A total 9,248 adult patients with acute cholecystitis were selected from one million samples from January 2004 to December 2011. Because the follow-up period should be at least one year, we included 377 acute cholecystitis patients who underwent PTGBD between January 2004 and December 2010. Twelve patients were excluded because of previous PTGBD before the index admission. The data for 365 acute cholecystitis patients who underwent PTGBD at the index admission were collected. A total of 190 patients with a mean age of 68.42 ± 13.17 years underwent further CCY within 2 months after the index admission. The other 175 patients, with a mean age of 72.67 ± 13.75 years, did not accept further CCY within 2 months after the index admission. The baseline CCI score, 5.77 ± 3.41 in the CCY within 2 months group and 7.79 ± 4.10 in the no CCY within 2 months group, was significantly higher in the no CCY group (p=0.01). As for the components of the CCI, the proportions of patients with congestive heart failure (10.53% vs. 25.14%, p<0.01), hemiplegia or paraplegia (0% vs. 3.43%, p=0.04), and chronic kidney disease (9.47% vs. 25.14%, p<0.01) were significantly higher in the no CCY group. The total follow-up duration was significantly longer in the CCY within 2 months group than in the no CCY within 2 months group (39.68 ± 23.47 vs. 23.47 ± 20.26, p=0.047). The detailed baseline demographic data are shown in Table 1.
Reflecting the culture in Taiwan, surgical intervention is the last choice for treatment. In our analysis, only 190 (52.05%) of the 365 patients underwent CCY within 60 days after previous PTGBD during index admission for acute cholecystitis. In addition, 25 patients eventually accepted CCY during follow-up, and 15 (60%) of these patients underwent laparoscopic CCY. The overall mortality rate was 19.47% in the CCY within 2 months group and 50.29% in the no CCY within 2 months group, in which the patients had higher CCI scores and older age. In terms of RBE-related mortality, 5 patients died in the no CCY within 2 months group, while no patients died in the CCY within 2 months group. Therefore, the CCY within 2 months group had a better survival probability in our analysis.
RBEs
The definition of RBE included ER visits and admissions due to cholelithiasis, cholecystitis, cholangitis, and biliary pancreatitis. Although the time to the event was shorter in the CCY within 2 months group (9.6 ± 15.18 months) than in the no CCY within 2 months group (11.21 ± 13.92 months), the total number of RBEs was higher in the no CCY within 2 months group. The total number of RBEs was 111 events in 59 patients in the CCY within 2 months group and 173 RBEs in 81 patients in the no CCY within 2 months group, which showed more RBEs in the no CCY within 2 months group. This situation resulted in the total medical expenses for RBEs being much higher in the no CCY within 2 months group (68561 ± 85343 NT$ vs. 120284 ± 151225 NT$).
RBE-free survival
To evaluate the safety and protective effects of CCY after PTGBD for acute cholecystitis, we examined the RBE-free survival, which referred to both RBEs or mortality events as end points for measurements. RBE-free survival was significantly better in the CCY within 2 months group than in the no CCY within 2 months group (60% vs. 42%, p<0.001). The results are shown in Figure 2. After we stratified the CCY within 2 months group patients by age and CCI score, the RBE-free survival became similar to that of the no CCY within 2 months group patients when patients were older than 80 years old (56% vs. 42%, p=0.421) or had a CCI score ≥ 9 (54% vs. 42%, p=0.425). Detailed information is provided in Figure 3.
Medical expenses
Medical expenses for the index admission, CCY, and subsequent admissions and ER visits due to RBEs and the total medical charges were calculated. We isolated the 25 patients who eventually accepted CCY at least 2 months apart from the index admission from patients without CCY within 2 months.
The average medical expenses for the index admission were 89,951 NT$, 53,866 NT$, and 188,212 NT$ in the CCY within 2 months group, CCY after 2 months group, and no CCY group, respectively. The much higher medical expenses in the no CCY group indicated the complicated clinical condition and significant comorbidities in this group of patients. For the medical expenses of RBEs, the average expenses were 120,707 NT$ in the no CCY group, which was much higher than the 68,561 NT$ in the CCY within 2 months group.
The average total medical costs were 243,114 NT$, 190,970 NT$, and 172,370 NT$ in the no CCY group, CCY after 2 months group, and CCY within 2 months group (p<0.01), which suggests the later CCY was performed, the higher the medical expenses were. The medical cost comparisons are shown in Table 3.