Mortality risk estimation in acute calculous cholecystitis: beyond the Tokyo Guidelines

Ana María González-Castillo, Juan Sancho-Insenser, Maite De Miguel-Palacio, Josep-Ricard Morera-Casaponsa, Estela Membrilla-Fernández, María-José Pons-Fragero, Miguel Pera-Román, Luis Grande-Posa, Ana María González-Castillo, Juan Sancho-Insenser, Maite De Miguel-Palacio, Josep-Ricard Morera-Casaponsa, Estela Membrilla-Fernández, María-José Pons-Fragero, Miguel Pera-Román, Luis Grande-Posa

Abstract

Background: Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The recommended treatment is the early laparoscopic cholecystectomy; however, the Tokyo Guidelines (TG) advocate for different initial treatments in some subgroups of patients without a strong evidence that all patients will benefit from them. There is no clear consensus in the literature about who is the unfit patient for surgical treatment. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification.

Methods: Retrospective unicentric cohort study of patients emergently admitted with and ACC during 1 January 2011 to 31 December 2016. The study comprised 963 patients. Primary outcome was the mortality after the diagnosis. A propensity score method was used to avoid confounding factors comparing surgical treatment and non-surgical treatment.

Results: The overall mortality was 3.6%. Mortality was associated with older age (68 + IQR 27 vs. 83 + IQR 5.5; P = 0.001) and higher Charlson Comorbidity Index (3.5 + 5.3 vs. 0+2; P = 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.7-12.8 P = 0.001), dementia (OR 4.12; 95% CI 1.34-12.7, P = 0.001), age > 80 years (OR 1.12: 95% CI 1.02-1.21, P = 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.5-28.3, P = 0.001) which predicted the mortality in a 92% of the patients. The receiver operating characteristic curve yielded an area of 88% significantly higher that 68% (P = 0.003) from the TG classification. When comparing subgroups selected using propensity score matching with the same morbidity and severity of ACC, mortality was higher in the non-surgical treatment group. (26.2% vs. 10.5%).

Conclusions: Mortality was higher in ACC patients treated with non-surgical treatment. ACME identifies high-risk patients. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC.

Trial registration: Retrospectively registered and recorded in Clinical Trials. NCT04744441.

Keywords: Acute calculous cholecystitis; Acute cholecystitis; Charlson Comorbidity Index; Delayed cholecystectomy; Early cholecystectomy; High-risk patient; Mortality; Non-surgical treatment; Percutaneous cholecystostomy; Tokyo Guidelines.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Patient selection and patient flow diagram
Fig. 2
Fig. 2
Mortality depending on the precise etiology of ACC
Fig. 3
Fig. 3
Charlson Comorbidity Index components as risk for mortality in acute cholecystitis
Fig. 4
Fig. 4
ROC curve for mortality: ACME vs TG18

