Mary C Nally, MD, John Kubasiak, MD, Shauna Sheppard, MD, Hongyu Zhao, Jennifer Poirier, PhD, Daniel J Deziel, MD, Samir K Gupta, MD. Rush University Medical Center
INTRODUCTION: Traditionally, acute cholecystitis has been managed operatively with cholecystectomy. Percutaneous drainage is used to temporize the acute infection in high risk patients with significant comorbidities, life threatening acute illness, surgically hostile abdomens, or disseminated disease needing palliation. Evidence exists showing benefits of both treatments, but, as demonstrated in a recent Cochrane review, there is limited data to identify parameters for patient selection. We propose that the NSQIP Risk Calculator can be used as a tool to distinguish patients who would benefit from each procedure.
METHODS: A retrospective chart review was conducted from 2010 to 2015. Patients were identified based on CPT code as having undergone cholecystectomy or cholecystostomy. To isolate critically ill patients, those in the cholecystectomy cohort with ASA less than 3 and those in the cholecystostomy cohort with surgically hostile abdomens or need of palliation were excluded. Statistical analyses including Welch’s t-test and Fisher’s exact test were conducted to compare the amount of predicted risk using the ACS NSQIP Surgical Risk Calculator and the actual outcomes associated with each procedure.
RESULTS: When patients receiving a cholecystectomy (n=215) were compared to those who underwent cholecystostomy (n=22), there were statistically significant differences in both the NSQIP predicted risk as well as in actual outcomes (p<0.05).
|Serious Complications*||5.8 (5.4)||20.2 (9.1)|
|Any Complications*||9.3 (8.0)||28.8 (13.7)|
|Cardiac Complications*||0.5 (0.8)||2.9 (2.3)|
|Death*||0.8 (1.5)||16.6 (15.6)|
|Serious Complications*||23 (11%)||12 (55%)|
|Any Complications*||26 (12%)||12 (55%)|
|Cardiac Complications*||1 (<0.05%)||3 (14%)|
|Death*||0 (0%)||2 (9%)|
*Using Significant for FWER=.05.
CONCLUSION: Cholecystostomy is a less invasive treatment option for high risk patients who have the potential for significant morbidity and mortality with surgical intervention for the treatment of acute cholecystitis. As patients who underwent cholecystostomy had statistically higher rates of pre procedure risk and actual complications compared to cholecystostomy patients, we propose that the NSQIP risk calculator can be used to identify patients who would benefit from cholecystostomy tube placement prior to a definitive operation.