A population-based analysis of the clinical course of 10,304 patients with acute cholecystitis, discharged without cholecystectomy

BACKGROUND: Randomized trials and expert opinion support early laparoscopic cholecystectomy for most patients with acute cholecystitis (AC); however, practice patterns remain variable worldwide, and delayed cholecystectomy remains a common practice. We therefore present a population-based analysis of the clinical course of patients with AC discharged without cholecystectomy. METHODS: Using administrative databases capturing all emergency department (ED) visits and hospital admissions within a geographic region encompassing 13 million persons, we identified adults with a first emergency admission for uncomplicated AC during the period of 2004 to 2011. In those discharged without cholecystectomy, the probability of a subsequent gallstone-related event (gallstone-related ED visit or hospital admission) was evaluated using Kaplan-Meier methods. The association of patient characteristics with time to first gallstone-related event after discharge was explored through multivariable time to event analysis. RESULTS: Of 25,397 patients with AC, 10,304 (41%) did not undergo cholecystectomy on first admission. The probability of a gallstone-related event by 6 weeks, 12 weeks, and 1 year after discharge was 14%, 19%, and 29% respectively. Of these events, 30% were for biliary tract obstruction or pancreatitis. When controlling for sex, income, and comorbidity level, the risk of a gallstone-related event was highest for patients 18 years to 34 years old. CONCLUSION: For patients who do not undergo cholecystectomy on first admission for AC, the probability of a gallstone-related ED visit or hospital admission within 12 weeks of discharge is 19%. The increased risk in younger patients reinforces the value of early cholecystectomy in the nonelderly. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV.