medwireNews: Acute cholecystitis surgery in older adults with multimorbidity leads to fewer hospital readmissions and lower long-term healthcare costs than conservative management, a US study concludes.
The results challenge “the convention that this patient population is ‘too sick’ to undergo operative management for acute cholecystitis and demonstrates the importance of considering cholecystectomy in all patients with acute cholecystitis at the index presentation,” write Rachael Acker (University of Pennsylvania Health System, Philadelphia, USA) and colleagues in JAMA Surgery.
Until now, “there had been no large national studies comparing operative and nonoperative management of acute cholecystitis in a population of older adults with multimorbidity, leaving the optimal treatment course unknown,” the authors say.
The study analyzed data from 32,527 Medicare beneficiaries aged 65.5 years and older who were admitted to the emergency department (ED) with cholecystitis between 2016 and 2018.
The patients were a median of 78.8 years old, 54.2% were men, and 86.2% were White. The most common comorbid conditions in the surgical and conservative groups were congestive heart failure (29 vs 41%) and controlled diabetes (23 vs 24%).
Patients who underwent surgery (n=21,728) primarily had laparoscopic cholecystectomy (89.4%), open cholecystectomy (11.7%), or common bile duct exploration (1.9%), and 26.8% had an intraoperative cholangiogram. A further 10,799 patients were managed conservatively with antibiotics alone, and 32.1% of these had a percutaneous cholecystostomy tube inserted.
Patients undergoing surgery had a significantly lower mortality rate than those managed nonoperatively, with respective rates of 3.7% versus 10.2% at 30 days, and 6.3% and 16.8% at 90 days. In addition, surgery led to lower rates of hospital readmission (17.3 vs 29.9% at 30 days; 24.3 vs 43.6% at 90 days) and ED revisits (12.3 vs 19.6% at 30 days; 19.5 vs 31.3% at 90 days).
Fewer surgical than nonsurgical patients were readmitted for acute cholecystitis within 30 days (2.7 vs 19.7%). The most common reasons for 30-day readmission in the surgical group included sepsis (6.4%) and post-procedural infection (4.8%).
Using inverse propensity weighting to adjust for covariates including demographic characteristics, comorbid conditions, and frailty, the investigators found that operative treatment still significantly reduced both the 30- and 90-day mortality risk relative to nonoperative management, as well as significantly reducing the likelihood of readmission and ED revisits at the two timepoints.
And when assessing patients for whom the decision to operate was in clinical equipoise, there was no significant difference between operative and nonoperative approaches in terms of mortality risk, but surgery led to a significantly lower risk for readmission and ED revisits at both 30 and 90 days.
Finally, while healthcare costs for patients in clinical equipoise who underwent surgery were US$ 2,870.84 (€ 2523.63) more expensive than in the nonoperative management group during index surgery, costs among the former were significantly lower at 90 and 180 days, with differences of $ 5,495.39 (€ 3830.75) and $ 9,134.67 (€ 8029.88), respectively.
Acker and colleagues acknowledge limitations to the retrospective study, including a lack of information regarding differences in patient physiology that may have influenced a surgeon’s decision to operate.
Additionally, the overall survival benefit “does not necessarily mean that clinicians should favor operative treatment for all patients,” note the researchers, adding that there “are likely patients in our nonoperative group who would not tolerate an operation given their functional status.”
Instead, the data “refute conclusions that operative treatment of acute cholecystitis is less safe than nonoperative treatment when the treatment decision is in clinical equipoise,” the authors say.
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