Surgical Site Infections after Cholecystectomy in the Acute Care Surgery Era

Author(s):
Abagail Raiter; Krista Wilhelmson; Melissa Harry; Kristin Colling

Background:

In the era of acute care surgery (ACS) urgent cholecystectomies (UC) performed by ACS specialists has led to higher rates of successful laparoscopic operations and improved outcomes, even with increased case complexity. However data on surgical infection risk following UC is lacking.

Hypothesis:

We hypothesize that patient and case complexity will be associated with higher rates of SSI.

Methods:

A prospective observational study was performed including all UC by the ACS team at a rural level 1 trauma center between April 2021 and March 2022. Patient demographics, comorbidities, hospital data, operative data and pathology were collected. The severity of cholecystitis was graded using the Parkland grading scale (PGS) for cholecystitis.

Results:

213 patients underwent UC. Patients ages ranged between 18-95, and approximately half were female (table below). Most patients had pre-existing comorbidities. Laparoscopic cholecystectomy was successful in 93% of cases, 4% converted to open, 2% underwent laparoscopic subtotal cholecystectomy and 0.5% underwent planned open procedure. SSI occurred in 17 patients (6 patients had superficial SSI, 10 organ space SSI and one patient both superficial and organ space SSI). Many pre-operative patient factors were associated with increased risk of infection; however none were modifiable. Antibiotic dosing and duration varied; similar number of patients received perioperative, both peri- and postoperative, and pre-, peri- and postoperative antibiotics. However, antibiotics pre- or postoperatively did not decrease infections. The SSI rate was similar or lower for patients receiving only peri-operative antibiotics compared to longer duration. Intra-operative factors associated with increased risk of SSI were severe cholecystitis (higher PCG scores), longer case duration, bile spillage, and surgical drains. Patients with SSI had significantly longer hospital stays and readmissions.

Conclusions:

SSIs occurred in 8% of UCs. Pre and intraoperative factors were associated with increased risk of SSI and those with SSI had worse postoperative outcomes. Most factors were not modifiable prior to surgery but avoidance of bile spillage may decrease SSI. Appropriate antibiotic timing is still unclear, however more antibiotics did not decrease SSIs.