Comprehensive assessment of the management of acute cholecystitis in Scotland: population-wide cohort study.

BACKGROUND: Acute cholecystitis is one of the most common diagnoses presenting to emergency general surgery and is managed either operatively or conservatively. However, operative rates vary widely across the world. This real-world population analysis aimed to describe the current clinical management and outcomes of patients with acute cholecystitis across Scotland, UK. METHODS: This was a national cohort study using data obtained from Information Services Division, Scotland. All adult patients with the admission diagnostic code for acute cholecystitis were included. Data were used to identify all patients admitted to Scottish hospitals between 1997 and 2019 and outcomes tracked for inpatients or after discharge through the unique patient identifier. This was linked to death data, including date of death. RESULTS: A total of 47 558 patients were diagnosed with 58 824 episodes of acute cholecystitis (with 27.2 per cent of patients experiencing more than one episode) in 46 Scottish hospitals. Median age was 58 years (interquartile range (i.q.r.) 43-71), 64.4 per cent were female, and most (76.1 per cent) had no comorbidities. A total of 28 741 (60.4 per cent) patients had an operative intervention during the index admission. Patients who had an operation during their index admission had a lower risk of 90-day mortality compared with non-operative management (OR 0.62, 95% c.i. 0.55-0.70). CONCLUSION: In this study, 60 per cent of patients had an index cholecystectomy. Patients who underwent surgery had a better survival rate compared with those managed conservatively, further advocating for an operative approach in this cohort.

APACHE IV Score is Useful For Assessment and Stratification of Elderly Patients Over 65 Years With Acute Cholecystitis.

PURPOSE: One of the main problems concerning the design of clinical trials in critically ill patients with acute cholecystitis (AC) is the lack of validated, well-established scoring systems to stratify the severity of patient disease states. The aim of this study was to evaluate the performance of the Acute Physiology and Chronic Health Evaluation IV (APACHE IV) scoring system in patients over 65 years with AC. METHODS: All patients over 65 years of age admitted to our hospital for treatment of AC in the intensive care unit between January 2013 and January 2019 were retrospectively analyzed. RESULTS: A total of 443 consecutive patients with AC were enrolled in this study. As for the patients over 65 years, the survivors had lower APACHE IV scores and lower risk of death than nonsurvivors (P<0.01). The discrimination of the APACHE IV score prediction was good, with an area under the curve of 0.850 (95% confidence interval, 0.780-0.932). The APACHE IV models were well-calibrated with the Hosmer-Lemeshow goodness-of-fit test (P=0.635). Similar results were obtained for patients over 85 years of age. CONCLUSION: The APACHE IV model was good at predicting hospital mortality in elderly patients with AC, which would be helpful to make clinical and therapeutic decisions in the future.

Evolution of incidence, mortality and cost of nontraumatic abdominal emergencies treated in Brasil in a period of nine years.

OBJECTIVE: To evaluate the incidence, mortality and cost of non-traumatic abdominal emergencies treated in Brazilian emergency departments. METHODS: This paper used DataSus information from 2008 to 2016 (http://www.tabnet.datasus.gov.br). The number of hospitalizations, costs - AIH length of stay and mortality rates were described in acute appendicitis, acute cholecystitis, acute pancreatitis, acute diverticulitis, gastric and duodenal ulcer, and inflammatory intestinal disease. RESULTS: The disease that had the highest growth in hospitalization was diverticular bowel disease with an increase of 68.2%. For the period of nine years, there were no significant changes in the average length of hospital stay, with the highest increase in gastric and duodenal ulcer with a growth of 15.9%. The mortality rate of gastric and duodenal ulcer disease increased by 95.63%, which is significantly high when compared to the other diseases. All had their costs increased but the one that proportionally had the highest increase in the last nine years was the duodenal and gastric ulcer, with an increase of 85.4%. CONCLUSION: Non-traumatic abdominal emergencies are extremely prevalent. Hence, the importance of having updated and comparative data on the mortality rate, number of hospitalization and cost generated by these diseases to provide better healthcare services in public hospitals.

A Calculated Risk: Performing Laparoscopic Cholecystectomy for Acute Cholecystitis on Patients with End Stage Renal Disease.

