Emergency Gallbladder Surgery?

Rochester, Minnesota - Gallstone pain is one of the most common reasons patients visit emergency rooms. Figuring out who needs emergency gallbladder removal and who can go home and schedule surgery at their convenience is sometimes a tricky question, and it isn’t always answered correctly. A new Mayo Clinic study found that 1 in 5 patients who went to the emergency room with gallbladder pain and were sent home to schedule surgery returned to the ER within 30 days needing emergency gallbladder removal.

The surgical complication rate rises with the time lag before surgery, the researchers say.

“It makes a big difference if you get the right treatment at the right time,” says co-lead author Juliane Bingener-Casey, M.D., a gastroenterologic surgeon at Mayo Clinic in Rochester. The study is published in the Journal of Surgical Research.

Often it’s obvious who needs emergency gallbladder removal, a procedure known as cholecystectomy, who can delay it and who doesn’t need surgery at all. But sometimes patients fall into a gray area. Mayo researchers are working to develop a reliable tool to help determine the best course of action in those cases, and the newly published study is a first step, Dr. Bingener-Casey says.

How to handle gallstone patients is a cost and quality issue in health care. In the United States, 1 in 10 women and 1 in 15 men have gallstones, and more than 1 million people a year are hospitalized for gallstone disease. The fatty food common in U.S. diets is a contributing factor, Dr. Bingener-Casey says.

ER visits and emergency surgery are typically more expensive than scheduled surgeries. In addition to cost issues, patients often prefer the convenience of scheduling surgery, so they can arrange child care and leave from work, for example. But delaying a needed gallbladder removal more than six days increases the surgical complication rate and may make patients likelier to need open-abdomen surgery rather than a minimally invasive laparoscopic procedure, the researchers noted.

“Gallbladder disease is very frequent and it’s one of the most expensive diseases for the nation as a whole. If we can get that right the first time, I think we can make things better for a lot of people,” Dr. Bingener-Casey says.

Researchers studied the billing records of 3,138 patients at Mayo in Rochester between 2000 and 2013 who went to the emergency department for abdominal pain within 30 days before gallbladder surgery. Of those, 1,625 were admitted for emergency gallbladder surgery, and 1,513 were allowed to go home and schedule surgery at a later date. Of the patients who went home, 20 percent came back to the emergency room within a month needing a cholecystectomy urgently, and of those, 55 percent were back in the ER within a week for emergency surgery.

Among those discharged from the ER, younger patients who were otherwise healthy and older patients who did have other health problems were likelier than people in their 40s and 50s to return to the emergency room within a month and need gallbladder removal urgently, the study found. That suggests that younger patients, older patients and those with other serious medical conditions may benefit from a second look before they are discharged from the emergency room, the researchers say.

Researchers analyzed test results typically considered indicators of gallbladder disease including white blood cell count, temperature and heart rate and saw no difference between those who left the ER and didn’t make a repeat visit and those who left the emergency room only to come back within a month. Such metrics may be incorporated into a decision tool if they hold up during future research.

The study was funded in part by the National Institute of Diabetes and Digestive and Kidney Diseases award number K23DK93553.

The co-lead author is Elizabeth Habermann, Ph.D., scientific director of surgical outcomes research at Mayo Clinic’s Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.

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