V4 Management of Acute cholecystitis and CHOlecystostomy - the MACHO study

BACKGROUND: Acute cholecystitis is a common reason for surgical admission. Gold standard of care includes early laparoscopic cholecystectomy (LC). Some patients may receive a cholecystostomy drain in place of this. The use of cholecystostomy in current practice is not well defined. The aim of this study is to describe variation in practice, and outcomes of drainage in acute cholecystitis. METHODS: A multicentre retrospective observational cohort study was carried out over an interval three month period. Patients were identified through clinical coding. Demographics, clinical outcomes, and intervention descriptors were collected. Logistic regression was performed to identify characteristics of patients receiving a drain, and to propensity match for clinical outcomes. RESULTS: Seven centres reported on 1131 patients. Cholecystostomy rate was 6.4%. The median age of patients was 61 (16-97). Median Charlson Comorbidity Index (CCI) was 2 (range 0-13). Drain used was associated with longer length of stay and increased readmission rates. Regression modelling found positive associations between cholecystostomy and C-reactive protein, white cell count, CCI, and acute kidney injury at admission. Propensity matching of cholecystostomy vs index LC found no difference in rates of major complications.Rates of any complication were higher in cholecystostomy vs index LC (37.0% vs 11.3%, p = 0.002). Drains were not associated with any difference in complications when compared to conservative treatment (37.1% vs 21.0%, p = 0.075). CONCLUSION: Cholecystostomy is deployed in a subgroup of unwell patients. It is not clear whether this leads to poor outcomes, or if this is a proxy marker of fitness.