A prospective cohort study of 200 acute care gallbladder surgeries: The same disease but a different approach

BACKGROUND: For patients who present to the emergency department (ED) with symptomatic cholelithiasis, surgery is indicated only if they are diagnosed of acute cholecystitis (AC). We hypothesized that, because preoperative signs and diagnostic tests are not sensitive enough to diagnose AC, coupled with the potential health care burden of non-AC gallbladder, surgery may be offered sooner. METHODS: We prospectively evaluated 200 patients who presented to ED with clinical suspicion of gallbladder disease, including a right upper quadrant/epigastric abdominal pain and cholelithiasis, and who underwent laparoscopic cholecystectomy. We correlated the preoperative clinical findings, including ultrasonography results, with the surgeon's intraoperative assessment (OR-GB) and with the pathology report (PA-GB). A multiple logistic regression model was performed. RESULTS: Of the gallbladders, 116 were declared AC by OR-GB but only 54 by PA-GB, (r = 0.31, p < 0.001). The median time to surgery was 17 hours; 75% of the patients underwent surgery within 24 hours. The sensitivity of ultrasonography for AC according to PA-GB was 38%, and 16% when combined all preoperative findings. Both figures dropped to 27% and 11% when correlated to OR-GB. Our regression identified persistent abdominal pain, positive ultrasonography result, and a body mass index of greater than 40 to be significant predictors of AC according to PA-GB; however, only the persistent abdominal pain remained significant according to OR-GB. CONCLUSION: The study confirmed the lack of sensitivity of signs and diagnostic tools to diagnose AC. Because of the acute care surgery model, we believe that the approach to the patients who present to the ED with suspected gallbladder disease is to offer them surgery as soon as feasible, with or without AC. This approach will avoid an unnecessary delay as well as quickly relieve patient's pain and suffering; the health care system will benefit from a cost-effective reduction in number of outpatient referrals and repeated ED visits. LEVEL OF EVIDENCE: Diagnostic study, level II.