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Sex Matters in Cholecystitis
Mariam F. Eskander*, Gyulnara G. Kasumova, Tara S. Kent, Mark Callery, Sing Chau Ng, Jonathan F. Critchlow, Charles H. Cook, Jennifer F. Tseng
Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Boston, MA
Background: Single-center studies suggest that male gender may be associated with more severe cholecystitis. We use state-level data to describe practice patterns for cholecystitis and quantify the impact of gender on outcomes.
Methods: The Massachusetts State Inpatient Database 2010-2012 was queried for adult patients with a primary diagnosis of cholecystitis. Type of operation and its timing, use of cholecystostomy tubes and post-surgical complications were compared between males and females by chi-square. Gender difference in length of stay (LOS) was compared by Wilcoxon rank sum. Longitudinal revisit data were used to compare 30-day readmission rates. Multivariate logistic regression models were built to evaluate the association between gender and odds of gangrenous cholecystitis, open cholecystectomy, any complication, and 30-day readmission.
Results: Of 17,522 patients with cholecystitis, 6,963 (39.7%) were male. Males were more likely to have gangrenous cholecystitis (17.0% vs. 11.7%, p<0.0001) and a concomitant diagnosis of cholangitis (3.6% vs. 2.2%, (p<0.0001) or sepsis (1.7% vs. 0.9%, p<0.0001). Of 14,117 (80.6%) patients having a cholecystectomy on index admission: 8,791 (62.3%) female vs. 5,326 (37.7%) male, p<0.0001. 682 (3.9%) had a percutaneous cholecystostomy tube placed on index admission: 5.2% male vs. 3.0% female, p<0.0001. Males were older (median age 62 [IQR 48, 74] vs. 52 [IQR 37, 69], p<0.0001) and more likely to have comorbidities (77.5% vs. 71.1%, p<0.0001). Males were more likely to have an open cholecystectomy (18.3% vs. 9.5%, p<0.0001), to have a laparoscopic cholecystectomy converted to open (12.8 vs. 6.6%, p<0.0001), and to have a partial cholecystectomy or operative cholecystostomy (1.2% vs. 0.5%, p<0.0001.) Gender did not influence timing of cholecystectomy during index admission (p=0.8573). LOS after surgery was 3 days for males (IQR 2,5) vs. 3 days for females (IQR 2,4), p<0.0001. Complication rates during index admission were 12.8% for males and 6.9% for females, p<0.0001. Males were more likely to have a post-surgical 30-day readmission (9.1% vs. 8.0%, p=0.0290). Multivariate analysis showed male gender as an independent predictor of gangrenous cholecystitis (OR 1.407, 95% CI 1.288-1.536), open cholecystectomy (OR 1.858, 95% CI 1.675-2.060), and any complication (OR 1.514, 95% CI 1.337-1.715), but not 30-day readmission (OR 0.995, 95% 0.876-1.130).
Conclusions: Males are less likely to receive an upfront cholecystectomy for cholecystitis. Male gender is a significant and robust risk factor for severe cholecystitis, open cholecystectomy, and post-surgical complications, but not for hospital readmission. Potential explanations may include differing disease etiologies, delays in care and suboptimal utilization of hospital services.
Operative treatment of acute, purely chronic, and gangrenous cholecystitis in females.
  Operative treatment of acute, purely chronic, and gangrenous cholecystitis in females.
Operative treatment of acute, purely chronic, and gangrenous cholecystitis in males.
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