Enhancing the management of acute and gangrenous cholecystitis: a systematic review supported by the TriNetX database.

Background: Acute cholecystitis (AC) leads to emergency hospital admissions, and is categorized into mild, moderate, or severe grades, and affects hospital stay, surgery rates, costs, and prognosis. Gangrenous cholecystitis (GC) is the severe form and entails gallbladder wall necrosis and infection, possibly leading to emphysematous cholecystitis (EC), a life-threatening variant: early recognition of such a condition is crucial, since its symptoms may mimic uncomplicated AC. The current literature lacks comprehensive reviews on EC and GC due to their rarity and this study aims to bridge this gap by utilizing the TriNetX database, comparing clinical data of AC with GC outcomes.

Methods: The study involved data retrieval from PubMed and Medline and the TriNetX database. Initially, 981 English articles were identified, focusing on emphysematous and GC and cholecystectomy. After filtering and reviewing, 73 articles were suitable for inclusion. We analyzed electronic medical records of adults diagnosed with AC, comparing demographics, comorbidities, and medications between medical and surgical intervention groups. Propensity score matching balanced cohorts, and Kaplan-Meier analysis estimated outcomes, while other statistical analyses, including risk ratios (RRs) and odds ratios (ORs), were conducted within TriNetX, with significance set at P<0.05. The study aimed to compare 5-year all-cause mortality in AC patients treated with or without surgery.

Results: We found 9 retrospective studies and 3 prospective studies. Additionally, 70 patients from 62 case reports were utilized for descriptive analyses. From the TriNetX database, a total of 245,668 patients hospitalized for AC we identified. Despite, overweight/obesity was more frequent in the surgery group (24% vs. 14%, P<0.001), hypertension, diabetes mellitus, ischemic heart disease, chronic kidney disease and cerebrovascular diseases were more frequent in the non-operated patients (37% vs. 36%; 20% vs. 17%; 19% vs. 13%; 12% vs. 8%; 11% vs. 6%, respectively, all with P<0.001). The data concerning gastric medications are particularly eloquent, since 43% of operated patients were treated with such drugs versus 33% of non-operated subjects, before surgery (P<0.001). As for Kaplan-Meier analyses, patients who underwent surgery for AC presented generally lower mortality rates in the whole period of follow-up extended to 5 years (RR 0.415, 95% CI: 0.403-0.426; OR 0.364, 95% CI: 0.353-0.376; P<0.001) and this was particularly evident in the first 200 days of observation since index event.

Conclusions: In GC, timely surgical intervention within 72-96 hours reduces complications, such as infections and hospital admissions. Laparoscopic surgery decreases intensive care unit (ICU) admissions and intra-abdominal abscesses. For AC, proton pump inhibitors (PPIs) seem to increase the risk of surgical intervention. In general, surgery is crucial for overall survival in the first 200 days of post-hospitalization. Anyway, confirmation through additional studies is needed.