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Reducing percutaneous cholecystostomy for acute calculous cholecystitis: A multisite quality improvement initiative
Abby R Gross1, Michael Littau2, Chase J Wehrle2
1Department of General Surgery, Quality Improvement & Patient Safety, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH.
Insights
A new care pathway reduced percutaneous cholecystostomy use for acute calculous cholecystitis, improving patient survival. This initiative also saw increased laparoscopic cholecystectomy rates, with a slight rise in minor bile leaks.
Area of Science:
- Surgical Quality Improvement
- Gastrointestinal Surgery
- Health Services Research
Background:
- Laparoscopic cholecystectomy is standard for acute calculous cholecystitis.
- Percutaneous cholecystostomy is reserved for high-risk patients due to complications.
- Quality initiative aimed to decrease percutaneous cholecystostomy in suitable surgical candidates.
Purpose of the Study:
- To evaluate the impact of a multidisciplinary care pathway on percutaneous cholecystostomy use.
- To assess changes in patient outcomes, including mortality and complications.
- To determine the effect on laparoscopic cholecystectomy rates and surgical resource utilization.
Main Methods:
- Implementation of a standardized care pathway across 8 teaching hospitals in October 2023.
- Definition of prohibitive surgical risk using established criteria (e.g., ACS NSQIP, Child-Pugh C, ASA IV).
- Retrospective analysis of adult patients with acute calculous cholecystitis before and after pathway implementation using ICD-10 codes.
Main Results:
- Percutaneous cholecystostomy use decreased from 9.7% to 7.2% (P=.01), with a nadir of 4.4%.
- Post-intervention, a higher proportion of percutaneous cholecystostomy recipients met prohibitive-risk criteria (67.3% vs 51.4%, P=.02).
- Reduced odds of percutaneous cholecystostomy (OR 0.71) and 30-day mortality (OR 0.60) were observed. Laparoscopic cholecystectomy rates increased (94.5% to 96.3%, P=.047), while minor bile duct leaks slightly increased (0.9% to 2.1%, P=.031).
Conclusions:
- A structured care pathway effectively reduced percutaneous cholecystostomy use for acute calculous cholecystitis.
- The pathway was associated with improved patient mortality, despite a small increase in minor bile leaks.
- Further evaluation is warranted to assess the broader applicability of this quality improvement initiative.
Background:
Laparoscopic cholecystectomy is the gold standard for treating acute calculous cholecystitis, whereas percutaneous cholecystostomy is typically reserved for patients at prohibitive surgical risk, given its greater complication rates. This multisite quality improvement initiative aimed to reduce the use of percutaneous cholecystostomy in patients at acceptable risk for surgery.
Methods:
In October 2023, a multidisciplinary team implemented an acute calculous cholecystitis care pathway across 8 teaching hospitals. Prohibitive surgical risk was defined as predicted mortality exceeding 10% by the American College of Surgeons National Surgical Quality Improvement Program Calculator, Child-Pugh Class C cirrhosis, or American Society of Anesthesiologists class IV. Adult patients with acute calculous cholecystitis were identified using International Classification of Diseases, Tenth Revision, codes 1 year before and after implementation.
Results:
Among 2,948 patients (1,438 pre- and 1,510 postimplementation), use of percutaneous cholecystostomy decreased from 9.7% to 7.2% (P = .01), reaching a nadir of 4.4%. More recipients of percutaneous cholecystostomy met prohibitive-risk criteria postintervention (51.4% vs 67.3%; P = .02). Risk-adjusted analysis showed reduced odds of percutaneous cholecystostomy (odds ratio, 0.71; 95% confidence interval, 0.62-0.80) and 30-day mortality (odds ratio, 0.60; 95% confidence interval, 0.51-0.70) after implementation. LC rates increased (94.5-96.3%, P = .047), whereas open surgery declined. Minor bile duct leaks increased from 0.9% to 2.1% (P = .031), largely among patients with gangrenous disease or subtotal cholecystectomy. No major duct injuries occurred. Reoperation, cost, readmission, and length of stay were unchanged.
Conclusion:
Implementation of a structured acute calculous cholecystitis pathway was associated with lower percutaneous cholecystostomy use and improved mortality, with a modest increase in minor bile leaks likely reflecting greater surgical complexity. Broader applicability warrants further evaluation.
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