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Published on: February 28, 2025
Cholecystostomy: a bridge to hospital discharge but not delayed cholecystectomy
Charles de Mestral1, David Gomez, Barbara Haas
1Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada. charles.demestral@mail.utoronto.ca
Insights
Percutaneous cholecystostomy (PC) for acute cholecystitis is often a bridge to surgery, but less than half of patients undergo cholecystectomy. High mortality and ongoing surgical contraindications are common, with a significant risk of gallstone-related events post-discharge.
Area of Science:
- Gastroenterology
- Surgical Oncology
- Public Health
Background:
- Limited data exist on the long-term outcomes of acute cholecystitis patients treated with percutaneous cholecystostomy (PC).
- This study analyzes a population-based cohort to describe the characteristics and clinical course of patients managed with PC.
Purpose of the Study:
- To evaluate the clinical course and outcomes of patients with acute cholecystitis managed with percutaneous cholecystostomy (PC).
- To determine the rates of subsequent cholecystectomy, mortality, and gallstone-related events after PC.
Main Methods:
- Retrospective cohort study using administrative databases (2004-2011) of over 13 million individuals.
- Included adults with a first emergency admission for acute cholecystitis treated with PC.
- Analyzed cumulative incidences of cholecystectomy and death, using logistic regression and Kaplan-Meier methods for gallstone-related events.
Main Results:
- Of 27,718 acute cholecystitis patients, 890 (3.3%) underwent PC; the cohort was elderly (mean age 75) with 14% ICU admission.
- In-hospital mortality was 5%. Within 1 year post-PC, only 40% had cholecystectomy, 18% died without surgery, and 49% experienced gallstone-related ED visits or admissions.
Conclusions:
- Percutaneous cholecystostomy (PC) is frequently not followed by cholecystectomy, with high mortality and persistent surgical contraindications in many patients.
- A substantial risk of recurrent gallstone-related events persists after PC, highlighting the need for further investigation into optimal management strategies.
Background:
Current data on the clinical course of patients with acute cholecystitis managed with percutaneous cholecystostomy (PC) are limited by small sample size and imperfect follow-up. We present the characteristics and clinical course of a population-based cohort with acute cholecystitis managed with PC.
Methods:
We designed a retrospective cohort study using administrative databases capturing all emergency department (ED) visits and hospital admissions within a geographic region with a population of more than 13 million. From all adults with a first emergency admission for acute cholecystitis from 2004 to 2011, those managed with PC were included in the cohort. The cumulative incidences of subsequent cholecystectomy and death were calculated, considering death a competing risk to cholecystectomy. Polytomous logistic regression was then used to examine differences in patient characteristics across outcome status at 1 year: cholecystectomy, dead without cholecystectomy, or alive without cholecystectomy. Moreover, the risk of a gallstone-related ED visit or hospital admission after discharge was estimated using the Kaplan-Meier method.
Results:
Of 27,718 patients with acute cholecystitis, 890 (3.3%) underwent PC. The cohort was elderly with a mean (SD) age of 75 (14) years, and 14% were in the intensive care unit on the day of PC. In-hospital mortality was 5%. By 1 year after PC, only 40% had undergone cholecystectomy, while an additional 18% had died without cholecystectomy. The risk of a gallstone-related ED visit or hospital admission was 49% by 1 year after discharge.
Conclusion:
While PC is often performed with the intent of delayed cholecystectomy, less than half of patients actually go on to surgery. High mortality and likely ongoing contraindications to surgery preclude intervention in most patients, although the risk of gallstone-related ED visit or hospital admission remains high. Further prospective investigation is warranted to clarify the potential mortality and quality-of-life gains from elective cholecystectomy following PC.
Level Of Evidence:
Prognostic study, level III.
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