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Cholecystostomy: A bridge to hospital discharge but not delayed cholecystectomy

de Mestral, Charles MD; Gomez, David MD, PhD; Haas, Barbara MD, PhD; Zagorski, Brandon MS; Rotstein, Ori D. MD, MSc; Nathens, Avery B. MD, PhD, MPH

Journal of Trauma and Acute Care Surgery: January 2013 - Volume 74 - Issue 1 - p 175–180
doi: 10.1097/TA.0b013e31827890e1
AAST 2012 PLENARY PAPERS
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BACKGROUND Current data on the clinical course of patients with acute cholecystitis managed with percutaneous cholecystostomy (PC) are limited by small sample size and imperfect follow-up. We present the characteristics and clinical course of a population-based cohort with acute cholecystitis managed with PC.

METHODS We designed a retrospective cohort study using administrative databases capturing all emergency department (ED) visits and hospital admissions within a geographic region with a population of more than 13 million. From all adults with a first emergency admission for acute cholecystitis from 2004 to 2011, those managed with PC were included in the cohort. The cumulative incidences of subsequent cholecystectomy and death were calculated, considering death a competing risk to cholecystectomy. Polytomous logistic regression was then used to examine differences in patient characteristics across outcome status at 1 year: cholecystectomy, dead without cholecystectomy, or alive without cholecystectomy. Moreover, the risk of a gallstone-related ED visit or hospital admission after discharge was estimated using the Kaplan-Meier method.

RESULTS Of 27,718 patients with acute cholecystitis, 890 (3.3%) underwent PC. The cohort was elderly with a mean (SD) age of 75 (14) years, and 14% were in the intensive care unit on the day of PC. In-hospital mortality was 5%. By 1 year after PC, only 40% had undergone cholecystectomy, while an additional 18% had died without cholecystectomy. The risk of a gallstone-related ED visit or hospital admission was 49% by 1 year after discharge.

CONCLUSION While PC is often performed with the intent of delayed cholecystectomy, less than half of patients actually go on to surgery. High mortality and likely ongoing contraindications to surgery preclude intervention in most patients, although the risk of gallstone-related ED visit or hospital admission remains high. Further prospective investigation is warranted to clarify the potential mortality and quality-of-life gains from elective cholecystectomy following PC.

LEVEL OF EVIDENCE Prognostic study, level III.

From the Li Ka Shing Knowledge Institute (C.D.M., D.G., B.H., O.D.R., A.B.N.), St Michael’s Hospital; and Institute for Clinical Evaluative Sciences (C.D.M., B.Z., A.B.N.), Toronto, Ontario, Canada.

Submitted: August 29, 2012, Revised: September 27, 2012, Accepted: October 3, 2012.

This study was presented at the 71st annual meeting of the American Associationfor the Surgery of Trauma, September 12–15, 2012, in Kauai, Hawaii.

Address for reprints: Charles de Mestral, MD, 30 Bond St, Queen Wing 3-076, Toronto, ON, Canada, M5B 1W8; email: charles.demestral@mail.utoronto.ca.

© 2013 Lippincott Williams & Wilkins, Inc.