Waiting for cholecystectomy: determinants of prioritization for delayed cholecystectomy in a universal public healthcare system-post hoc analysis of RELAPSTONE cohort (WAIT-CHOL study)

Abstract

BACKGROUND: Symptomatic gallstone disease is a common and burdensome condition, with early cholecystectomy recommended to prevent relapses. However, delayed cholecystectomies lack standardized prioritization criteria. This study aimed to identify determinants independently associated with shorter waiting times for delayed cholecystectomy, and to assess the alignment of current surgical prioritization with relapse predictors described in the previous RELAPSTONE study. METHODS: This was a post hoc analysis of the Spanish RELAPSTONE cohort, comprising patients admitted for a first episode of symptomatic gallstone disease between January 2018 and April 2020, who did not undergo cholecystectomy during the index hospital admission. The primary outcome was waiting time (in months) to delayed cholecystectomy. Linear regression models with ?-coefficients were used to identify clinical factors associated with surgical delays (primary outcome of interest). Secondarily, the impact of relapse on prioritization was also evaluated. RESULTS: This study analysed 1508 patients of the 3016 included in the RELAPSTONE cohort. Median age was 68.2 (interquartile range 53.9-76.6) years; 51.4% were men. Median waiting time to delayed cholecystectomy was 4.5 (interquartile range 2.3-7.0) months. Initial presentation as acute cholecystitis (? = -2.2, P = 0.048) and multiple cholelithiasis (? = -0.6, P = 0.006) were linked to shorter waiting times, whereas older age (> 54 years; ? = 0.8, P = 0.002), advanced liver disease (? = 2.4, P = 0.047), and relapse (? = 0.5, P = 0.036) were associated with longer delays, compared with their respective reference groups. Among 575 patients (38.1%) with relapse, time to delayed cholecystectomy did not differ by relapse type. Several known risk factors for relapse identified in previous RELAPSTONE analyses, including the performance of endoscopic sphincterotomy and leucocyte and alanine aminotransferase levels, did not influence prioritization. CONCLUSION: Determinants of surgical timing were not well aligned with previously identified predictors of relapse. These findings support the need for evidence-based triage strategies to improve timing and outcomes of delayed cholecystectomy.