Cholecystostomy Tube Placement in Gallstone-Related Acute Cholecystitis: Implications From a National Survey

Abstract

Introduction: While cholecystectomy (CCY) is the standard of care for gallstone-related acute cholecystitis, cholecystostomy (CCY) tube is an alternative option in patients with significant comorbid conditions. We sought to determine predictors, immediate and longitudinal hospital outcomes of patients who underwent CCY-tube placement on a national level in the United States (US). Methods: We identified all adults (age ≥18 years) with a primary diagnosis of acute cholecystitis from Jan-Nov 2013 in the Nationwide Readmission Database. Patients with concurrent diagnosis of acute pancreatitis, choledocholithiasis, hepatobiliary, and intestinal malignancy were excluded. Outcomes of patients undergoing CCY and CCY-tube were compared. Univariate and multivariate analyses were performed to identify (a) predictors of CCY-tube placement and (b) predictors of not undergoing standard of care CCY following CCY-tube during longitudinal inpatient follow-up of 1 year. Results: A total of 181,221 patients had index hospitalization with acute cholecystitis where 178,095 (98.3%) patients underwent cholecystectomy and 3167 (1.7%) patients were managed with CCY-tubes. Among patients with CCY-tubes, 1,196 (37.8 %) underwent eventual CCY in 2013 where as 1,971 (62.2%) did not. Patients receiving CCY-tube incurred a 21.4% 30-day readmission rate with poor outcomes during index hospitalization.(Table 2). For patients with index admission with acute cholecystitis; on multivariate analysis, increasing age (OR 1.20, 95% CI 1.16-1.25), men (OR 1.35, 95% CI 1.18- 1.56), coronary artery disease (OR 1.54, 95% CI 1.28-1.85), cirrhosis (OR 1.65, 95% CI 1.20-2.27), atrial fibrillation (OR 1.48, 95% CI 1.27-1.74), diastolic CHF (OR 1.55, 95% CI 1.13-2.14) and sepsis (OR 4.53, 95% CI 3.53, 5.82) were associated with CCY tube placement (Table 1). Following placement of CCY-tube; on multivariate analysis, the following factors were associated with not undergoing a CCY (standard of care): older age (OR 1.16, 95% 1.09-1.23), Elixhauser score 3-4 (OR 1.92, 95% CI 1.03-3.57), cirrhosis (OR 3.23, 95% CI 1.59-6.67) and diastolic CHF (OR 2.44, 95% CI 1.33-4.55).Table: Table. Univariate Analysis for 30-day Readmission Rates, In-hospital Mortality and Hospital Resources for Patients With and Without Cholecystostomy TubeTable: Table. Analysis of National Readmission Database 2013: Mulitvariate Analysis of Baseline Characteristics for Cholecystostomy-tube Placement in Gallstone-related Acute CholecystitisConclusion: Nearly 2 in 3 patients who receive CCY-tube for acute cholecystitis failed to get standard of care CCY during one-year longitudinal hospital follow-up. Apart from improving immediate outcomes of index admission, focused healthcare delivery efforts to ensure prompt CCY is necessary.