Beware of the interval cholecystectomy

BACKGROUND Despite limited data regarding the indications and effectiveness of percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis (AC), usage has increased by over 500% since 1994. Many of these patients subsequently undergo interval cholecystectomy (IC), a procedure that has not been rigorously evaluated. This aim of this study was to quantify the morbidity and mortality associated with the IC. METHODS We included all consecutive adult patients (>18 years old) who underwent PC and IC from January 2008 to December 2013. Conversion rate, length of operation, biliary injury, estimated blood loss, surgical site infection, length of stay, and mortality were compared with 227 patients who underwent cholecystectomy for AC during the same time interval. RESULTS Of 18,501 patients who underwent cholecystectomy, 337 had at least one PC and 177 underwent subsequent IC. Compared with patients undergoing cholecystectomy for clinically diagnosed AC, patients undergoing IC were older (69.8 vs. 54.9 years; p < 0.001), thinner (body mass index, 28.7 vs. 31.1; p = 0.002), more complex by Tokyo grade (1.9 vs. 1.1; p < 0.001), and American Society of Anesthesia classification (3.0 vs. 2.5; p < 0.001), had longer operative times (120.7 vs. 92.5 minutes; p < 0.0001), more blood loss (30 vs. 15 mL; p = 0.01), and increased rates of conversion (26.6% vs. 12.8%; p < 0.001), surgical site infection (12.4% vs. 0.4%; p < 0.001), bowel injury (6.2% vs. 0.4%; p < 0.001), and 1-year mortality (15.3% vs. 0.4%; p < 0.01). Nonsignificant trends included significant biliary tract injury (3 vs. 0; p = 0.08) and longer length of stay (7.3 vs. 4.8 days; p = 0.39). Linear regression identified body mass index (p = 0.03), time from admission to PC (p = 0.03), and American Society of Anesthesia classification (p = 0.06) as predictors of a difficult IC. CONCLUSION PC has been widely adopted with limited description of the subsequent IC. Our data detail the factors predicting the challenges of IC and document that it is a difficult operation associated with significant morbidity. LEVEL OF EVIDENCE Therapeutic, level IV.