Philippe Paci, MD1, Pepa Kaneva, MSc2, Julio F. Fiore Jr, PhD1, Gerald M. Fried, MD, FRCSC, FACS1, Nancy E. Mayo, PhD3, Liane S. Feldman, MD, FRCSC, FACS1. 1Division of General Surgery, McGill University, Montreal, Canada, 2Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Centre, Montreal, Canada, 3Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Canada
INTRODUCTION: While evidence supports early compared to delayed cholecystectomy as the optimal management of acute calculous cholecystitis (ACC), significant variability in practice remains. The purpose of this study was to identify variables associated with early cholecystectomy, in order to target opportunities to improve adherence to best practices.
METHODS AND PROCEDURES: Adult patients admitted to surgical units at two hospitals in a university network from June 2010 to June 2014 were reviewed. The 2013 Tokyo Guidelines were used to define ACC diagnosis as well as severity of presentation (grade 2: ACC with leukocytosis>18,000, RUQ mass, symptoms>72 hours or perforated or gangrenous gallbladder; grade 1: mild ACC, not meeting criteria for grade 2). Patients with concurrent pancreatitis, cholangitis or grade 3 ACC (organ system failure) were excluded. Early cholecystectomy was defined as surgery performed during same admission and within 7 days of presentation. Delayed management was defined as admission for ACC treated conservatively, with or without eventual cholecystectomy. Surgeons were classified according to whether they performed elective cholecystectomy. Risk of concurrent choledocholithiasis was classified as low or intermediate/high based on the 2010 ASGE guidelines. The primary outcome was early cholecystectomy; other outcomes included time to cholecystectomy, complications, and total hospital length of stay (LOS).
RESULTS: A total of 278 patients were included (128 in site 1 and 150 in site 2). 181 patients (65%) underwent early cholecystectomy, 39 (14%) were treated conservatively and underwent delayed cholecystectomy, and 58 (21%) were only treated conservatively. Median time to OR from presentation to the hospital was 38 hours [22-64] for early cholecystectomy patients and 62 days [44-111] for the delayed management patients. The conversion rate in early cholecystectomy patients was 10%. When comparing both groups, early cholecystectomy patients were younger (52 +/- 17 vs 61 +/- 17 years, p<0.001), were treated more often at site 1 (55% vs 45%, p<0.001), and had a lower median total LOS (3 [2-5] vs 5 [4-8], p<0.001). There were no differences in gender, comorbidities, severity of ACC, complications during hospitalization or 90-day readmissions between the groups. On multiple logistic regression analysis, lower age, hospital site and lower risk of concurrent choledocholithiasis were all significantly associated with early cholecystectomy (p<0.05).
CONCLUSION: We identified patient and systems factors associated with early cholecystectomy. This suggests that multiple strategies will be necessary to promote adherence to best practices in the management of ACC.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80529
Program Number: S101
Presentation Session: Acute Care Surgery
Presentation Type: Podium
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