Emergency cholecystectomy: risk factors and impact of delay on electively booked patients, a 5-year experience of a tertiary care center

Abstract

Background

Gallstone disease is one of the most resource-intensive surgical conditions. Despite the significant burden of emergency cholecystectomy on healthcare system, there is lack of research assessing the risk factors predisposing scheduled elective cholecystectomy patients to emergency surgery. Characterization of patients with gallstones helps to prioritize delivery of health care to avoid urgent surgery. The objective of the present study is to analyze risk factors associated with emergency cholecystectomy and assess the impact of delay on electively scheduled patients.

Methods

This retrospective cohort study at a tertiary care center in Jeddah, Saudi Arabia, between January 2018 and June 2022. Net total of 823 patients.The study has collected data retrospectively from an electronic health record system. The data were entered and coded in excel sheet. All statistical tests were 2-sided and were conducted using SAS statistical software version 9.4 (SAS Institute Inc. Cary, NC).

Results

A total of 823 patients met the inclusion criteria and enrolled in the analysis. Among them, 129 patients (15.67%) underwent emergency cholecystectomy, while 694 patients (84.33%) underwent elective cholecystectomy. The waiting time in days was significantly longer for patients undergoing emergency cholecystectomy (mean of 362 days) compared to those undergoing elective cholecystectomy (mean of 305 days). Patients with more than two previous ED visits were over five times more likely to undergo emergency cholecystectomy compared to those who had never visited the ED previously (p-value < 0.0001) Moreover, patients diagnosed with acute cholecystitis and pancreatitis were more likely to undergo emergency cholecystectomy compared to those not diagnosed with these conditions (p-value < 0.0001; p-value 0.02).

Conclusion

Analysis of risk factors and delay in patients with gallstones scheduled for elective cholecystectomy demonstrates that long waiting times, severity of the initial visit setting, Hemolytic anemia, and male gender were significantly related to emergency cholecystectomy. Independent risk factors for emergency cholecystectomy were frequency of ED visits, acute cholecystitis, pancreatitis, and CBD stone. Patients with these risk factors should be given priority on the waiting list to avoid emergency surgery. Future research is required to design a scoring system or specific criteria for elective patients at risk of developing acute cholecystitis.

Highlights

• •Highlight the impact of surgery delay on electively scheduled patients with gallstone

• •To identify the risk factor leading to emergency cholecystecomy

• •To measure the rate of emergency cholecystectomy among electively scheduled patients

Introduction

Emergency general surgery patients represent a unique subset of high-risk surgical patients. Annually, 3 million patients get admitted with emergent surgical conditions, and more than 25% of them require surgery at that admission [1]. These admissions impose a significant financial burden, as each emergency general surgery costs $10,744 per admission, which equates to $28 billion per year [2]. General surgical procedures performed on an urgent basis have been linked to significant morbidity and mortality at rates of 32.8% and 12.5%, respectively [3]. In 2010, around 896,000 deaths were attributed to complications following emergency general surgeries [4]. Compared to patients receiving elective surgery, patients receiving emergency open gastrointestinal surgery are five times more likely to die within 30 days postoperatively [5].

Emergency appendectomy, cholecystectomy, partial colectomy, small bowel resections, peptic ulcer, peritoneal adhesiolysis, and laparotomy constitute most emergency general surgeries with the highest admissions, complications, deaths, and inpatient costs. Among these surgeries, emergency cholecystectomy is the second most common emergency general surgery, after appendectomy, with a complication rate of 8% and an average cost of $10,579 per surgery [6]. Cholecystectomy performed urgently is usually due to biliary complications resulting from long-standing biliary colic in gallstone patients. Many patients who developed these biliary complications had a chronic gallstone course [7,8,9]. A meta-analysis of randomized control trials found the rate of emergency cholecystectomy to be 17.5% in gallstone patients awaiting elective surgery [10]. The long waiting period experienced by patients who require emergency cholecystectomy suggests that early intervention may prevent acute biliary complications in gallstone patients, which can improve postoperative outcomes and cost savings.

Gallstone disease is one of the most resource-intensive surgical conditions. Despite the significant burden of emergency cholecystectomy on healthcare system, there is an evident lack of research assessing the risk factors predisposing scheduled elective cholecystectomy patients to emergency surgery. Characterization of patients with gallstones helps to prioritize delivery of health care to avoid urgent surgery. Hence, the present study is aimed to determine the risk factors associated with emergency cholecystectomy and the impact of delay on electively scheduled cholecystectomy.