End-stage renal disease (ESRD) is a multifactorial disease linked to socioeconomic status and associated with worse surgical outcomes. We explore intraoperative and postoperative outcomes in patients with cholecystitis undergoing laparoscopic cholecystectomy (LC). The Nationwide Inpatient Sample from 2005 to 2012 was used to identify patients undergoing LC for cholecystitis using ICD-9 codes. Outcomes of interest were mortality, common bile duct injury, conversion to open, intraoperative complications, postoperative complications, length of stay (LOS), and total charge. Univariate analysis was performed using t test for continuous variables and chi-squared test for categorical variables. Multivariable models were created that adjusted for age, demographics, year of admission, comorbidities, and presence of ESRD. Of 225,058 patients that underwent LC, 2,115 had ESRD. On univariate analysis, the ESRD cohort had a higher incidence of mortality and complications: intraoperative, mechanical wound, respiratory, cardiovascular, and postoperative infections. ESRD patients had higher median LOS and total charge. Multivariate analysis showed ESRD as an independent risk factor for mortality, mechanical wound complications, and intraoperative complications. Negative binomial regression analysis showed that ESRD patients had LOS 50.4 per cent longer than non-ESRD patients. Linear regression analysis showed that, after adjustment, ESRD patients had total charge 6.82 per cent higher than non-ESRD patients. In this large retrospective analysis, we find that after adjusting for clinical, socioeconomic, and demographic variables, ESRD is an independent risk factor for increased mortality, intraoperative complications, mechanical wound complications, increased LOS, and cost for patients undergoing LC. Prospective studies exploring risk optimization strategies for patients with ESRD are warranted.

Evolution of incidence, mortality and cost of nontraumatic abdominal emergencies treated in Brasil in a period of nine years

SUMMARY OBJECTIVE: To evaluate the incidence, mortality and cost of non-traumatic abdominal emergencies treated in Brazilian emergency departments. METHODS: This paper used DataSus information from 2008 to 2016 (http://www.tabnet.datasus.gov.br). The number of hospitalizations, costs - AIH length of stay and mortality rates were described in acute appendicitis, acute cholecystitis, acute pancreatitis, acute diverticulitis, gastric and duodenal ulcer, and inflammatory intestinal disease. RESULTS: The disease that had the highest growth in hospitalization was diverticular bowel disease with an increase of 68.2%. For the period of nine years, there were no significant changes in the average length of hospital stay, with the highest increase in gastric and duodenal ulcer with a growth of 15.9%. The mortality rate of gastric and duodenal ulcer disease increased by 95.63%, which is significantly high when compared to the other diseases. All had their costs increased but the one that proportionally had the highest increase in the last nine years was the duodenal and gastric ulcer, with an increase of 85.4%. CONCLUSION: Non-traumatic abdominal emergencies are extremely prevalent. Hence, the importance of having updated and comparative data on the mortality rate, number of hospitalization and cost generated by these diseases to provide better healthcare services in public hospitals.

RESUMO OBJETIVO: Avaliar a evolução da Incidência, mortalidade e custo das urgências abdominais não traumáticas atendidas nos serviços de emergência do Brasil durante o período de nove anos. MÉTODOS: Este trabalho utilizou informações do DataSus de 2008 a 2016, (http://www.tabnet.datasus.gov.br). Foram analisados número de internações, valor médio das internações (AIH), valor total das internações, dias de permanência hospitalar e taxa de mortalidade das seguintes doenças: apendicite aguda, colecistite aguda, pancreatite aguda, diverticulite aguda, úlcera gástrica e duodenal, e doença inflamatória intestinal. RESULTADOS: A doença que teve o maior crescimento do número de internações foi a doença diverticular do intestino, com o valor de 68,2%. Ao longo dos nove anos não houve grandes variações da média de permanência hospitalar, sendo que o maior aumento foi o da úlcera gástrica e duodenal, com crescimento de 15,9%. A taxa de mortalidade da doença por úlcera gástrica e duodenal teve um aumento de 95,63%, consideravelmente significante quando comparada com as outras doenças. Todas tiveram seus valores de AIH aumentados, porém, a que proporcionalmente teve o maior aumento nos últimos nove anos foi a úlcera gástrica e duodenal, com um acréscimo de 85,4%. CONCLUSÃO: As urgências abdominais de origem não traumática são de extrema prevalência, por isso a importância em ter dados atualizados e comparativos sobre a taxa de mortalidade, o número de internações e os custos gerados por essas doenças, para melhor planejamento dos serviços públicos de saúde.

Impact of medical or surgical admission on outcomes of patients with acute cholecystitis.

