Management of acute cholecystitis in cancer patients: a comparative effectiveness approach

Abstract

Host factors and therapy characteristics predispose cancer patients to a high risk of acute cholecystitis. Management of cholecystitis is often difficult given complex decision making involving the underlying cancer, possible interruption of treatment, and surgical fitness of the patient. A management pathway was developed for cholecystitis in cancer patients which incorporated patient-specific survival and risks of recurrence. Estimates were obtained from a multistage systematic review. A decision tree with a lifetime horizon was constructed to compare conventional strategies [conservative treatment (CT), percutaneous cholecystostomy (PC) and definitive cholecystectomy (DC)] with the new pathway (NP). The decision tree was optimized for highest estimated survival. Sensitivity analyses were performed. In low surgical risk patients with cancer-specific survival of 12 months, the NP yielded estimated survivals of 11.9 versus 11.8 (CT) versus 11.8 (PC) versus 11.9 months for the DC arm. For high-risk patients, the estimated survival was 11.6 (NP), 9.9 (DC), 11.4 (PC), and 11 (CT) months, respectively. The decision to perform a DC at 6 weeks after a PC was optimum in patients expected to survive 24 months (23.2 months from the NP) or with a shorter expected survival but a high recurrence risk (>20 %). Model estimates were robust in sensitivity analyses. Incorporation of the surgical risk and the risk of recurrent cholecystitis, while balancing the patient-specific survival and the impact of antineoplastic therapy in the management of cholecystitis yields improved survival. This work provides measures to evaluate surgical judgment, and can augment the physician-patient decision making.