Methods

This retrospective cohort study is aimed to analyze risk factors associated with emergency cholecystectomy and assess the impact of delay on electively scheduled patients. The study has collected data retrospectively from an electronic health record system, of patients with gallstones treated at a tertiary care center in Jeddah, Saudi Arabia, between January 2018 and June 2022. A non-consecutive sampling technique was used in selecting the data subjects. This study included symptomatic patients with gallstones, aged between 18 and 70 years, who were placed on the waiting list for a scheduled cholecystectomy during the specified study period. However, pregnant patients, individuals with acalculous cholecystitis, and patients without clinical presentation prior to surgery were excluded from the study to maintain homogeneity of the sample. Included patients were categorized into two groups: group (I) patients who underwent elective cholecystectomy on the scheduled day; and group (II) waitlisted patients who required emergency cholecystectomy. Both groups were placed on the waiting list for a scheduled cholecystectomy at the initial visit. As per standard clinical guidelines, cholecystectomy was scheduled for every gallstone patient who presented with biliary colic [11, 12]. Patients with the earliest booked appointment were given priority to be seen in the clinic first. The surgery schedule system prioritized patients chronologically based on the initial visit date, where patients with the earliest initial visit got priority on the waiting list. The surgery may be postponed upon the patient’s request or when further anesthetic assessment is needed.

The variables considered in this study included demographics, comorbidities, setting of the first visit, waiting time, number of previous biliary-related emergency department (ED) visits, clinical symptoms, acute biliary complications, American Society of Anesthesiologists (ASA) score, lab findings, and ultrasound findings.

The initial visit was defined as the first visit at which the patient presented with relevant gallstone symptoms. Waiting time was defined as the duration between the initial visit and surgery. For an accurate estimation of the waiting period, the start point of the waiting time calculation was set at the initial visit, regardless of the hospital setting, assuming that patients were scheduled for surgery at the initial visit. Biliary-related ED visits or hospital admissions were defined as each discrete emergency or elective visit or admission secondary to symptomatic gallstone disease as a chief complaint that occurred while on the waiting list. An elective cholecystectomy was defined as a planned surgery performed on the previously scheduled day after placement on the waiting list. An emergency cholecystectomy was defined as an urgent, unplanned surgery performed while awaiting the scheduled cholecystectomy.

Statistical analysis

To examine the population’s characteristics, we conducted a univariate analysis using chi-square, Fisher exact test for categorical variables, and t-test for numeric variables. In the multivariate analysis, we used a multiple binary logistic model with an outcome of emergent vs. elective cholecystectomy. The model was adjusted for demographic variables (age, gender, BMI, and visit characteristics). The blood profile was not included in the final model due to large missing values. Due to the large number of potential predictor variables, we used the forward stepwise selection method to select a subset of variables from the larger set of predictor variables that are most relevant for predicting emergent cholecystectomy [13, 14]. We chose an entry probability of < 0.05 and < 0.03 by the stepwise selection method. During the model-comparison phase, we evaluated and compared the effectiveness of the three predictive models based on their area under the curve (AUC) values derived from receiver operating characteristic (ROC) curves and decision curve analysis (DCA)(Fig. 1). Subsequently, we identified and chose the model that demonstrated the greatest overall diagnostic efficacy for additional validation [15]. The binary logistic regression assumptions were examined and successfully satisfied the criteria [16]. Moderate multicollinearity was observed among the predictor variables. All statistical tests were 2-sided and were conducted using SAS statistical software version 9.4 (SAS Institute Inc. Cary, NC).

Fig. 1

Area under the curve for model evaluation

Results

A total of 823 patients met the inclusion criteria and enrolled in the analysis. Among them, 129 patients (15.67%) underwent emergency cholecystectomy, while 694 patients (84.33%) underwent elective cholecystectomy. A higher percentage of males underwent emergency cholecystectomy (31.78%) compared to those who underwent elective cholecystectomy (23.49%). The waiting time in days was significantly longer for patients undergoing emergency cholecystectomy (mean of 362 days) compared to those undergoing elective cholecystectomy (mean of 305 days), with a p-value of less than 0.0001. Moreover, the interval in days between the onset of symptoms and the first medical visit was significantly longer among patients undergoing elective cholecystectomy (mean of 134 days) compared to those undergoing emergency cholecystectomy (mean of 66 days), with a p-value of 0.008 (Table 1).

