1100 Outcomes of Cholecystostomy With and Without Follow-Up Cholecystectomy in Patients With Cirrhosis

Abstract

INTRODUCTION: Cirrhotic patients are twice as likely as the general population to form gallstones and are therefore at increased risk for acute cholecystitis. Cholecystectomy (CCY) is currently the definitive therapy for cholecystitis, but cirrhotic patients have been shown to have dramatically higher mortality rates during CCY in previous studies. Percutaneous cholecystostomy tube (PCT) placement is therefore an alternative to CCY in cirrhosis. Subsequently these patients require CCY. However, data on PCT and subsequent CCY cirrhotics are not reported. We studied the trends and outcomes of PCT with and without follow-up CCY in cirrhotic patients. METHODS: The National Readmissions Database (NRD), using pre-validated ICD-9 codes was queried to study the patients with acute calculous cholecystitis between the years of 2010-2014 who underwent either CCY or PCT with or without follow-up CCY. Study groups included non-cirrhotics (NC), compensated cirrhotics (CC) and decompensated cirrhotics (DC). DC patients were classified using Baveno IV criteria. Variables included were patient and hospital characteristics, Elixhauser co-morbidities, rates of CCY, rates of PCT with or without follow-up CCY, and approach to CCY- open vs closed. Primary outcomes included 30-day readmission rates, plus index and calendar year mortality. Secondary outcomes were rates of PCT placement, rates of CCY after PCT, length of stay and cost. RESULTS: PCT are more commonly placed in cirrhotics (3.7%) compared to non-cirrhotics with acute cholecystitis (1.4%). Within cirrhotics, DC (7.7%) received far more PCT than CC (2.9%). Inversely, NC underwent more CCY vs CC and DC (98.9%, 97.4% and 92.9%, respectively). Predictors of PCT were DC (P < 0.001), but not CC (P = 0.23) compared to NC. PCT was followed by CCY less in cirrhotics than NC with DC having the lowest rates (NC: 39.9%, CC: 28.6%, and DC: 16.1%). Presence of CC and DC were predictors of not receiving CCY after PCT ((OR: 0.57; CI: 0.35-0.92) and (OR:0.29; CI:0.14-0.60), respectively). Finally, outcomes of CCY after PCT were shown to be similar between NC vs all cirrhotics with all comparisons not being statistically significant. CONCLUSION: Cirrhosis was seen as a risk factor for PCT without subsequent CCY with DC having the lowest rates. However, while CC and DC had lower rates of CCY after PCT, their outcomes were similar to NC. Allowing time for medical optimization with PCT tubes, especially in CC, may result in similar surgical outcomes to NC undergoing follow-up CCY.