Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis

https://doi.org/10.1016/j.amjsurg.2017.11.002Get rights and content

Highlights

  • Percutaneous (PC), laparoscopic (LC), and open cholecystectomy (OC) outcomes.

  • LC has improved overall peri- and post-operative outcomes compared to other groups.

  • Outcomes, cost, and LOS in PC are worse compared to LC and converted cases.

  • LC may be superior to PC for high-risk patients with calculous cholecystitis (CC).

  • Recommend attempted LC for CC unless an absolute surgical contraindication exists.

Abstract

Background

The role of percutaneous cholecystostomy (PC) is undefined in patients with multiple comorbidities presenting with emergent calculous cholecystitis (CC). This study compared outcomes between PC, laparoscopic (LC), and open cholecystectomy (OC).

Methods

The Vizient UHC database was queried for high-risk patients with CC who underwent PC, LC, OC, or laparoscopic converted to open cholecystectomy (CONV). Demographics, outcomes, mortality, length of stay (LOS), and direct cost were compared between the groups.

Results

LC was the most common approach with the lowest risk of death, complications, LOS, and cost. Complication risk was highest in OC. Nearly 20% of patients underwent PC. Complication rate, LOS, infection, aspiration pneumonia, and mortality were higher in PC. Direct cost was lowest in LC, followed by CONV, PC, and OC.

Conclusions

Emergent cholecystectomy for CC in high-risk patients is safer and more cost effective than PC and this study supports the use of cholecystectomy as the primary treatment approach in these patients.

Introduction

Calculous cholecystitis (CC) is a common surgical indication; up to two percent of patients with asymptomatic disease develop complicated cholelithiasis every year.1 Cholecystectomy is currently the standard of care for patients with CC, but in recent years, percutaneous cholecystostomy (PC) tubes have been used as a bridge to surgery in patients deemed high surgical risk.2, 3, 4 While this is an accepted treatment option for critically ill patients with acalculous cholecystitis (AC), little data supports the use of PC in patients with emergent CC.2, 5 Supportive data frequently originates from studies that included a broad range of severity of illness (SOI), a small number of patients, or reported outcomes only for patients undergoing PC.3, 6, 7, 8 A randomized multicenter trial titled “laparoscopic cholecystectomy versus percutaneous cholecystostomy in acute calculous cholecystitis in high-risk patients,” otherwise known as the CHOCOLATE Trial, is currently underway and aims to determine the role of PC in CC, however results are not yet available.9

The etiologies of calculous and acalculous cholecystitis are very different, as are the patient populations. AC frequently develops during the hospital admission and in the setting of other severe illnesses; whereas CC typically is present at admission and in the absence of other systemic illnesses.3, 10 This distinction is important to note. While the use of PC in critically ill patients with AC is supported in the literature, the associated mortality and morbidity rates are still high.2, 11, 12, 13 A 2009 Cochrane review of 53 studies and 1918 patients demonstrated that the 30-day mortality rate for patients undergoing PC was three-fold higher than those who underwent immediate surgery for CC (15.4% v 4.5%).14 In addition, PC was associated with longer ICU stays, more complications, and higher readmission rates compared to cholecystectomy.14

Here, we demonstrate that surgical outcomes are superior to percutaneous drainage in high-risk patients with emergent CC. Our study is distinguished in that we have reported both outcomes and cost in a large number of patients who received either emergency surgery or percutaneous drainage. In addition, we have restricted our analysis to only high-risk patients in order to determine what role, if any, PC has in the management of emergent CC in this population.

Section snippets

Database description

The Vizient Clinical Database, formerly known as University Health Consortium, is an administrative database of more than 350 academic medical centers and affiliated hospitals that contains patient-level data regarding patient demographics, 30-day outcomes, length of stay (LOS), and financial data such as cost.15, 16 Using the All Patients Refined Diagnosis Related Groups (APR-DRG) classification system, Vizient assigns each patient a SOI score using a validated clinical algorithm that assesses

Results

Between October 2013 and October 2015, 9561 patients received treatment for CC in an emergent setting. Surgical treatment was offered for 82.4% of the patients (OC: n = 658; LC: n = 6456; CONV: n = 765), whereas nearly 20% of patients (n = 1682) received PC. Conversion rate for laparoscopic cases was 10.6%. The majority of patients were white. Patients in the LC group were predominantly female, whereas a higher proportion of males were seen in PC, CONV, and OC. Patients who underwent LC tended

Discussion

To the best of our knowledge, this is the first study comparing outcomes between surgery and percutaneous drainage in high-risk patients undergoing treatment for emergent CC. Even though little data supports the use of PC in these patients, the utilization of percutaneous drainage is increasing; nearly 20% of the patients in our study underwent percutaneous drainage as the primary treatment.18 While this may be due to the increasing availability of Interventional Radiology, surgeons may also

Conclusions

In summary, our data challenge the routine use of percutaneous cholecystostomy in high-risk patients who present emergently with acute calculous cholecystitis. This study is an important prelude to the upcoming randomized CHOCOLATE trial and we recommend that consideration be given to performing laparoscopic cholecystectomy in high-risk patients unless there exists an absolute contraindication for surgery including: inability to administer anesthesia, prohibitive bleeding risk, or severe

Conflicts of interest

All authors have nothing to disclose.

Funding

Funding for this study was provided by the Center for Advanced Surgical Technology at the University of Nebraska Medical Center and the Foundation for Surgical Fellows.

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