References

    1. Pisano M, Allievi N, Gurusamy K, Borzellino G, Cimbanassi S, Boerna D, Coccolini F, Tufo A, di Martino M, Leung J, Sartelli M, Ceresoli M, Maier RV, Poiasina E, de Angelis N, Magnone S, Fugazzola P, Paolillo C, Coimbra R, di Saverio S, de Simone B, Weber DG, Sakakushev BE, Lucianetti A, Kirkpatrick AW, Fraga GP, Wani I, Biffl WL, Chiara O, Abu-Zidan F, Moore EE, Leppäniemi A, Kluger Y, Catena F, Ansaloni L. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg. 2020;15(1):1–26. doi: 10.1186/s13017-020-00336-x.
    1. Shaffer EA. Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st century? Curr Gastroenterol Rep. 2005;7(2):132–140. doi: 10.1007/s11894-005-0051-8.
    1. Yokoe M, Takada T, Hwang TL, Endo I, Akazawa K, Miura F, Mayumi T, Mori R, Chen MF, Jan YY, Ker CG, Wang HP, Itoi T, Gomi H, Kiriyama S, Wada K, Yamaue H, Miyazaki M, Yamamoto M. Validation of TG13 severity grading in acute cholecystitis: Japan-Taiwan collaborative study for acute cholecystitis. J Hepatobiliary Pancreat Sci. 2017;24(6):338–345. doi: 10.1002/jhbp.457.
    1. Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, Iwashita Y, Hibi T, Pitt HA, Umezawa A, Asai K, Han HS, Hwang TL, Mori Y, Yoon YS, Huang WSW, Belli G, Dervenis C, Yokoe M, Kiriyama S, Itoi T, Jagannath P, Garden OJ, Miura F, Nakamura M, Horiguchi A, Wakabayashi G, Cherqui D, de Santibañes E, Shikata S, Noguchi Y, Ukai T, Higuchi R, Wada K, Honda G, Supe AN, Yoshida M, Mayumi T, Gouma DJ, Deziel DJ, Liau KH, Chen MF, Shibao K, Liu KH, Su CH, Chan ACW, Yoon DS, Choi IS, Jonas E, Chen XP, Fan ST, Ker CG, Giménez ME, Kitano S, Inomata M, Hirata K, Inui K, Sumiyama Y, Yamamoto M. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55–72. doi: 10.1002/jhbp.516.
    1. Zafar SN, Obirieze A, Adesibikan B, Cornwell EE, Fullum TM, Tran DD. Optimal time for early laparoscopic cholecystectomy for acute cholecystitis. JAMA Surg. 2015;150(2):129–136. doi: 10.1001/jamasurg.2014.2339.
    1. Gutt CN, Encke J, Köninger J, Harnoss JC, Weigand K, Kipfmüller K, Schunter O, Götze T, Golling MT, Menges M, Klar E, Feilhauer K, Zoller WG, Ridwelski K, Ackmann S, Baron A, Schön MR, Seitz HK, Daniel D, Stremmel W, Büchler MW. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC Study, NCT00447304) Ann Surg. 2013;258(3):385–391. doi: 10.1097/SLA.0b013e3182a1599b.
    1. Kao LS, Ball CG, Chaudhury PK. Evidence-based reviews in surgery. early cholecystectomy for cholecystitis. Ann Surg. 2018;268(6):940–942. doi: 10.1097/sla.0000000000002867.
    1. Macafee DA, Humes DJ, Bouliotis G, Beckingham IJ, Whynes DK, Lobo DN. Prospective randomized trial using cost-utility analysis of early versus delayed laparoscopic cholecystectomy for acute gallbladder disease. Br J Surg. 2009;96(9):1031–1040. doi: 10.1002/bjs.6685.
    1. Campanile FC, Catena F, Coccolini F, Lotti M, Piazzalunga D, Pisano M, Ansaloni L. The need for new “patient-related” guidelines for the treatment of acute cholecystitis. World J Emerg Surg. 2011;6(1):2–4. doi: 10.1186/1749-7922-6-44.
    1. Pisano M, Campanile FC. Acute calculus cholecystitis: commentary on Tokyo Guidelines 2018. J Hepatobiliary Pancreat Sci. 2018;25(3):E3–4. 10.1002/jhbp.535. Accessed 2011.
    1. Kortram K, van Ramshorst B, Bollen TL, Besselink MGH, Gouma DJ, Karsten T, Kruyt PM, Nieuwenhuijzen GAP, Kelder JC, Tromp E, Boerma D. Acute cholecystitis in high risk surgical patients: Percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): Study protocol for a randomized controlled trial. Trials. 2012;13(1):1–7. doi: 10.1186/1745-6215-13-7.
    1. The Royal College of Surgeons of England/Department of Health. The Higher Risk General Surgical Patient: Towards Improved Care for a Forgotten Group. London; 2011. .
    1. González-Muñoz JI, Franch-Arcas G, Angoso-Clavijo M, Sánchez-Hernández M, García-Plaza A, Caraballo-Angeli M, Muñoz-Bellvís L. Risk-adjusted treatment selection and outcome of patients with acute cholecystitis. Langenbeck’s Arch Surg. 2017;402(4):607–614. doi: 10.1007/s00423-016-1508-y.
