Association for Academic Surgery
Cholecystostomy offers no survival benefit in patients with acute acalculous cholecystitis and severe sepsis and shock

https://doi.org/10.1016/j.jss.2014.02.043Get rights and content

Abstract

Background

Acute acalculous cholecystitis is often managed with cholecystectomy or cholecystostomy, but data guiding surgical practice are lacking.

Materials and methods

Longitudinal analysis of the California Office of Statewide Health Planning and Development Patient Discharge Data was performed from 1995–2009. Patients with acute acalculous cholecystitis were identified by International Classification of Diseases 9 code. Cox proportional hazard analysis found predictors of time to death, adjusting for patient demographics, sepsis, shock, frailty, Charlson comorbidity index, length of stay, insurance status, teaching hospital status, and year.

Results

Of 43,341 patients, 63.5% received a cholecystectomy, 2.8% received a cholecystostomy, and 1.2% received both. Overall, 30.4% of patients died, with higher mortality among patients with cholecystostomy (61.7%) or no procedure (42.0%) than cholecystectomy (23.0%). In patients with severe sepsis and shock, there was no difference in survival of patients with cholecystostomy versus no intervention (hazard ratio [HR] 1.13, P = 0.256), although patients with cholecystectomy (with or without prior cholecystostomy) had improved survival (HR 0.29, P < 0.001; HR 0.56, P < 0.001). Results were similar among patients on the ventilator >96 h.

Conclusions

Although cholecystostomy offered no survival benefit for patients with severe sepsis and shock, cholecystectomy offered improved survival compared with patients without surgical management. Cholecystostomy may not benefit the sickest patients in whom cholecystectomy may never be considered.

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.

Section snippets

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.

References (15)

There are more references available in the full text version of this article.

Cited by (41)

  • Persistent acute cholecystitis after cholecystostomy – increased mortality due to treatment approach?

    2022, HPB
    Citation Excerpt :

    In the CCY group, leukaemia, pulmonary septic shock and pleural empyema were listed as cause of death during the initial stay. In an analysis of over 43′000 patients with severe sepsis and shock, Anderson et al. demonstrated a 62% lethality in PC patients, compared to a 35% lethality in patients with PC and subsequent CCY.14 In this study, the non-intervention group had a lower mortality (42%) than the PC group.

  • Cholecystostomy: Are we using it correctly?

    2019, American Journal of Surgery
    Citation Excerpt :

    Since cholecystectomy remains the definitive treatment for gallstone related disease, interval cholecystectomy with PCT removal is often subsequently performed. Despite increasing usage of PCT, the literature regarding indications for this procedure is highly variable.7–10 Current data regarding outcomes for PCT and its impact on mortality are limited by study design and variability of outcomes, with some investigators calling for a robust review of outcomes from tertiary centers with a history of performing PCT.11

  • Chapter 34 - Percutaneous treatment of gallbladder disease

    2016, Blumgart's Surgery of the Liver, Biliary Tract and Pancreas: Sixth Edition
View all citing articles on Scopus

This article was presented at Academic Surgical Congress on February, 6 2014.

View full text