BACKGROUND: Although acute cholecystitis (AC) is a surgical disease, patients with the condition may be admitted to medical-related services (MS). This may lead to delayed cholecystectomy thereby affecting outcomes and quality of care. METHODS: Between July 2010 and March 2013, 329 patients under 70 years old presented to a community-based tertiary care hospital with AC and underwent same admission cholecystectomy. Outcomes were compared between patients admitted to MS and surgical services (SS). RESULTS: Two hundred fifteen patients (65.3%) were admitted to a MS. Patients under the MS had longer LOS (3.0 days vs. 2.0 days, p < 0.001), waiting time to surgical consultation (7.3 h vs. 5.0 h, p < 0.001) and to cholecystectomy (1.0, 0-2 days vs. 1.0, 0-1 day, p < 0.001), and increased hospital costs ($3685 vs. $4,688, p < 0.001) compared to the SS. Readmission and mortality rates were not significantly different between groups. CONCLUSION: Patients under 70 years old with AC undergoing cholecystectomy admitted to MS had increased LOS, delay to the operation, and hospital costs compared to those admitted to a SS. Admission of patients with AC to a SS needs to be emphasized to reduce costs and improve quality of care.

Optimal time for early laparoscopic cholecystectomy for acute cholecystitis.

IMPORTANCE: There is growing evidence in support of performing early laparoscopic cholecystectomy (LC) for acute cholecystitis. However, the definition of early LC varies from 0 through 10 days depending on the research protocol. The optimum time to perform early LC is still unclear. OBJECTIVES: To determine whether outcomes after early LC for acute cholecystitis vary depending on time from presentation to surgery and to determine the optimum time to perform LC for acute cholecystitis. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective review of prospectively collected data from the Nationwide Inpatient Sample (NIS) for 2005 through 2009. The population-based sample included 95,523 adults (18 years and older) who underwent LC within 10 days of presentation for acute cholecystitis. INTERVENTIONS: Patients were categorized and analyzed in 2 ways based on length of time from presentation to surgery. First, patients were categorized into 3 groups: 0 through 1 day, 2 through 5 days, and 6 through 10 days. Second, we compared outcomes for each incremental preoperative day (days 0-5). MAIN OUTCOMES AND MEASURES: Outcomes of interest were mortality, length of stay, complications, and cost. Propensity score matching and generalized linear modeling were used. The hypothesis being tested was formulated after data collection was complete. RESULTS: A total of 95,523 patients were selected. After matching the 3 groups based on propensity scores, patients who underwent surgery during days 2 through 5 and days 6 through 10 had increasingly worse outcomes when compared with those undergoing surgery on days 0 through 1. The odds of mortality were 1.26 (95% CI, 1.00-1.58) and 1.93 (95% CI, 1.38-2.68), and the odds of postoperative infections were 0.88 (95% CI, 0.69-1.12) and 1.53 (95% CI, 1.05-2.23) for days 2 through 5 and days 6 through 10, respectively. Adjusted mean hospital cost increased from $8974 (days 0-1) to $17,745 (days 6-10). Analysis by each incremental day revealed the optimal time of surgery to be within the first 48 hours of presentation. CONCLUSIONS AND RELEVANCE: Laparoscopic cholecystectomy performed within 2 days of presentation of acute cholecystitis yielded the best outcomes and lowest costs. Although causality could not be established, delaying LC was associated with more complications, higher mortality, and higher costs.

Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304).

OBJECTIVE: Acute cholecystitis is a common disease, and laparoscopic surgery is the standard of care. BACKGROUND: Optimal timing of surgery for acute cholecystitis remains controversial: either early surgery shortly after hospital admission or delayed elective surgery after a conservative treatment with antibiotics. METHODS: The ACDC ("Acute Cholecystitis-early laparoscopic surgery versus antibiotic therapy and Delayed elective Cholecystectomy") study is a randomized, prospective, open-label, parallel group trial. Patients were randomly assigned to receive immediate surgery within 24 hours of hospital admission (group ILC) or initial antibiotic treatment, followed by delayed laparoscopic cholecystectomy at days 7 to 45 (group DLC). For infection, all patients were treated with moxifloxacin for at least 48 hours. Primary endpoint was occurrence of predefined relevant morbidity within 75 days. Secondary endpoints were as follows: (1) 75-day morbidity using a scoring system; (2) conversion rate; (3) change of antibiotic therapy; (4) mortality; (5) costs; and (6) length of hospital stay. RESULTS: Morbidity rate was significantly lower in group ILC (304 patients) than in group DLC (314 patients): 11.8% versus 34.4%. Conversion rate to open surgery and mortality did not differ significantly between groups. Mean length of hospital stay (5.4 days vs 10.0 days; P < 0.001) and total hospital costs (€2919 vs €4262; P < 0.001) were significantly lower in group ILC. CONCLUSIONS: In this large, randomized trial, laparoscopic cholecystectomy within 24 hours of hospital admission was shown to be superior to the conservative approach concerning morbidity and costs. Therefore, we believe that immediate laparoscopic cholecystectomy should become therapy of choice for acute cholecystitis in operable patients. (NCT00447304).

Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): study protocol for a randomized controlled trial.

BACKGROUND: Laparoscopic cholecystectomy in acute calculous cholecystitis in high risk patients can lead to significant morbidity and mortality. Percutaneous cholecystostomy may be an alternative treatment option but the current literature does not provide the surgical community with evidence based advice. METHODS/DESIGN: The CHOCOLATE trial is a randomised controlled, parallel-group, superiority multicenter trial. High risk patients, defined as APACHE-II score 7-14, with acute calculous cholecystitis will be randomised to laparoscopic cholecystectomy or percutaneous cholecystostomy. During a two year period 284 patients will be enrolled from 30 high volume teaching hospitals. The primary endpoint is a composite endpoint of major complications within three months following randomization and need for re-intervention and mortality during the follow-up period of one year. Secondary endpoints include all other complications, duration of hospital admission, difficulty of procedures and total costs. DISCUSSION: The CHOCOLATE trial is designed to provide the surgical community with an evidence based guideline in the treatment of acute calculous cholecystitis in high risk patients. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR2666.

Failure to perform cholecystectomy for acute cholecystitis in elderly patients is associated with increased morbidity, mortality, and cost.

BACKGROUND: Cholecystectomy during initial hospitalization is the current recommended therapy for acute cholecystitis. The rate of cholecystectomy and subsequent health care trajectory in elderly patients with acute cholecystitis has not been evaluated. STUDY DESIGN: We used 5% national Medicare sample claims data from 1996 to 2005 to identify a cohort of patients aged 66 years and older, requiring urgent or emergent admission for acute cholecystitis. We evaluated cholecystectomy rates on initial hospitalization, factors independently predicting receipt of cholecystectomy, factors predicting further gallstone-related complications, and 2-year survival in the cholecystectomy and no cholecystectomy groups in univariate and multivariate models. RESULTS: There were 29,818 Medicare beneficiaries who were urgently or emergently admitted for acute cholecystitis from 1996 to 2005. Mean age was 77.7 +/- 7.3 years, 89% of patients were white, and 58% were female. Twenty-five percent of patients did not undergo cholecystectomy during the index admission. Lack of definitive therapy was associated with a 27% subsequent cholecystectomy rate and a 38% gallstone-related readmission rate in the 2 years after discharge; the readmission rate was only 4% in patients undergoing cholecystectomy (p < 0.0001). No cholecystectomy on initial hospitalization was associated with worse 2-year survival (hazard ratio 1.56, 95% CI 1.47 to 1.65) even after controlling for patient demographics and comorbidities. Readmissions led to an additional $7,000 in Medicare payments per readmission. CONCLUSIONS: Our study demonstrated that 25% of cholecystectomies on Medicare beneficiaries were not performed on initial hospitalization, leading to readmissions in 38% of surviving patients. For patients requiring readmission, the percentage of open procedures was increased, and the additional Medicare payment was $7,000 per re-admission. Cholecystectomy for acute cholecystitis in elderly patients should be performed during initial hospitalization to prevent recurrent episodes of cholecystitis, multiple readmissions, higher readmission rates, and increased costs.

Hospitalization rates for cholelithiasis and acute cholecystitis doubled for the aged population in Greece over the past 30 years.

OBJECTIVE: Gallbladder disease is becoming increasingly prevalent in Western countries and is a common cause of hospitalization. The objective of this study was to determine time trends in cholelithiasis and acute cholecystitis for hospitalization and disease case fatality in Greece between 1970 and 1998. MATERIAL AND METHODS: Data were obtained from the Annual Bulletin for the Social Welfare and Health Statistics of the National Statistics Service of Greece. Percentage changes in time trends were estimated by comparing the median values of the initial (1970-78) to the last (1989-98) 10-year study period for cholelithiasis and acute cholecystitis at discharge and for all deaths attributed to the disease. RESULTS: Over the study period, age-standardized hospitalization rates for cholelithiasis increased. The median hospitalization rate between the initial and last (178 and 258 per 100,000 of the population, respectively) 10-year study period increased by 44.7%, but peaked to 70.1% and 208.3% for the 70-79 and >80 years age groups, respectively. Case fatality rate declined by 56.8% and the median value was 0.24 per 100 patients hospitalized during the last 10-year period. CONCLUSIONS: Hospitalization rates for cholelithiasis and/or acute cholecystitis increased by 45%, and doubled for elderly patients, while the case fatality rate of the disease halved in Greece over the past 30 years.