Gross Abby R, Littau Michael, Wehrle Chase J, Slaibi Anas, Leo Rachel, Said Sayf Al-Deen, Simon Robert, Joyce Daniel, Asfaw Sofya H, Walsh R Matthew, Miller Benjamin T
Department of General Surgery, Quality Improvement & Patient Safety, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH.
Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH.
Surgery. 2025 Oct;186:109580. doi: 10.1016/j.surg.2025.109580. Epub 2025 Jul 28.
Laparoscopic cholecystectomy is the gold standard for treating acute calculous cholecystitis, whereas percutaneous cholecystostomy is typically reserved for patients at prohibitive surgical risk, given its greater complication rates. This multisite quality improvement initiative aimed to reduce the use of percutaneous cholecystostomy in patients at acceptable risk for surgery.
In October 2023, a multidisciplinary team implemented an acute calculous cholecystitis care pathway across 8 teaching hospitals. Prohibitive surgical risk was defined as predicted mortality exceeding 10% by the American College of Surgeons National Surgical Quality Improvement Program Calculator, Child-Pugh Class C cirrhosis, or American Society of Anesthesiologists class IV. Adult patients with acute calculous cholecystitis were identified using International Classification of Diseases, Tenth Revision, codes 1 year before and after implementation.
Among 2,948 patients (1,438 pre- and 1,510 postimplementation), use of percutaneous cholecystostomy decreased from 9.7% to 7.2% (P = .01), reaching a nadir of 4.4%. More recipients of percutaneous cholecystostomy met prohibitive-risk criteria postintervention (51.4% vs 67.3%; P = .02). Risk-adjusted analysis showed reduced odds of percutaneous cholecystostomy (odds ratio, 0.71; 95% confidence interval, 0.62-0.80) and 30-day mortality (odds ratio, 0.60; 95% confidence interval, 0.51-0.70) after implementation. LC rates increased (94.5-96.3%, P = .047), whereas open surgery declined. Minor bile duct leaks increased from 0.9% to 2.1% (P = .031), largely among patients with gangrenous disease or subtotal cholecystectomy. No major duct injuries occurred. Reoperation, cost, readmission, and length of stay were unchanged.
Implementation of a structured acute calculous cholecystitis pathway was associated with lower percutaneous cholecystostomy use and improved mortality, with a modest increase in minor bile leaks likely reflecting greater surgical complexity. Broader applicability warrants further evaluation.
腹腔镜胆囊切除术是治疗急性结石性胆囊炎的金标准，而经皮胆囊造瘘术通常适用于手术风险极高的患者，因为其并发症发生率更高。这项多中心质量改进计划旨在减少手术风险可接受的患者中经皮胆囊造瘘术的使用。
2023年10月，一个多学科团队在8家教学医院实施了急性结石性胆囊炎护理路径。极高手术风险定义为美国外科医师学会国家外科质量改进计划计算器预测死亡率超过10%、Child-Pugh C级肝硬化或美国麻醉医师协会IV级。使用国际疾病分类第十版代码在实施前后1年识别患有急性结石性胆囊炎的成年患者。
在2948例患者中（实施前1438例，实施后1510例），经皮胆囊造瘘术的使用率从9.7%降至7.2%（P = 0.01），最低降至4.4%。干预后，更多接受经皮胆囊造瘘术的患者符合极高风险标准（51.4%对67.3%；P = 0.02）。风险调整分析显示，实施后经皮胆囊造瘘术的几率降低（优势比，0.71；95%置信区间，0.62 - 0.80），30天死亡率降低（优势比，0.60；95%置信区间，0.51 - 0.70）。腹腔镜胆囊切除术的比例增加（94.5 - 96.3%，P = 0.047），而开放手术减少。小胆管漏从0.9%增加到2.1%（P = 0.031），主要发生在坏疽性疾病或胆囊次全切除术患者中。未发生主要胆管损伤。再次手术、费用、再入院率和住院时间均未改变。
结构化急性结石性胆囊炎护理路径的实施与经皮胆囊造瘘术使用率降低和死亡率改善相关，小胆管漏略有增加可能反映了手术复杂性增加。更广泛的适用性值得进一步评估。
