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Comparative Operative Outcomes of Early and Delayed Cholecystectomy for Acute Cholecystitis: A Population-Based Propensity Score Analysis

de Mestral, Charles MD, PhD*,‡; Rotstein, Ori D. MD, MSc; Laupacis, Andreas MD, MSc†,‡; Hoch, Jeffrey S. MA, PhD†,‡; Zagorski, Brandon MS; Alali, Aziz S. MD*; Nathens, Avery B. MD, PhD, MPH*,†,‡

doi: 10.1097/SLA.0b013e3182a5cf36
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Objective: To compare the operative outcomes of early and delayed cholecystectomy for acute cholecystitis.

Background: Randomized trials comparing early to delayed cholecystectomy for acute cholecystitis have limited contemporary external validity. Furthermore, no study to date has been large enough to assess the impact of timing of cholecystectomy on the frequency of serious rare complications including bile duct injury and death.

Methods: This is a population-based retrospective cohort study of patients emergently admitted to hospital with acute cholecystitis and managed with cholecystectomy over the period of April 1, 2004, to March 31, 2011. We used administrative records for the province of Ontario, Canada. Patients were divided into 2 exposure groups: those who underwent cholecystectomy within 7 days of emergency department presentation on index admission (early cholecystectomy) and those whose cholecystectomy was delayed. The primary outcome was major bile duct injury requiring operative repair within 6 months of cholecystectomy. Secondary outcomes included major bile duct injury or death, 30-day postcholecystectomy mortality, completion of cholecystectomy with an open approach, conversion among laparoscopic cases, and total hospital length of stay. Propensity score methods were used to address confounding by indication.

Results: From 22,202 patients, a well-balanced matched cohort of 14,220 patients was defined. Early cholecystectomy was associated with a lower risk of major bile duct injury [0.28% vs 0.53%, relative risk (RR) = 0.53, 95% confidence interval [CI]: 0.31–0.90], of major bile duct injury or death (1.36% vs 1.88%, RR = 0.72, 95% CI: 0.56–0.94), and, albeit non-significant, of 30-day mortality (0.46% vs 0.64%, RR = 0.73, 95% CI: 0.47–1.15). Total hospital length of stay was shorter with early cholecystectomy (mean difference 1.9 days, 95% CI: 1.7–2.1). No significant differences were observed in terms, open cholecystectomy (15% vs 14%, RR = 1.07, 95% CI: 0.99–1.16) or in conversion among laparoscopic cases (11% vs 10%, RR = 1.02, 95% CI: 0.93–1.13).

Conclusions: These results support the benefit of early overdelayed cholecystectomy for patients with acute cholecystitis.

No study to date has been large enough to compare bile duct injury or mortality rates between early and delayed cholecystectomy for acute cholecystitis. This population-based analysis showed that early cholecystectomy is associated with a reduced risk of major bile duct injury and of major bile duct injury or death.

*Sunnybrook Research Institute, Sunnybrook Health Sciences Center

Li Ka Shing Knowledge Institute, St Michael's Hospital; and

Institute for Clinical Evaluative Sciences, Toronto, Canada.

Reprints: Charles de Mestral, MD, PhD, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, D574, Toronto, ON, Canada M4N 3M5. E-mail: charles.demestral@mail.utoronto.ca.

Disclosure: No authors have conflicts of interest to declare. The project was funded by operating grants from the Canadian Surgical Research Fund and Physician Services, Inc, Foundation. In addition, this study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. The authors declare no conflicts of interest.

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© 2014 by Lippincott Williams & Wilkins.