Table 1 Demographic characteristics for the cholecystectomy patients (N=823)

There were no statistically significant differences in the distribution of comorbidity between patients undergoing emergency cholecystectomy and those undergoing elective cholecystectomy, except for chronic hemolytic anemia (p-value 0.0001). A higher percentage of patients diagnosed with chronic hemolytic anemia (CHA) was observed in the emergency cholecystectomy group (4.65%) compared to the elective cholecystectomy group (0.58%) (Table 2). Regarding cholecystectomy-related characteristics, nearly half of the patients reported nausea and/or vomiting, with a slightly higher percentage among those undergoing emergency cholecystectomy (45.74% vs. 42.94% in elective cholecystectomy), and (48.06% in emergency cholecystectomy vs. 33% in elective cholecystectomy) (Table 3).

Table 2 Characteristics for the cholecystectomy patients

Table 3 Cholecystectomy related characteristics

The number of previous biliary-related ED visits was significantly higher among patients undergoing emergency cholecystectomy (79.07%) compared to elective cholecystectomy (9.42%) with a p-value of less than 0.0001. Additionally, a higher percentage of patients had at least one previous hospital admission among those who underwent emergency cholecystectomy (20.16%) compared to those who underwent elective cholecystectomy (13.11%). More than 50% of patients undergoing emergency cholecystectomy were diagnosed with acute cholecystitis, whereas only 10.52% of those undergoing elective cholecystectomy were diagnosed with acute cholecystitis (p-value < 0.0001). Similar patterns were observed for pre-operative ERCP and pericholecystic fluid, with higher percentages in emergency cholecystectomy patients compared to elective (16.28% vs. 6.2% with a p-value < 0.0001; 17.83% vs. 5.19% with a p-value < 0.0001) (Table 3). In terms of blood profile, there were no statistically significant differences between both groups except for white blood cells, alkaline phosphatase, and total bilirubin. were the mean of all was significantly higher among emergency cholecystectomy compared to elective (8.39 vs. 7.62 p-values 0.008; 132.66 vs. 106.39, p-value 0.04: 24.41 vs. 17.66, p-value 0.04 respectively) (Table 4).

Table 4 Cholecystectomy related characteristics

In the multivariate analysis using multiple logistic regression, the number of previous biliary-related ED visits showed a statistically significant difference between patients undergoing emergency and elective cholecystectomy. Patients with more than two previous ED visits were over five times more likely to undergo emergency cholecystectomy compared to those who had never visited the ED previously (Odds Ratio [OR] 5.69; confidence interval [CI] 2.76, 11.69; p-value < 0.0001) (Fig. 2),(Table 5). Conversely, patients with more than two previous admissions were less likely to undergo emergent cholecystectomy compared to those who had never been admitted (OR 0.28; CI 0.14, 0.58; p-value 0.006). Moreover, patients diagnosed with acute cholecystitis and pancreatitis were more likely to undergo emergency cholecystectomy compared to those not diagnosed with these conditions (OR 12.51, CI 7.61, 20.57; p-value < 0.0001; OR 2.26; CI 1.07, 4.77; p-value 0.02; OR 13.51; CI 6.79, 26.86; p-value < 0.0001, respectively) (Fig. 2),(Table 5).

Fig. 2

Odds ratio

Table 5 Multivariate logistic regression analysis for predictors of emergent vs elective cholecystectomy

Discussion

This study examined the factors predisposing patients with gallstones to receive emergency cholecystectomy. Using our institutional data, we found that long waiting times, the severity of the setting of the initial visit, chronic hemolytic anemia, and male gender are predisposing factors to emergency cholecystectomy. In multivariate analysis, the number of biliary-related ED visits, acute cholecystitis, pancreatitis, and common bile duct stones were independent predisposing factors. Further, patients who had more than two biliary-related ED visits while awaiting their elective surgery are five times more likely to receive an emergency cholecystectomy than those who never visited the ED. Characterization of patients with gallstones helps to prioritize delivery of health care to patients based on clinical urgency and risk factor profile.

