Impact of early cholecystectomy on the readmission rate in patients with acute gallstone cholangitis: a retrospective single-centre study

Abstract

Background and aimsThe pathogenesis of acute cholangitis (AC) occurs with biliary obstruction followed by bacterial growth in the bile duct. The leading cause of AC is obstructing gallstones. There have been conflicting theories about the optimal timing for cholecystectomy following AC. The aim of this study is to assess the impact of early cholecystectomy on the 30-day readmission rate, 30-day mortality, 90-day readmission rate and the length of hospital stay.MethodsThis retrospective study was performed between January 2015 and January 2021 in a high-volume tertiary referral teaching hospital. Included patients were 18 years or older with a definitive diagnosis of acute gallstone cholangitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) with complete clearance of the bile duct as an index procedure. We divided the patients into two groups: patients who underwent ERCP alone and those who underwent ERCP with laparoscopic cholecystectomy (LC) on the same admission (ERCP+LC). Data were extracted from electronic medical records. The primary endpoint of the study was the 30-day readmission rate.ResultsA total of 114 patients with AC met the inclusion criteria of the study. The ERCP+LC group had significantly lower rates of 30-day readmission (2.2% vs 42.6%, p<0.001), 90-day readmission (2.2% vs 30.9%, p<0.001) and 30-day mortality (2.2% vs 16.2%, p=0.017) when compared with the ERCP group. In a multivariate logistic regression analysis, patients in the ERCP+LC group had 90% lower odds of 30-day readmission compared with patients who did not undergo LC during admission (OR=0.1, 95% CI (0.032 to 0.313), p<0.001).ConclusionPerforming LC on same day admission was associated with a decrease in 30-day and 90-day readmission rate as well as 30-day mortality.

Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event

“…Cholecystectomy, either early or delayed, thus remains the best protector against RBE [ 29 , 30 , 51 ], approaching 90% of protection [ 7 ]. In addition, reviews showed that RBE is definitively lower if cholecystectomy is carried out early vs delayed (2–10% vs 24–47%) [ 13 , 15 , 29 – 31 ]. While a better reduction in the risk of RBE is achieved the sooner cholecystectomy is carried out [ 12 , 42 , 52 ], the definition of “early” cholecystectomy after endoscopic treatment of choledocholithiasis remains variable [ 1 , 28 , 53 ].…”

“…In the present study, elderly and patients with higher comorbidity score are not significantly associated with an increased incidence of RBE (Table 1 ). Yet, index cholecystectomy after ERCP have been demonstrated to be secure, with fewer or at least no increased risk of complications [ 12 , 13 , 25 – 27 , 42 , 49 , 51 ], along with the prevention of RBE [ 3 , 7 , 16 , 20 , 21 , 29 – 31 , 43 , 44 , 49 – 51 ]. Age and comorbidity should not be an obstacle or a deterrent to proceed to early cholecystectomy or even at the index admission after the endoscopic removal of CBDS, except when risk is prohibitive [ 4 ].…”

“…Unlike the majority of studies evaluating the occurrence and risk of RBE and complications in delayed cholecystectomy [ 7 , 13 , 17 , 19 , 21 , 24 , 28 , 35 ], the present study rather examined the outcome in patients suffering RBE independently of the timing of surgery. Even if the occurrence of surgical complications did not reach statistical significance between groups, open cholecystectomy, either planned or converted, was significantly more frequent in patients who had RBE (Table 3 ).…”

“…On the other hand, early cholecystectomy was not associated with increased surgical complications [ 4 , 15 , 27 , 28 , 31 , 53 ] or conversion to open surgery [ 19 , 25 , 27 , 28 , 31 , 53 , 55 , 62 ]. Some studies even demonstrated association with a better surgical outcome in early cholecystectomy [ 13 , 29 , 30 , 59 , 61 ]. Consequently, guidelines have been elaborated but with varying time frames [ 2 , 5 – 7 , 12 , 18 , 20 , 22 , 32 – 41 ] reflecting the lack of evidence of optimal timing of cholecystectomy [ 28 , 34 ] from the prospective randomized controlled trials [ 18 , 19 ].…”

“…Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for the removal of CBDS [ 11 , 13 ]. ERCP remains insufficient, since recurrence of CBDS occurs in up to 30% [ 4 , 14 ], and recurrence of any related biliary events (RBE) in up to 47% of the cases [ 15 , 16 ] despite clearance of the common bile duct (CBD).…”