Y. Sanaiha1, Y. Juo1, R. Jaman1, S. Rudasill2, H. Khoury2, H. Xing2, A. L. Mardock2, P. Benharash2 1University Of California – Los Angeles,General Surgery,Los Angeles, CA, USA 2University Of California – Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA
Introduction: Gallstone disease is highly prevalent amongst the aging population. Acute cholecystitis is most often managed with cholecystectomy, but clinical instability and advanced age have been cited as indications for gallbladder decompression with percutaneous cholecystostomy. The aim of the present study was to evaluate the mortality, morbidity, readmissions and resource utilization associated with management of cholecystitis in this high risk population
Methods: This was a retrospective cohort study using the Nationwide Readmissions Database (NRD), one of the largest, all-payer discharge databases, representing nearly 57% of all US hospitalizations through survey-weighted estimates. All non-elective admissions for cholecystitis in adults ≥70 years who underwent either percutaneous cholecystostomy (PC), laparoscopic (LC) or open cholecystectomy (OC) from 2010-2015 were identified. Significant predictors of in-hospital mortality, composite comorbidity including neurologic, cardiovascular, renal and infectious complications, unplanned early (30-days from discharge), and intermediate readmissions (30-90 days from discharge) were analyzed using logistic regression models. Linear regression models were utilized to identify incremental costs and length of stay with each treatment modality.
Results:Of the estimated 416,902 patients over the age of 70 years who were admitted non-electively for management of cholecystitis, 9.7% underwent PC, 13.5% OC, and 76.1% LC. Patients who underwent PC were older (81.2 vs 79.0 vs 78.7 years, P<0.001) with a higher proportion of patients with an Elixhauser comorbidity score ≥ 4 (53.6 vs 38.2 vs 34.1%, P<0.001). The unadjusted index mortality rate was lowest for LC (Figure 1A). Composite complication, early, and intermediate readmission rate were higher in the PC cohort (Figure 1A). In this elderly cohort, OC and LC had significantly lower odds of mortality, composite morbidity, early, and intermediate readmission compared to PC (Figure 1B). Of all patients who received PC at index hospitalization and were readmitted within 30 days, 8.7% underwent interval LC and 3.7% OC. Compared to LC, PC was associated with significantly increased risk-adjusted costs ($3,318, P<0.0001) and length of stay (2.8 days, P<0.001).
Conclusion:As expected, patients undergoing cholecystostomy had higher rates of mortality, complications, and readmissions, which is a reflection of baseline comorbidity prohibitive of surgical intervention. Further study of mechanisms of readmission reduction and post-discharge care for patients undergoing PC may help decrease the total resource utilization for this high-risk population, especially as OC in this high-risk population is being supplanted by PC.