Many authors recommend early surgical intervention for patients with uncomplicated biliary colic on index admission [17,18,19,20,21]. Despite these recommendations, performing early cholecystectomy in centers dealing with high volumes of biliary admissions and long elective surgery waiting times remains a challenge. These centers are under significant strain on timely surgical interventions, resulting in unwanted delays [22]. Our institution is a tertiary center that deals with a high volume of biliary admissions and prioritizes them chronologically, with early presentations getting higher priority. Although prioritizing patients chronologically should have ensured minimal waiting time, our results showed that waiting time is long even for elective cases, with an average period of 305 days. Previous analysis of the impact of delay on elective cholecystectomy for patients with gallstones was found to be associated with emergency surgery [7,8,9]. Similarly, our findings supported this observation by showing an increased risk of emergency cholecystectomy in patients with long waiting times, with an average period of 362 days. Patients with long waiting times are susceptible to developing recurrent biliary colic or acute biliary complications such as acute cholecystitis (50.39%), pancreatitis (22.48%), or CBD stones (7.75%) as found in this study. Each of these complications was an independent predisposing factor for emergency cholecystectomy in our multivariate analysis. The risk of developing biliary complications is directly proportional to the waiting time and increases substantially after 20 weeks as the probability of performing emergency surgery approaches 40% within 40–52 weeks after being scheduled for surgery [7]. A recent study reported that 83% of patients requiring emergency cholecystectomy had evidence of chronic inflammation on pathology, implying chronicity of biliary symptoms in such a cohort [9].

Several factors have been attributed to the delay of cholecystectomy beyond the recommended timeframe. Some of these factors restrain access to care, such as lack of insurance, difficulty in booking a follow-up appointment, difficulty in finding transportation, and conflicts with work schedules [9]. Other factors limit healthcare delivery, such as the availability of operating theaters and beds, receiving more urgent cases, and allocating a high volume of patients to surgeons [20, 22, 23]. Despite the results of the present study, specific patients may benefit from waiting, such as those on anticoagulants or patients with cardiopulmonary conditions requiring optimization and meticulous anesthetic assessment prior to surgery [24, 25].

While on the waiting list, the frequency of ED presentations increases due to symptom escalation. R. David et al. reported that 40.9% of patients who presented to the ED with biliary colic returned with either recurrent attacks or the development of biliary complications [20]. J. Gazzetta et al. demonstrated that over 20% of patients who presented to the ED were unable to undergo a timely elective cholecystectomy and subsequently returned to the ED due to biliary-related conditions [26]. Mestral et al. reported that the probability of biliary-related ED visits or admissions within 12 weeks in gallstone patients after the first episode of acute cholecystitis is 19%, with 30% of the events for pancreatitis [27]. Our multivariate analysis showed that patients with more than two biliary-related ED visits are five times more likely to receive emergency cholecystectomy. Emad et al. showed that 42% of patients with a history of biliary-related ED visits on the waiting list required emergency cholecystectomy [28]. Surprisingly, our findings showed less frequency of hospital admissions in patients who underwent emergency cholecystectomy, contrary to biliary-related ED visits. Similar findings were reported by Lucocq et al. who noticed lower hospital admissions in patients required emergency cholecystectomy compared to their elective counterparts [29]. Arguably, patients with multiple hospital admissions may have severe biliary pathology, thus they are more likely to require emergency surgery. Despite the feasibility of this concept, multiple contributing factors may interplay and generate different results. In contrast to ED visits, hospital admissions require surgical consultations, and based on the severity of the disease, surgeons may expedite the scheduled surgery for earlier date, which reduces the waiting time and the risk of emergency surgery. Another explanation is that some surgeons prefer to not operate during an acute admission with active inflammation, but rather delay the surgery until the acute episode is settled.

The severity of the initial presentation setting, the hospital setting where the patient was first seen symptomatic, plays a role in the multiplicity of biliary-related ED visits. Patients initially presented to the ED are prone to visit the ED more frequently than patients initially presented to outpatient clinics [30, 31]. Likewise, patients requiring admission on initial presentations have a 48% risk of emergency readmission within the first 10 months while awaiting elective cholecystectomy [21]. Although the association between the severity of initial presentation and the multiplicity of biliary-related ED visits was not analyzed in this study, we found an association between the severity of initial presentation and emergency cholecystectomy. Comparably, a billing record analysis found that 20% of patients initially presented to the ED returned within 30 days, requiring emergency cholecystectomy [32].

