Risk-adjusted treatment selection and outcome of patients with acute cholecystitis.

Abstract

Age and comorbidities increase the surgical risk for patients with acute cholecystitis and impact on the initial treatment selection. The aim of this article is the implementation of objective risk criteria that may be used to select the most appropriate treatment. We carried out a prospective cohort study of all patients who were admitted to the hospital with a diagnosis of acute cholecystitis during 2014. They were initially allocated to three different treatment groups according to cholecystitis grade, number of days from clinical onset, and surgical risk scores as follows: immediate surgery by sepsis (EmergS), early surgery (EarlyS), or medical treatment group (MedT). Differences in the outcomes between the treatment groups were evaluated using bivariate and logistic regression analyses. A total of 149 patients were admitted; 44% were >80years old and 40% were American Society of Anesthesiologists (ASA)>II. The mortality rate of the series was 0% in EarlyS, 17% in MedT, and 19% in EmergS. The mortality rate was significantly associated with a higher degree of cholecystitis, age, and worse score values in risk scales and Charlson index. Logistic regression identified that the only independent predictors of death at the time of admission were the degree of cholecystitis (OR 2.87, p=0.018) and the Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) score (OR 1.14, p=0.001). The evaluation for the initial treatment in acute cholecystitis should include a systematic determination of the degree of cholecystitis and a surgical risk assessment. Tokyo guideline recommendations should be reviewed.