Impact of timing of cholecystectomy and bile duct interventions on quality of cholecystitis care.

BACKGROUND Laparoscopic cholecystectomy (LC), with or without staged bile duct interventions (BDIs), is increasingly used in acute cholecystitis. However, few studies have concurrently evaluated the timing of cholecystectomy procedures and BDIs, and quality of cholecystectomy care in cholecystitis patients. We investigated the effects of timing of BDIs and cholecystectomy on resource utilization, in order to assess the suitability of procedure timing or approach as quality indicators. METHODS In 2006, 5914 cholecystectomy patients were treated for cholecystitis at 423 hospitals in Japan. We analyzed patient demographics, BDIs (including endoscopic retrograde cholangiopancreatography, percutaneous gallbladder or common bile duct drainage, endoscopic sphincterotomy, and extraction of choledocholithiasis), procedure-related complications, hospital teaching status, postoperative length of stay (LOS) and charges (TC). Multivariate analysis was used to measure the impact of study variables on LOS, TC and complications. RESULTS Open cholecystectomy (OC) was performed in 1318 patients and LC in 4596. Acute inflammation was diagnosed in 52% of OC and 28% of LC patients. The incidence of complications was 8.1% for OC and 5.5% for LC. BDIs were more frequent in LC patients, especially preoperatively. Early cholecystectomy was associated with lower resource use. Postoperative BDIs had a significant impact on LOS and complications. Laparoscopic early cholecystectomy was associated with fewer postoperative BDIs. Hospital variation was found among postoperative resource use and outcomes. CONCLUSIONS Delayed cholecystectomy and postoperative BDIs are not recommended. Use of postoperative BDIs might be a promising quality indicator for monitoring quality of preoperative care when performing early laparoscopic cholecystectomy in cholecystitis patients.