Among the included comorbidities in this study, only CHA showed a significant relation with emergency cholecystectomy. A possible explanation is that patients with hemoglobinopathies are at higher risk of infections than the general population, particularly following splenectomy. Gurro et al. examined the gallbladders of symptomatic patients with CHA, and most of the specimens were found to be inflamed and infected [33]. Another explanation is that biliary complications could be confused with vaso-occlusive crises in SCD patients, as both have similar presentations with abdominal pain, jaundice, and fever leading to inappropriate management and misdiagnosis. A previous study reported that 67% of patients with SCD required emergency cholecystectomy [34]. In thalassemia patients, acute cholecystitis leads to pronounced life-threatening complications compared with acute cholecystitis in the general population as most mortality in thalassemia patients who underwent cholecystectomy is due to acute cholecystitis [35]. NIH consensus conference guideline recommends cholecystectomy for only symptomatic gallstone patients and asymptomatic patients at high risk of gallbladder cancer [12]. EASL clinical practice guideline recommends cholecystectomy for asymptomatic patients with CHA only when performed simultaneously with another major abdominal surgery [11]. These recommendations may limit the eligibility criteria for cholecystectomy in patients with CHA resulting in delayed surgery. Unfortunately, the majority of symptomatic patients with SCD have advanced clinical presentation at the time of cholecystectomy, and 75% of patients showed a chronic inflammatory state on pathology [36, 37]. Based on the results of this study, patients with CHA should be at least given priority on the waiting list to ensure timely intervention and avoid emergency cholecystectomy in this vulnerable population.

Identifying social and demographic determinants of health can additionally help in recognizing risk factors associated with recurrent biliary-related ED visits. Gender variance in the severity of biliary diseases, and male gender as a predisposing factor for complicated gallstone disease has been a topic of interest. Russell et al. stated that symptomatic males with gallstones have a different and more virulent disease compared to females [38]. Symptomatic males tend to experience more extensive gallbladder inflammation and fibrosis, with a higher rate of complications such as necrotizing or gangrenous cholecystitis [39]. Our results supported this context by showing a significant relation between male gender and emergency cholecystectomy. Similar results were reported by Kanakala et al., who found a significant portion of male patients required emergency cholecystectomy [40]. Margiotta et al. reported that males are 1.5 times more likely to receive emergency cholecystectomy due to acute cholecystitis than females [41]. Lein et al. hypothesized that higher pain threshold expressed by males delay their presentation and expose them to recurrent, undiagnosed cholecystitis [42]. Moreover, recent surgical studies have concluded that socially disadvantaged populations would benefit more from undergoing surgery at the time of their initial ED presentation rather than being discharged for elective follow-up. Up to 50% of these patients are lost to follow-up due to a variety of factors, making them significantly more likely to experience adverse outcomes and complications. Among patients diagnosed with symptomatic cholelithiasis in the ED, the absence of a primary care physician, Black race, lack of insurance, and unemployment were independently associated with a higher likelihood of re-presentation to the ED for biliary symptoms. The reasons for racial disparities are unlikely to be solely due to disease burden and are more likely the result of multifactorial social and systemic influences [26].

The present study has several limitations that must be considered. First, the number of episodes of acute biliary complications and the duration between each episode in patients with recurrent biliary complications were not recorded. This variable may generate a new subgroup at risk of emergency cholecystectomy with a different risk ratio. Second, patients who received another abdominal surgery simultaneously with cholecystectomy were not excluded. These patients may undergo surgery earlier since other abdominal surgeries have shorter waiting lists, and surgeons may choose to perform a concomitant cholecystectomy on the scheduled day of the second surgery. Third, although presuming that patients were scheduled for surgery at the initial visit, despite its setting, can give a better estimation of the waiting time, this approach may not fully reflect clinical reality. For example, surgery for patients initially presented to the ED is usually scheduled after discharge and follow-up in outpatient surgical clinics but not in the ED. However, this approach allowed us to not overlook the symptomatic period between the initial ED visit and follow-up in the outpatient surgical clinic.

Conclusion

Analysis of risk factors and delay in patients with gallstones scheduled for elective cholecystectomy demonstrates that long waiting times, severity of the initial visit setting, Hemolytic anemia, and male gender were significantly related to emergency cholecystectomy. Independent risk factors for emergency cholecystectomy were frequency of ED visits, acute cholecystitis, pancreatitis, and CBD stone. Patients with these risk factors should be given priority on the waiting list to avoid emergency surgery. Future research is required to design a scoring system or specific criteria for elective patients at risk of developing acute cholecystitis.