The American Journal of Surgery (2013) 206, 935-941 Southwestern Surgical Congress Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study Anton Simorov, M.D.a, Ajay Ranade, M.D.a, Jeremy Parcells, M.D.a, Abhijit Shaligram, M.D.a, Valerie Shostrom, M.S.b, Eugene Boilesen, B.S.b, Matthew Goede, M.D.a, Dmitry Oleynikov, M.D.a,* aDepartment of Surgery, University of Nebraska Medical Center, 985126 Nebraska Medical Center, Omaha, NE 68198-5126, USA; bDepartment of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA KEYWORDS: Abstract Laparoscopic; BACKGROUND: Morbidity and mortality are very high for critically ill patients who develop acute Cholecystectomy; acalculous cholecystitis (AAC). The aim of this study was to compare outcomes in extremely ill pa- Cholecystostomy; tients with AAC treated with percutaneous cholecystostomy (PC), laparoscopic cholecystectomy Acalculous; (LC), or open cholecystectomy (OC), which were also analyzed together in the LC-plus-OC (LO) Cholecystitis; group. Outcomes assessment METHODS: Discharge data from the University HealthSystem Consortium database were accessed using International Classification of Diseases codes. The University HealthSystem Consortium’s Clin- ical Data Base/Resource Manager allows member hospitals to compare patient-level, risk-adjusted out- comes. Multivariate regression models for extremely ill patients undergoing PC or LO for the diagnosis of AAC were created and analyzed. RESULTS: A total of 1,725 extremely ill patients were diagnosed with AAC between October 2007 and June 2011. Patients undergoing PC (n 5 704) compared with the LO group (n 5 1,021) showed decreased morbidity (5.0% with PC vs 8.0% with LO, P , .05), fewer intensive care unit admissions (28.1% with PC vs 34.6% with LO, P , .05), decreased length of stay (7 days with PC vs 8 days with LO, P , .05), and lower costs ($40,516 with PC vs $53,011 with LO, P , .05). Although perioperative outcomes of PC compared with LC were statistically similar, PC had lower costs compared with LC ($40,516 vs 51,596, P , .005). Multivariate regression analysis showed that LC (n 5 822), compared with OC (n 5 199), had lower mortality (odds ratio [OR], .3; 95% confidence interval [CI], .1 to .6), lower morbidity (OR, .4; 95% CI, .2 to .7), reduced intensive care unit admission (OR, .3; 95% CI, .2 to .5), and similar 30-day readmission rates (OR, 1.0; 95% CI, .6 to 1.5). Also, decreased length of stay (7 days with LC vs 8 days with OC) and costs ($51,596 with LC vs $61,407 with OC) were observed, with a 26% conversion rate to an open procedure. CONCLUSIONS: On the basis of this experience, extremely ill patients with AAC have superior out- comes with PC. LC should be performed in patients in whom the risk for conversion is low and in The authors declare no conflicts of interest. * Corresponding author. Tel.: 11-402-559-4581; fax: 11-402-559-7750. E-mail address: [email protected] Manuscript received April 22, 2013; revised manuscript July 29, 2013 0002-9610/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2013.08.019 936 The American Journal of Surgery, Vol 206, No 6, December 2013 whom medical conditions allow. These results show PC to be a safe and cost-effective bridge treatment strategy with perioperative outcomes superior to those of OC. Ó 2013 Elsevier Inc. All rights reserved. Acalculous cholecystitis is a necroinflammatory disease patient characteristics, length of stay (LOS), 30-day of the gallbladder, associated with high mortality and readmission rate, overall and specific postoperative mor- morbidity.1 It frequently develops as a complication in ex- bidity, risk-adjusted in-hospital mortality, and inpatient tremely ill patients being treated for other medical condi- care costs.6,7 The refined diagnosis-related group metho- tions. After initial reluctance, with the development of the dology is used to assign a level of severity by grouping pa- technique and growing experience, laparoscopic cholecys- tients on the basis of the severity and complexity of their tectomy (LC) is currently the standard of care for acute secondary diagnoses (comorbidities and complications). cholecystitis.2 Early LC for acalculous cholecystitis has The UHC assigns a severity of illness (SOI) to a patient been proved to be safe and shortens hospital stays.3 on the basis of 30 previously described comorbid condi- Although most cases of acalculous cholecystitis can be tions, such as congestive heart failure, hypertension, renal considered uncomplicated, some patients may develop and liver failure, obesity, and diabetes. Depending on the sepsis that requires intensive care medicine and distinct number of comorbid conditions, the severity class is group- treatment options, taking into account the patient’s poor ed as minor (0), moderate (1 or 2), major (3 or 4), or ex- general condition. Cholecystectomies performed on