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[JAMA Surg发表论文]:妊娠不同阶段急性胆囊炎的手术与非手术治疗
2024年01月06日 时讯速递, 进展交流 [JAMA Surg发表论文]:妊娠不同阶段急性胆囊炎的手术与非手术治疗已关闭评论

Original Investigation 

November 15, 2023

Operative vs Nonoperative Management of Acute Cholecystitis During the Different Trimesters of Pregnancy

Mariam N. Hantouli, David J. Droullard, Michael G. Nash, et al

JAMA Surg. Published online November 15, 2023. doi:10.1001/jamasurg.2023.5803

Key Points

Question  For pregnant patients presenting with acute cholecystitis (AC), is there a difference in adverse outcomes between those who do or do not receive cholecystectomy?

Findings  In this cohort study of 3426 pregnant patients with AC and 1-year follow-up, 34.5% underwent cholecystectomy during pregnancy. Compared with nonoperative management, patients who received cholecystectomy had lower odds of adverse outcomes (preterm delivery or pregnancy loss) across trimesters.

Meaning  These findings support cholecystectomy during pregnancy across trimesters and suggest that increased use of surgery for patients with AC may be an opportunity to improve pregnancy outcomes.

Abstract

Importance  Acute cholecystitis (AC) management during pregnancy requires balancing the risk of pregnancy loss or preterm delivery (adverse pregnancy outcomes [APOs]) with or without surgery. Guidelines recommend cholecystectomy across trimesters; however, trimester-specific evidence on the risks of AC and its management is lacking.

Objective  To assess cholecystectomy frequency in pregnant people with AC, compare the rates of APOs in pregnant people with or without AC, and compare the rates of APOs in people with AC who did or did not undergo cholecystectomy.

Design, Setting, and Participants  This retrospective, population-based cohort study used data for pregnant people with AC from the IBM MarketScan Commercial Claims and Encounters Database from January 1, 2007, to December 31, 2019, and a propensity score–matched cohort of pregnant people without AC. Trimester status (first [T1], second [T2], and third [T3]), APOs, and cholecystectomy were defined by administrative claims. Data were analyzed from October 2021 to July 2022.

Exposures  Pregnant patients with or without AC. Pregnant patients with AC who did or did not receive cholecystectomy.

Main Outcomes and Measures  The main outcomes were cholecystectomy during pregnancy and APOs (ie, preterm delivery and pregnancy loss). Pregnant patients with and without AC were compared to assess the association of AC with risk of APOs. Propensity score inverse-probability weighting was used to calculate treatment-associated APO risk among patients with 1-year follow-up.

Results  The study included 5759 pregnant patients with AC (mean [SD] age, 30.1 [6.6] years) and 23 036 controls (mean [SD] age, 29.9 [6.7] years) after propensity score matching. Among 3426 pregnant patients with AC and 1-year follow-up, 1182 (34.5%) underwent cholecystectomy during the pregnancy (684 [41.7%] presenting with AC in T1, 404 [40.4%] in T2, and 94 [12.0%] in T3). Acute cholecystitis during pregnancy, irrespective of treatment, was associated with higher odds of APO compared with no AC during pregnancy across all trimesters (odds ratio [OR], 1.69 [95% CI, 1.54-1.85]). Compared with nonoperative management, receipt of surgery was associated with lower odds of APOs across all trimesters (OR, 0.75 [95% CI, 0.63-0.87]), in T1 (OR, 0.81 [95% CI, 0.66-1.00]), in T2 (OR, 0.71 [95% CI, 0.50-1.00]), and in T3 (OR, 0.45 [95% CI, 0.28-0.70]).

Conclusions and Relevance  In this study, cholecystectomy was associated with lower risk of APO in patients with AC across all trimesters, with the greatest benefit in T3. However, only 34.5% overall and 12.0% of patients in T3 had a cholecystectomy. These findings support guidelines recommending cholecystectomy during pregnancy and should inform decision-making discussions. Greater guideline adherence and surgery use, especially in T3, may represent an opportunity to improve outcomes for pregnant people with AC.

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