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TOPLINE:

Surgical treatment of acute cholecystitis in older patients with multiple comorbidities was linked to lower rates of readmissions and emergency department (ED) revisits than nonoperative treatment, challenging the convention that these patients are “too sick” for surgery.

METHODOLOGY:

• Acute cholecystitis in older patients with multiple health issues is linked to a a high risk for morbidity and mortality, but there is a debate about whether surgical or nonsurgical treatment is the option.
• Researchers conducted a nationwide, retrospective study from 2016 to 2018 to compare the effectiveness of operative treatment with that of nonoperative treatment in 32,527 Medicare beneficiaries (median age, 78.8 years; 54.2% men) with multiple health issues who were hospitalized emergently with acute cholecystitis.
• Among them, 21,728 (66.8%) underwent surgical treatment, and 10,799 (33.2%) received nonsurgical treatment.
• The primary outcome was 30- and 90-day mortality, and secondary outcomes were readmission rates, ED revisit rates, and treatment costs.
• A preference-based instrumental variable approach was used to identify cases in which the decision to operate was in clinical equipoise, meaning cases in which there was genuine uncertainty about the best treatment option.

TAKEAWAY:

• Among all patients, operative treatment was associated with a lower risk for 30- and 90-day mortality than nonoperative treatment (risk difference [RD], −0.03 and −0.04, respectively; P < .001 for both).
• Operative treatment was also associated with a lower risk for 30- and 90-day readmissions (RD, −0.12 and −0.18, respectively; P < .001 for both) and 30- and 90-day ED revisits (RD, −0.06 and −0.10, respectively; P < .001 for both).
• In patients with treatment decisions in clinical equipoise, surgical treatment was linked to a lower risk for 30- and 90-day readmissions (RD, −0.15 and −0.23, respectively; P < .001 for both), as well as reduced 30- and 90-day ED revisits (RD, −0.09 and −0.12, respectively; P < .001 for both). However, differences in mortality rates between the two groups did not reach clinical significance.
• Surgical treatment was linked to significantly higher care costs at index hospitalization but significantly lower costs at 90 and 180 days.

IN PRACTICE:

“This challenges 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,” the authors wrote.

SOURCE:

This study, led by Rachael C. Acker, MD, Department of Surgery, University of Pennsylvania Health System, Philadelphia, was published online in JAMA Surgery.

LIMITATIONS:

Because the research was a retrospective cohort study using administrative claims data, differences in patient physiology that may have influenced surgical decisions were unknown. Researchers did not examine postoperative complications due to limited accuracy in documentation of surgical complications in Medicare claims data. Additionally, outcomes beyond 90 days were not examined.

DISCLOSURES:

This study was supported by a grant from the National Institute on Aging. One author reported receiving grants from the American College of Surgeons Resident Research Scholarship outside the submitted work, and another author reported receiving grants from the National Institutes of Health during conduct of the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.