Association for Academic SurgeryCholecystostomy offers no survival benefit in patients with acute acalculous cholecystitis and severe sepsis and shock
Introduction
In contrast to cholecystitis with calculi (gallstones), acalculous cholecystitis is typically a complication of an existing disease in a critically ill patient or after surgery, trauma, anorexia, or burns [1], [2], [3], [4], [5]. In these critically ill patients who are frequently deemed unfit for surgery, percutaneous cholecystostomy is often considered the standard of care, either offering definitive treatment or serving as a bridge to cholecystectomy [6], [7], [8], [9], [10], [11]. However, data guiding surgical practice are lacking. Numerous institutional studies have examined outcomes, but there have been no controlled trials or population-based studies to compare the outcomes of cholecystostomy with cholecystectomy in these patients.
This study uses a statewide database of all patients with acute acalculous cholecystitis over multiple years to compare long-term mortality among patients who received cholecystostomy, cholecystectomy with or without prior cholecystostomy, or no surgical intervention.
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Methods
Longitudinal analysis of the California Office of Statewide Health Planning and Development Patient Discharge Data was performed from 1995–2009. This database includes diagnosis and procedure codes for all patients admitted to every community hospital in California over the time period. Patients who were admitted with acute acalculous cholecystitis were identified by International Classification of Diseases (ICD)–9 diagnosis code (575.0). Using unique identification codes for each patient, all
Results
Of 43,341 patients with acute acalculous cholecystitis identified from 1995–2009, 63.5% received a cholecystectomy, 2.8% received a cholecystostomy, and 1.2% received both (Table 1). Over 51.7% of patients were female and 12.3% of patients were admitted to a teaching hospital. Compared with patients with cholecystectomy, patients with cholecystostomy had the highest mean number of Charlson comorbidities (5.0 versus 3.8), the highest percentage of severe sepsis and shock (27.0% versus 3.8%), the
Discussion
When adjusting for comorbidities, age, and other variables, cholecystectomy offers a survival benefit compared with cholecystostomy or no intervention among all patients with acalculous cholecystitis and subsets of patients with severe sepsis and shock and patients on the ventilator for more than 96 h. Furthermore, among patients with severe sepsis and shock and patients on the ventilator for more than 96 h, cholecystostomy offered no survival benefit compared with no intervention. Instead,
Conclusions
Cholecystostomy does not offer a survival benefit compared with cholecystectomy or no surgical interventions in patients with acute acalculous cholecystitis. In contrast, among all patients and among subsets of patients with severe sepsis and shock and patients on the ventilator for more than 96 h, patients with either primary or interval cholecystectomy had decreased mortality. These findings have important implications for surgical management of patients with acalculous cholecystitis. Unless
Acknowledgment
Author contributions: J.E.A. contributed to research conception and design, analysis and interpretation, writing the article, and critical revisions. T.I. contributed to analysis and interpretation and critical revision. M.A.T. and D.C.C. contributed to research conception and design, data collection, and critical revision.
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This article was presented at Academic Surgical Congress on February, 6 2014.