criti- treme (.5) severity.8 The UHC first classifies patients cally ill patients with acalculous cholecystitis in the inten- into risk pools according to refined diagnosis-related group sive care unit (ICU) have been associated with mortality or International Classification of Diseases, Ninth Revision, rates up to 50%.4,5 Patients with the diagnosis of acute acal- Clinical Modification (ICD-9-CM) diagnosis and proce- culous cholecystitis (AAC) have particularly increased dure codes to determine morbidity. They identify patients mortality rates, ranging from 22% to 71%.1 at risk for specific types of complications, reported as the However, the main concern for the adoption of LC in percentage of cases with R1 complication. Twenty-five elderly patients who are critically ill is the feasibility specific complications groups exist, such as postoperative (patient fitness for surgery) and high rate of conversion pulmonary compromise, septicemia, shock or cardiorespi- (11% to 28%) to an open procedure.3 Conversion to an ratory arrest, reopening of surgical site, postoperative in- open procedure not only increases the cost and complica- fections, and so on. The UHC database has no tion rates but loses the main advantage of the laparoscopic information available on death occurring after discharge, approach.4 even if the death occurred within 30 days from the date Another option for elderly and critically ill patients is a of operation. LOS was defined as the period from the index percutaneous cholecystostomy (PC), whereby a tube is procedure to hospital discharge, and 30-day readmission placed to decompress the acutely inflamed gallbladder. PC was defined as readmission for any reason within 30 days was developed as an alternative to surgical cholecystec- of discharge after the index procedure. The UHC clinical tomy in high-risk patients with acalculous cholecystitis– database provides an estimated cost of patient care using related sepsis.3 Although the role and benefit of PC have a ratio of cost to charge. been documented in a small series of high-risk patients with ACC, no large study has addressed its role in AAC Data analysis and its comparison with LC and open cholecystectomy (OC). The purpose of this retrospective study was to com- To extract the data, ICD-9-CM codes for OC (51.22 and pare the outcomes of elderly patients with critical illness 51.2), LC (51.23 and 51.24), and cholecystostomy (51.0 who were treated with PC, LC, and OC. and 51.01 to 51.04) were used as codes for principal procedure, between October 2007 and June 2011. The principal ICD-9-CM diagnosis code for AAC (575.0) was Methods used. We compared patient characteristics (age, gender, race, and SOI) and perioperative outcomes. The specific Database description ICD-9-CM coding for a case converted from a laparoscopic to an open procedure (conversion V64.41) was initially The University HealthSystem Consortium (UHC) is an introduced in October 1997 and later modified in October alliance of .100 academic medical centers and .250 of 2003. The conversion rate from LC to OC was calculated their affiliated hospitals, representing 90% of the nation’s by dividing the number of conversions encoded by ICD-9- nonprofit academic medical centers. The UHC database is CM (V64.41) by the sum of the conversions added to the an administrative, clinical, and financial database that number of LCs (codes 51.23 and 51.24). Patients were provides patient-level data for the purpose of comparative divided into the following age subgroups: 18 to 30 years, 31 analysis between institutions. The UHC database contains to 50 years, 51 to 64 years, and R65 years. We performed discharge information on inpatient hospital stay, including an intention-to-treat analysis and evaluated the cases that A. Simorov et al. Emergent cholecystostomy is the procedure of choice for acalculous cholecystitis 937 were started and finished laparoscopically (pure LC) and organ transplant, postoperative or intraoperative shock those cases that were started laparoscopically and then due to anesthesia, postoperative coma or stupor, and post- converted to open surgery (converted LC). We compared operative stroke. Patient groups were compared according initially PC versus LC and OC (LO) together and then to matched SOI classification. broke down LO into OC and LC. SAS version 9.2 (SAS Institute Inc, Cary, NC) was used for all summaries and analyses. The logistic procedure was used to run the Results multiple logistic regression models. Each multivariate logistic regression model was adjusted by age, gender, A total of 1,725 patients with major and extreme SOI race, and approach. Odds ratios (ORs) and 95% confidence were diagnosed with acalculous cholecystitis between intervals (CIs) as well as P values are presented for each fi- October 2007 and June 2011. Of these, LC was attempted nal model.