%) deaths were reported, only one of which was in the cholecystectomy group. Age, Tokyo Grade, liver function tests, ASA Class, and Charlson Comorbidity Index were significantly different between the interval cholecystectomy and no-cholecystectomy groups. Univariable regression was performed and variables with p < 0.2 were included in the multivariable model. Multivariable Poisson regression showed that increasing Tokyo Grade (IRR 0.454, p = 0.042, 95% CI 0.194–0.969); and increasing Charlson Comorbidity Score (IRR 0.890, p = 0.026, 95% CI 0.803–0.986) were associated with no-cholecystectomy. Higher Albumin (IRR 1.580, p = 0.011, 95% CI 1.111–2.244) was associated with having an interval cholecystectomy.
Patients in the no-cholecystectomy group were older, had more comorbidities, higher Tokyo Grade, ASA Class, and initial liver function test values than those that had interval cholecystectomy. Since interval cholecystectomy was performed with a low rate of complications, we may be too conservative in performing cholecystectomy after drainage and condemning many patients to destination tubes.
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La colecistitis aguda es una de las enfermedades más frecuentes a la que debe enfrentarse el cirujano general. En las últimas décadas se han observado distintos factores pronósticos y descrito modalidades de tratamiento efectivas con la finalidad de mejorar los resultados en pacientes con este padecimiento (baja morbimortalidad, menor estancia hospitalaria y mínima conversión de procedimientos laparoscópicos a abiertos). En general, la colecistectomía laparoscópica es el tratamiento estándar de la colecistitis aguda, pero dicho procedimiento quirúrgico no está exento de complicaciones, principalmente en pacientes con múltiples comorbilidades o en estado crítico. La colecistostomía percutánea surgió como una alternativa menos invasiva para el tratamiento de la colecistitis aguda en pacientes con falla orgánica o riesgo quirúrgico prohibitivo. Aunque es un procedimiento efectivo, existe controversia sobre su utilidad sobre las indicaciones precisas. Aunado a lo anterior, la evidencia sobre el manejo de la sonda de colecistostomía es escasa. Realizamos una revisión abordando las principales cuestiones que los médicos involucrados con el manejo de esta patología deben conocer.
Acute cholecystitis is one of the most frequent diseases faced by the general surgeon. In recent decades, different prognostic factors have been observed, and effective treatments described, to improve the results in patients with said pathology (lower morbidity and mortality, shorter hospital stay, and minimum conversion of laparoscopic to open procedures). In general, laparoscopic cholecystectomy is the standard treatment for acute cholecystitis, but it is not exempt from complications, especially in patients with numerous comorbidities or those that are critically ill. Percutaneous cholecystostomy emerged as a less invasive alternative for the treatment of acute cholecystitis in patients with organ failure or a prohibitive surgical risk. Even though it is an effective procedure, its usefulness and precise indications are subjects of debate. In addition, there is little evidence on cholecystostomy catheter management. We carried out a review of the literature covering the main aspects physicians involved in the management of acute cholecystitis should be familiar with.

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: The authors declare no conflicts of interest.

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Southwestern Surgical CongressEmergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study

Abstract

Background

Methods

Results

Conclusions

Section snippets

Database description

Results

Comments

Conclusions

Surgery

Am J Surg

J Am Coll Surg

HPB (Oxford)

Acute acalculous cholecystitis: incidence, risk factors, diagnosis, and outcome

Am Surg

Laparoscopic cholecystectomy in acute cholecystitis. A prospective comparative study in patients with acute vs. chronic cholecystitis

Surg Endosc

Management of acute cholecystitis in critically ill patients: contemporary role for cholecystostomy and subsequent cholecystectomy

Am Surg

Comparison of laparoscopic vs. open sigmoid colectomy for benign and malignant disease at academic medical centers

J Gastrointest Surg

Southwestern Surgical Congress
Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study