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Clinical Outcomes in Same Admission and Delayed Surgical Intervention in Acute Gallstone Disease

Krishnamurthy Vaishnavi

The University of Texas Medical Branch at Galveston

Introduction: Recent management of gallstone-related diseases presenting emergently favor same admission (SA) cholecystectomy based on cost savings. We hypothesize that the existence of complications during SA cholecystectomy could negate the cost savings. We evaluated the complications and charges in cholecystectomies performed at the University of Texas Medical Branch (University of Texas Medical Branch ) either on SA or later after conservative management (Delayed) over a 8.5-year period. Methods: A retrospective cohort study was conducted under an Institutional Review Board-approved protocol (IRB #18-0042) of all adult patients who underwent a cholecystectomy over an 8.5-year period (2010-2018) at University of Texas Medical Branch . Patient data was retrieved using the University of Texas Medical Branch acute care surgery database, Department of Surgery billing database and University of Texas Medical Branch Revenue Cycle Operations. Patient medical charts were reviewed from University of Texas Medical Branch ’s electronic medical records (EMR, Epic Hyperspace 2017, Epic Systems Corporation). Inclusion criteria consisted of a diagnosis of acute cholecystitis, choledocholithiasis, cholangitis, and/or gallstone pancreatitis. All subjects underwent a cholecystectomy performed either electively after presenting with acute gallstone disease or emergently on index admission. Exclusion criteria included cholecystectomies performed on chronic conditions, subjects operated via the Texas Department of Criminal Justice and, patients less than 18 years of age. Comparisons were analyzed with χ2, Fisher’s exact, and t-tests; significance was set at p<0.05. Results: Complication rates for acute cholecystitis were significantly increased on SA (18.5% vs. 4.4%, p=0.004). Specifically, patients with moderate disease (Tokyo 2) suffered significantly more complications in SA while none who were Delayed experienced a complication (26.4% vs. 0.0%, p=0.0003). Mortality rates for acute cholecystitis were 0.6% vs. 0% for SA vs. Delayed. However, the complication rates were not significantly different for choledocholithiasis and gallstone pancreatitis. Finally, more patients were uninsured in the SA compared to the Delayed group (28.8% and 2.9%, p<0.0001). Conclusions: Our observation of the complications in patients undergoing SA cholecystectomy for acute gallstone disease supports a selective approach to surgery. Specifically, if patients are not insured and they have moderate acute cholecystitis, they may experience more complications and charges incurred with same admission (SA) operations.

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