Outcomes in Older Patients with Grade III Cholecystitis and Cholecystostomy Tube Placement: A Propensity Score Analysis

Abstract

Background The Tokyo guidelines recommend initial cholecystostomy tube drainage, antibiotics, and delayed cholecystectomy in patients with grade III cholecystitis. Study Design We used Medicare data (1996–2010) to identify patients ≥66 years admitted with grade III acute cholecystitis. We evaluated adherence to the Tokyo guidelines and compared mortality, readmission, and complication rates with and without cholecystostomy tube placement in a propensity-matched (1:3) cohort of patients with grade III cholecystitis. Results 8,818 patients were admitted with grade III cholecystitis; 565 patients (6.4%) had a cholecystostomy tube placed. Cholecystostomy tube placement increased from 3.9% to 9.7% over the study period. Compared to 1,689 propensity-matched controls, patients with cholecystostomy tube placement had higher 30-day (HR 1.26, 95% CI 1.05–1.50), 90-day (HR 1.26, 95% CI 1.08–1.46) and 2-year mortality (HR 1.19, 95% CI 1.04–1.36) and were less likely to undergo cholecystectomy in the 2-years after initial hospitalization (33.4% vs. 64.4%, HR 0.26, 95% CI 0.21–0.31). Readmissions were also higher at 30 days (HR 2.93, 95% CI 2.12–4.05), 90 days (HR 3.48, 95% CI 2.60–4.64), and 2 years (HR 3.08, 95% CI 2.87–4.90). Conclusions Since introduction of the Tokyo Guidelines (2007), use of cholecystostomy tubes in patients with grade III cholecystitis has increased, but the majority of patients do not get cholecystostomy tube drainage as first line therapy. Cholecystostomy tube placement was associated with lower rates of definitive treatment with cholecystectomy, higher mortality and higher readmission rates. These data suggest a need for further evaluation and refinement of the Tokyo guidelines.

Clinical characteristics and short‐term outcomes in patients with acute cholecystitis over aged >80 years

“…Such a consensus might have led to the increase in the proportion of AC patients aged ≥80 years who received percutaneous drainage over time in the current study. However, a recent report from the USA found that cholecystostomy tube placement was associated with higher mortality (30‐day HR 1.26, 90‐day HR 1.26, 2‐year HR 1.19) and higher readmission rates (30‐day HR 2.93, 90‐day HR 3.48, 2 years HR 3.08) in 565 elderly (aged ≥66 years) patients admitted with grade III AC than in 1689 propensity‐matched controls, suggesting a need for the re‐evaluation of PC in patients with grade III AC endorsed by TG13 . The acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE) trial, which is the first randomized controlled trial evaluating the clinical value of PC against laparoscopic cholecystectomy in high‐risk AC patients, will hopefully clarify this point …”

Percutaneous cholecystostomy: prognostic factors and comparison to cholecystectomy

“…Several authors have established the safety and efficacy of early CCY for patients with acute cholecystitis, including high-risk populations [6, 22, 23]. In addition, a recent propensity-matched analysis by Dimou et al [24] found that cholecystostomy tube placement was associated with increased mortality among elderly patients with Grade III cholecystitis. However, level I evidence comparing PC to CCY is lacking.…”

Outcomes of early versus delayed laparoscopic cholecystectomy for acute cholecystitis performed at a single institution

“…Mizrahi et al reported a significantly high rate of conversion to open surgery among patients who had undergone PTGBD before DLC and showed PTGBD to be an independent risk factor for this conversion (11). Dimou et al reported that tube placement in the gallbladder was associated with readmission with severe cholecystitis and mortality (12). We suppose that the PTGBD tube could cause bile leakage or a foreign body reaction, which would cause the changes characteristic of pericystic scarring.…”

“…Dimou et al . reported that tube placement in the gallbladder was associated with readmission with severe cholecystitis and mortality . We suppose that the PTGBD tube could cause bile leakage or a foreign body reaction, which would cause the changes characteristic of pericystic scarring.…”

“…Similarly, DLC has been defined, for example, as surgery performed 6-12 weeks after symptom onset or 7-45 days after admission (3)(4)(5). In addition, reports vary as to whether percutaneous transhepatic gallbladder drainage (PTGBD) performed before DLC is beneficial (9)(10)(11)(12)(13)(14).…”