FROM JOURNAL OF SURGICAL RESEARCH

Patients who don’t receive surgical follow-up after an emergency department visit for cholelithiasis are at increased risk for further ED visits, extraneous imaging, and complications from the disease and from emergent cholecystectomy, according to the findings of a retrospective study.

“Our study identifies lack of surgical follow-up [as] a major contributor to the failure to perform cholecystecomy and highlights the importance of prompt surgical evaluation,” stated Taylor P. Williams of the University of Texas Medical Branch (UTMB), Galveston, and co-investigators.

Between August 2009 and May 2014, 71 patients were discharged from the ED at UTMB with a diagnosis of symptomatic gallstones. The study charted the care of these patients for a follow-up period of 2 years, and the findings were published the August issue of the Journal of Surgical Research ( 2015;197:318-23 ).

The mean age of patients was 41 years; 86% were women, and 49% were white. A majority of the patients (56.3%) had no health insurance, while 11.3% had Medicare, 11.3% were on Medicaid, and 21.1% had private insurance.

Of the 71 patients, 18 (25.4%) had outpatient surgical follow-up after an ED visit for a cholelithiasis episode, and they saw the surgeon an average of 7.7 days after the initial ED visit. In the 9 patients who then had an elective cholecystectomy, 8 of these operations occurred within a month of the initital ED visit.

A total of 53 (74.6%) had no immediate surgical follow-up after their ED visit.

The 62 patients who did not have a cholecystectomy had a different trajectory of care than did those who had surgery soon after their ED visit. Of the non-cholecystectomy group, 14.5% of this group eventually had outpatient surgical follow-up within a mean time of 137 days and 37.1% had repeat visits to the ED for gallstone symptoms (17.7% had two or more additional ED visits). Over half of those visits resulted in additional CT or ultrasound imaging. A total of 8 (12.9%) of the total group ended up with an emergent cholecystectomy.

The investigators looked at factors associated with surgical follow-up and eventual or emergent cholecystectomy. Laboratory values, demographics, and radiographic findings were similar between those who underwent cholecystectomy and those who did not. Patients with insurance were more likely to achieve surgical follow-up and more likely to have an elective cholecystectomy. Nausea and vomiting on presentation at the initial ED visit were associated with a greater likelihood of having a cholecystectomy.

The study showed that the 71 patients who presented at the ED with symptoms of cholelithiasis had a similar number of elective and emergent cholecystectomies. But those who did not pursue follow-up and delayed in having surgery incurred additional risks and costs.

A limitation of the study, according to the investigators, is that it involves a small sample from a single center in a community with a high proportion of patients who lack health insurance. In addition, UTMB protocol for acute gallbladder disease leads to a higher rate of admissions than is typical in the United States.

The investigators concluded that “lack of appropriate follow-up leads to multiple ED visits, high rates of emergent cholecystectomy, and redundant radiographic studies, increasing the cost of care and quality of life of those patients. Our data contribute to the literature supporting early surgical follow-up and elective cholecystectomy in preventing repeat ED visits and development of gallstone-related complications in patients presenting to the ED with symptomatic gallstones not severe enough to require emergency admission.”

The investigators had no relevant disclosures.

tborden@frontlinemedcom.com

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