EGS SO08 - How best to time the operative management of acute cholecystitis: Is there a difference in outcomes between hot and smouldering cholecystectomy?

Abstract

Abstract Background Laparoscopic Cholecystectomy (LC) is the main treatment for symptomatic gallstone disease. Acute cholecystitis (AC) is a common emergency presentation in the UK and the 2015 AUGIS guidelines recommend emergency cholecystectomy within 72 hours of admission if the patient is fit. On a practical level this can sometimes be difficult to implement and often patients are discharged to return for an elective procedure (the smouldering gallbladder). We aimed to analyse our practice at a large district general hospital for the management of patients with AC and their post-operative outcomes. Method All patients undergoing LC between 1st July 2020 and 30th June 2022 were identified. Patients with an ICD-10 code of K81 (AC) associated with an inpatient stay within a year of their operation were included. Those admitted and operated on during that admission were classified as hot cholecystectomies (HC), whereas those admitted and discharged for an elective procedure were termed smouldering cholecystectomies (SC). Patient and operative details were retrieved from their electronic record and a Charlson co-morbidity index was calculated. Statistical analysis was performed using SPSS with Chi-squared tests performed for categorical data and ANOVA for continuous data. Results 276 patients underwent cholecystectomy for AC with 52.2% elective and 47.8% emergency (91% within 72 hours of admission). HC patients were younger (52.3 vs. 57.5, p<0.01) and less-comorbid (1.67 vs 2.12, p<0.05). The subtotal cholecystectomy rate was comparable between the groups (9.8% vs 16.0%, p=0.131). HC patients had more post-operative drains (38.6% vs 27.1%, p<0.05) and thick-walled gallbladders (92.4% vs 64.6%, p<0.001). Median post-operative length of stay was 1 day for HC and 0 days for SC. No difference was observed for 30-day readmission (4.5% vs 7.6%, p=0.286), morbidity (12.9% vs 11.8%, p=0.786) or mortality (0.8% vs 0.7%, p=0.951). Conclusion This study adds to the evidence that emergency cholecystectomy is as safe an option as discharging patients to return for an elective procedure in the future. Although a proportion of those discharged to return for an elective operation will have thin-walled gallbladders, the rate of subtotal cholecystectomy remains similar, if not slightly higher in the elective group (although not reaching statistical significance). Most emergency cholecystectomy patients were discharged the following day, therefore demonstrating that they do not significantly contribute to bed blocking and reduce the burden on already strained elective waiting lists.