    1. Charlson ME, Pompei P, Ales KL, MacKenzie R, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis. 1987;40(5):373–383. doi: 10.1016/0021-9681(87)90171-8.
    1. Hernández M, Murphy B, Aho JM, et al. Validation of the AAST EGS acute cholecystitis grade and comparison with the Tokyo guidelines. Surgery. 2018;163(4):739–746. doi: 10.1016/j.surg.2017.10.041.
    1. Fagenson AM, Powers BD, Zorbas KA, Karhadkar S, Karachristos A, di Carlo A, Lau KN. Frailty predicts morbidity and mortality after laparoscopic cholecystectomy for acute cholecystitis: an ACS-NSQIP cohort analysis. J Gastrointest Surg. 2020;24(4):1–9. doi: 10.1007/s11605-020-04570-1.
    1. Resio BJ, Chiu AS, Zhang Y, Pei KY. Characterization of high mortality probability operations at national surgical quality improvement program hospitals. JAMA Surg. 2020;155(1):85–88. doi: 10.1001/jamasurg.2019.3750.
    1. Treinen C, Lomelin D, Krause C, Goede M, Oleynikov D. Acute acalculous cholecystitis in the critically ill: risk factors and surgical strategies. Langenbeck’s Arch Surg. 2015;400(4):421–427. doi: 10.1007/s00423-014-1267-6.
    1. Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status – historical perspectives and modern developments. Anaesthesia. 2019;74(3):373–379. doi: 10.1111/anae.14569.
    1. Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46(3):399–424. doi: 10.1080/00273171.2011.568786.
    1. Yokoe M, Takada T, Hwang TL, Endo I, Akazawa K, Miura F, Mayumi T, Mori R, Chen MF, Jan YY, Ker CG, Wang HP, Itoi T, Gomi H, Kiriyama S, Wada K, Yamaue H, Miyazaki M, Yamamoto M. Descriptive review of acute cholecystitis: Japan-Taiwan collaborative epidemiological study. J Hepatobiliary Pancreat Sci. 2017;24(6):319–328. doi: 10.1002/jhbp.450.
    1. Naidu K, Beenen E, Gananadha S, Mosse C. The yield of fever, inflammatory markers and ultrasound in the diagnosis of acute cholecystitis: a validation of the 2013 Tokyo Guidelines. World J Surg. 2016;40(12):2892–2897. doi: 10.1007/s00268-016-3660-5.
    1. Endo I, Takada T, Hwang TL, Akazawa K, Mori R, Miura F, Yokoe M, Itoi T, Gomi H, Chen MF, Jan YY, Ker CG, Wang HP, Kiriyama S, Wada K, Yamaue H, Miyazaki M, Yamamoto M. Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study. J Hepatobiliary Pancreat Sci. 2017;24(6):346–361. doi: 10.1002/jhbp.456.
    1. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Kiriyama S, Kimura Y, Tsuyuguchi T, Itoi T, Yoshida M, Miura F, Yamashita Y, Okamoto K, Gabata T, Hata J, Higuchi R, Windsor JA, Bornman PC, Fan ST, Singh H, de Santibanes E, Kusachi S, Murata A, Chen XP, Jagannath P, Lee S, Padbury R, Chen MF, Tokyo Guidelines Revision Committee New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci. 2012;19(5):578–585. doi: 10.1007/s00534-012-0548-0.
    1. Lin D, Wu S, Fan Y, Ke C. Comparison of laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy in aged acute calculous cholecystitis: a cohort study. Surg Endosc. 2020;34(7):2994–3001. doi: 10.1007/s00464-019-07091-4.
    1. Bekki T, Abe T, Amano H, Hanada K, Kobayashi T, Noriyuki T, et al. Validation of the Tokyo guideline 2018 treatment proposal for acute cholecystitis from a single-center retrospective analysis. Asian J Endosc Surg. 2020(1):1–7. 10.1111/ases.12801.
    1. Abe T, Amano H, Hanada K, Bekki T, Minami T, Yonehara S, Noriyuki T, Nakahara M. Efficacy and safety of early cholecystectomy for comorbid acute cholecystitis and acute cholangitis: Retrospective cohort study. Ann Med Surg. 2019;38:8–12. doi: 10.1016/j.amsu.2018.10.031.
    1. Pisano M, Ceresoli M, Allegri A, et al. Single center retrospective analysis of early vs. delayed treatment in acute calculous cholecystitis: application of a clinical pathway and an economic analysis. Ulus Travma Acil Cerrahi Derg. 2015;21(5):373–379. doi: 10.5505/tjtes.2015.62679.
