Outcomes following an index emergency admission with cholecystitis: a national cohort study

Mytton, Jemma; Daliya, Prita; Singh, Pritam; Parsons, Simon; Lobo, Dileep; Lilford, Richard; Vohra, Ravinder

Abstract

Objective
The objective of this study was to evaluate the differences between patients who undergo cholecystectomy following index admission for cholecystitis, and those that are managed non-operatively.

Summary Background Data
Index emergency cholecystectomy following acute cholecystitis is widely recommended by national guidelines, but its effect on clinical outcomes remains uncertain.

Methods
Data collected routinely from the Hospital Episode Statistics database (all admissions to National Health Service organizations in England and Wales) were extracted between
1st April 2002 and 31st March 2015. Analyses were limited to patients aged over 18- years with a primary diagnosis of cholecystitis. Exclusions included records with missing or invalid datasets, patients who had previously undergone a cholecystectomy, patients who had died without a cholecystectomy, and those undergoing cholecystectomy for malignancy, pancreatitis or choledocholithiasis. Patients were grouped as either ‘no cholecystectomy’ where they had never undergone a cholecystectomy following discharge, or ‘cholecystectomy’. The latter group was then subdivided as ‘emergency cholecystectomy’ when cholecystectomy was performed during their index emergency admission, or ‘interval cholecystectomy’ when a cholecystectomy was performed within 12 months following a subsequent (emergency or elective) admission. Propensity Score Matching was used to match emergency and interval cholecystectomy groups. Main outcome measures included 1) One-year total length of hospital stay due to biliary causes following an index emergency admission with cholecystitis. 2) One-year mortality; defined as death occurring within 1-year following the index emergency admission with acute cholecystitis.

Results
Of the 99,139 patients admitted as an emergency with acute cholecystitis, 51.1% (47,626) did not undergo a cholecystectomy within 1-year of index admission. These patients were older, with more co-morbidities (Charlson Comorbidity Score ≥ 5 in
23.5% vs. 8.1%, p[less than]< 0.001) when compared to patients who did have a cholecystectomy. While all-cause 1-year mortality was higher in the nonoperated versus the operated group (12.2% vs. 2.0%, P [less than] 0.001), gallbladder-related deaths were significantly lower than all other causes of death in the non-operated group (3.3% vs. 8.9%, P [less than] 0.001). Following matching, 1-year total hospital admission time was significantly higher following emergency compared with interval cholecystectomy (17.7 d vs. 13 d, P [less than] 0.001).

Conclusions
Over 50% of patients in England did not undergo cholecystectomy following index admission for acute cholecystitis. Mortality was higher in the nonoperated group, which was mostly due to non-gallbladder pathologies but total hospital admission time for biliary causes was lower over 12 months. Increasing the numbers of emergency cholecystectomy may risk over-treating patients with acute cholecystitis and increasing their time spent admitted to hospital.

Citation

Mytton, J., Daliya, P., Singh, P., Parsons, S., Lobo, D., Lilford, R., & Vohra, R. (2019). Outcomes following an index emergency admission with cholecystitis: a national cohort study. Annals of Surgery, https://doi.org/10.1097/SLA.0000000000003599

• Journal Article Type: Article
• Acceptance Date: Aug 14, 2019
• Online Publication Date: Sep 16, 2019
• Publication Date: Sep 16, 2019
• Deposit Date: Aug 16, 2019
• Publicly Available Date: Sep 17, 2020
• Journal: Annals of Surgery
• Print ISSN: 0003-4932
• Electronic ISSN: 1528-1140
• Publisher: Lippincott, Williams & Wilkins
• Peer Reviewed: Peer Reviewed
• DOI: https://doi.org/10.1097/SLA.0000000000003599
• Keywords: cholecystitis, emergency cholecystectomy, index cholecystectomy
• Public URL: https://nottingham-repository.worktribe.com/output/2439854
• Publisher URL: https://journals.lww.com/annalsofsurgery/Abstract/9000/Outcomes_Following_an_Index_Emergency_Admission.94911.aspx