K. B. Ricci1, A. Z. Paredes1, A. P. Rushing1, D. Ayturk2, A. Diaz1, V. T. Daniel2, H. E. Baselice1, S. Strassels1, A. M. Ingraham3, H. P. Santry1 1Ohio State University,Department Of Surgery, Division Of Trauma, Critical Care And Burns,Columbus, OH, USA 2University Of Massachusetts Medical School,Department Of Quantitative Health Sciences,Worcester, MA, USA 3University Of Wisconsin,Surgery,Madison, WI, USA
Introduction: Cholecystitis is a common cause of acute abdominal pain for which early operation is recommended. The effect of diagnostic radiology and endoscopic resources on timing of operation and associated clinical outcomes is unknown. We sought to evaluate the relationship between hospital resources, timing of operation, and outcomes for patients with acute cholecystitis with and without choledocholithiasis.
Methods: 2,811 U.S. hospitals were surveyed on emergency general surgery practices, including diagnostic radiology structures and processes (e.g. computerized tomography scan type, timeliness of results) and endoscopic retrograde cholangiopancreatography (ERCP) resources. 1,690 hospitals (60%) responded. Survey data from 510 hospitals was linked to corresponding 2015 Statewide Inpatient Sample data using American Hospital Association identifiers. Patients admitted emergently with a primary diagnosis code of acute cholecystitis were included. Radiology/ERCP resources associated with early cholecystectomy (≤72hrs) were analyzed using univariate and multivariable modeling. Differences in systemic or surgical complications between patients undergoing early (< 72hrs) vs late (>72hrs) operation were similarly analyzed.
Results: Of 24,339 acute cholecystitis patients, the majority were white (64%), with a median age of 57yr (IQR 40-72) and >3 comorbidities (39%). 88% had uncomplicated cholecystitis. Most presented to a hospital with CT scan (96%) and ultrasound (US) (98%) availability. Nearly half presented to a hospital with overnight teleradiology (46%), and round the clock US technicians (49%). 74% had an operation; 92% (N=16,535) early and 8% (N=1,494) late. Late-operation patients were older (62yr, IQR 46-75 vs 53yr, IQR 37-68), white (68% vs 63%) and had > 3 comorbidities (59% vs 32%) and choledocholithiasis (23% vs 13%) compared to early-operation patients (all p <0.001). Late-operation patients also had higher frequency of >2 systemic (5% vs. 2%) and >2 surgical (1.4% vs 0.9%) complications (both p<0.001). On multivariable analyses, patients cared for at hospitals lacking overnight teleradiology and CT technicians had 18% (aOR 0.82, 0.73-0.94) and 44% (aOR 0.56, 0.38-0.83) decreased odds of an early operation. Also, late-operation patients had 1.8 (95% CI 1.6-2.0) higher odds of systemic complication and longer length of stay (aOR 4.07, 3.92- 4.22). Age ≥65 (aOR 2.45, 1.91-3.14; aOR 2.09, 1.71-2.56) and black race (aOR 1.24, 1.04-1.48; aOR 1.25, 1.08-1.45) were also associated with major surgical and systemic complication, respectively.
Conclusion: Few radiologic or endoscopic resources were noted to affect timing of cholecystectomy. These data highlight the possible effect of late operations. Our findings have implications to optimize time to surgery for patients with acute cholecystitis to reduce risk of complications. Efforts to improve measures to reduce time to operative intervention should be further investigated.