    1. Amirthalingam V, Low JK, Woon W, Shelat V. Tokyo Guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too. Surg Endosc Other Interv Tech. 2017;31(7):2892–2900. doi: 10.1007/s00464-016-5300-4.
    1. Lee S-W, Yang SS, Chang C-S, Yeh H-J. Impact of the Tokyo guidelines on the management of patients with acute calculous cholecystitis. J Gastroenterol Hepatol. 2009;24(12):1857–1861. doi: 10.1111/j.1440-1746.2009.05923.x.
    1. Joseph B, Jehan F, Dacey M, et al. Evaluating the relevance of the 2013 Tokyo Guidelines for the diagnosis and management of cholecystitis. J Am Coll Surg. 2018;227(1):38–43. doi: 10.1016/j.jamcollsurg.2018.02.016.
    1. Lo C-M, Liu C-L, Fan S-T, Glas F, Lai EC, Wong J. Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg. 1998;227(4):461–467. doi: 10.1097/00000658-199804000-00001.
    1. Rice CP, Vaishnavi KB, Schaeffer AB, et al. Operative complications and economic outcomes of cholecystectomy for acute cholecystitis. World J Gastroenterol. 2019;25(48):6916–6927. doi: 10.3748/wjg.v25.i48.6916.
    1. Strasberg SM. Acute Calculous Cholecystitis. N Engl J Med. 2008;359(3):325. doi: 10.1056/NEJMx080023.
    1. Bonaventura A, Leale I, Carbone F, Liberale L, Dallegri F, Montecucco F, Borgonovo G. Pre-surgery age-adjusted Charlson Comorbidity Index is associated with worse outcomes in acute cholecystitis. Dig Liver Dis. 2019;51(6):858–863. doi: 10.1016/j.dld.2018.10.002.
    1. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG, Tokyo Guidelines Revision Committee TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos) J Hepatobiliary Pancreat Sci. 2013;20(1):35–46. doi: 10.1007/s00534-012-0568-9.
    1. Feigal DW, Blaisdell FW. The estimation of surgical risk. Med Clin North Am. 1979;63(6):1131–1143. doi: 10.1016/S0025-7125(16)31631-5.
    1. Anderloni A, Buda A, Vieceli F, Khashab MA, Hassan C, Repici A. Endoscopic ultrasound-guided transmural stenting for gallbladder drainage in high-risk patients with acute cholecystitis: a systematic review and pooled analysis. Surg Endosc. 2016;30(12):5200–5208. doi: 10.1007/s00464-016-4894-x.
    1. Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ. Variations in mortality after emergency laparotomy: The first report of the UK emergency laparotomy network. Br J Anaesth. 2012;109(3):368–375. doi: 10.1093/bja/aes165.
    1. Pisano M, Ceresoli M, Cimbanassi S, Gurusamy K, Coccolini F, Borzellino G, Costa G, Allievi N, Amato B, Boerma D, Calcagno P, Campanati L, Campanile FC, Casati A, Chiara O, Crucitti A, di Saverio S, Filauro M, Gabrielli F, Guttadauro A, Kluger Y, Magnone S, Merli C, Poiasina E, Puzziello A, Sartelli M, Catena F, Ansaloni L. 2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population. World J Emerg Surg. 2019;14(1):10. doi: 10.1186/s13017-019-0224-7.
    1. Loozen CS, Van Santvoort HC, Van Duijvendijk P, et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): Multicentre randomised clinical trial. BMJ. 2018;363:k3965. doi: 10.1136/bmj.k3965.
    1. Castillo-Angeles M, Cooper Z, Jarman MP, Sturgeon D, Salim A, Havens JM. Association of frailty with morbidity and mortality in emergency general surgery by procedural risk level. JAMA Surg. 2021;156(1):68–74. doi: 10.1001/jamasurg.2020.5397.
    1. Takemoto Y, Abe T, Amano H, Hanada K, Fujikuni N, Yoshida M, Kobayashi T, Ohdan H, Noriyuki T, Nakahara M. Propensity score-matching analysis of the efficacy of late cholecystectomy for acute cholecystitis. Am J Surg. 2017;214(2):262–266. doi: 10.1016/J.AMJSURG.2017.01.015.
    1. Asai K, Watanabe M, Kusachi S, Matsukiyo H, Saito T, Ishii T, Kujiraoka M, Katagiri M, Katada N, Saida Y. Evaluating the timing of laparoscopic cholecystectomy for acute cholecystitis in an experienced center based on propensity score matching. Asian J Endosc Surg. 2017;10(2):166–172. doi: 10.1111/ases.12353.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner