481 Management and Natural History of Older Patients Requiring Cholecystostomy Tube Drainage for Acute Gallbladder Disease

Abstract

INTRODUCTION: Tube cholecystostomy (TC) is used in patients with acute cholecystitis (AC) deemed to be poor surgical candidates. Little is known about the optimal management of these patients after placement of the cholecystostomy tube. Our goal was to examine the trajectory of care and outcomes in these patients. METHODS: We used 5% Medicare Claims data (1996 to 2011) to identify patients ≥66 years who underwent TC for AC. All patients were followed for 2 years after TC. Descriptive statistics were used to describe the study cohort and trajectory of care. Kaplan-Meier curves and cumulative incidence curves were used to describe mortality and compare patients who did or did not undergo cholecystectomy. RESULTS: A total of 1668 patients underwent TC. Their trajectory of care is described in Figure 1. Overall mortality during the study period was 52.6%. The mean age was 80.2 ± 7.9 years and 905 (54.3%) were female. The mean Charlson comorbidity index was 3.7±2.9. 251 patients (15%) underwent cholecystectomy during index admission (48% lap, 52% open), with a 6.8% mortality rate. 1417 patients did not have cholecystectomy at the index admission, and 208 (14.7%) died. Of the 1209 patients who did not have cholecystectomy and who survived to discharge, 732 patients had at least one gallstone-related admission and 121 required at least one tube-related procedure. Subsequent cholecystectomy was performed in 404 patients, of whom 43 had prior tube manipulation. Cholecystectomy was performed at a mean time of 3.2±3.1 months from initial discharge in those who required tube manipulation and 2.7±3.9 months in those who did not. 72% of cholecystectomy were emergent and 60.6% were open. Of the 655 patients who underwent cholecystectomy at any time during the study period, the 2-year survival rate was 75.5%, compared to 37% in 805 patients who survived hospitalization and never underwent cholecystectomy (p=0.0001). Themean age (77.8±7.14 vs. 81.72±8.0, p<0.001) and Charlson comorbidity index (3.1±2.80 vs. 4.2±2.9, p=0.1579) were lower in patients undergoing cholecystectomy. DISCUSSION: Older patients with AC require a TC due to both severity of their gallbladder disease and significant comorbidities that preclude immediate surgical intervention. Fewer than half require cholecystectomy and many die of other causes without requiring cholecystectomy. The worse survival in patients without cholecystectomy, likely represents a selection bias, with the healthiest patients undergoing cholecystectomy.