Cholecystitis treatment and outcome

Background

Acute cholecystitis (AC) is an inflamed gallbladder, generally caused by an obstructive gallstone or sludge. The incidence is high (6936 patients annually in The Netherlands, needing 38842 hospital admission days). Thus the clinical impact of creating uniformity in treatment; maximizing implementation of optimal treatment strategies, would be large. The challenge is that multiple kinds of specialists in all hospital types and sizes diagnose and treat cholecystitis. Therefore a snapshot study is ideal to investigate inter-hospital variation in treatment of cholecystitis and outcome.

In general, early laparoscopic cholecystectomy without postoperative antibiotics, is the primary treatment for cholecystitis, resulting in lowest total hospital stay and morbidity. However, daily practice largely varies due to logistic reasons, patients characteristics and surgeons preference. First, the timing of laparoscopic cholecystectomy for a 0-7 day existing cholecystitis remains variable. In the past, there was a trend to delay the cholecystectomy for 4-6 weeks as operating in the acute phase was thought to increase the iatrogenic injury rate. However, in randomized trials early laparoscopic cholecystectomy reduced total hospital stay and lowered costs without increasing complications. In daily practice, antibiotic treatment or gallbladder drainage are used as alternatives, especially as when symptom duration is longer. Specifically after 7 days of symptoms most patients do not undergo early laparoscopic cholecystectomy, as the Dutch guidelines suggests to delay surgery after this period. However, studies suggest that early laparoscopic cholecystectomy may be safe and decrease total hospital stay. Other variations are found in the use of postoperative antibiotics, a strong determinant for length of stay, and method of cystic stump closure which may determine the rate of cystic stump leakage.

Therefore, this snapshot will determine the variation in treatment of cholecystitis and its impact on outcome. Its clinical impact will be profound, forming an important incentive and guideline for optimisation of cholecystitis-treatment.

Objective

To determine adherence to the guidelines in the primary treatment of cholecystitis in the Netherlands and its impact on outcome

Main question

How are patients with a 0-7 day existing cholecystitis treated in the Netherlands and how do these treatment strategies perform? (primary outcome: total hospital stay, complication rate, re-interventions)

Sub questions

1. How are patients with a > 7 day existing cholecystitis treated in the Netherlands and how do these treatment strategies perform? (primary outcome: complication rate, total hospital stay)
2. What is the effect of different cystic duct closure type on postoperative cystic stump leakage?
3. What is the influence of hospital volume and type on treatment strategy and outcome?

Study design

Snapshot of a 4-6 month period in the Netherlands

Prospective data collection of all patients admitted to the hospital with a calculous cholecystitis

• Patient characteristics
• Hospital characteristics
• Cholecystitis characteristics
• Treatment characteristics
• Hospital stay (during primary admission and subsequent re-admissions <30-days)
• Complications and reinterventions

Study population

All patients >18 years with a calculous cholecystitis as primary reason for hospital admittance. Location of diagnosis may the emergency department, the ward during admittance for diagnostics, or during diagnostic laparoscopy. Cholecystitis is defined according to the TG18 diagnostic criteria for a definitive diagnosis of cholecystitis: A. Local signs of inflammation (Murphy’s sign and or  RUQ mass/pain/tenderness) + B. Systemic signs of inflammation (Fever, elevated CRP  and/or elevated WBC count) + C. Imaging findings characteristic of acute cholecystitis. Patients with a suspected diagnosis (one item in A + one item in B + C), of which the diagnosis is confirmed by intra-operative findings, are also included.

Main expected results

We expect that this snapshot will demonstrate a wide variation in treatment of cholecystitis in the Netherlands. Moreover, the impact of this variation on outcome will be determined, which will be an important directive for further improvement of cholecystitis treatment.

Planning

The first centres are expected to start in January 2023.

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