Sex Differences and Outcomes of Management of Acute Cholecystitis Mehrdad Nikfarjam, MD, PhD, FRACS, Efrant Harnaen, MBBS, Farrukh Tufail, MBBS, Vijayaragavan Muralidharan, MBBS, PhD, FRACS, Michael A. Fink, MBBS, FRACS, Graham Starkey, MBBS, FRACS, Robert M. Jones, MB ChB, FRACS, FACS, and Christopher Christophi, MBBS, MD, FACS, FRACS, FRCS Background: Several series have reported differences in character- istics, severity, operative complexity, and outcomes of patients with symptomatic gallstone disease according to sex. Whether sex truly influences outcomes of patients with acute cholecystitis in the current era of early laparoscopic cholecystectomy for acute chol- ecystitis is unknown. Methods: Patients with histologically confirmed acute cholecystitis treated by a specialized unit in a tertiary hospital between November 2005 and January 2011 were identified. Retrospective review of data was undertaken and patients were compared according to sex. Results: There were 386 cases of confirmed acute cholecystitis in this series, with 181 (47%) occurring in male patients. Male patients with acute cholecystitis tended to be older (66vs. 57 y; P < 0.001) and were more likely to have underlying diabetes (21% vs. 9%; P = 0.001), ischemic heart disease (24% vs. 8%; P < 0.001), chronic liver disease (6% vs. 1%; P = 0.015), and chronic obstructive airways disease (11% vs. 5%; P = 0.025). They were also more likely to be febrile, tachycardic, hypotensive, and exhibit right upper quadrant rigidity at presentation than females (P < 0.05), despite similar duration of symptoms before pre- sentation (P = 0.970). The operative technique, operative time, and rate of conversion to open surgery were similar between the sexes. Gangrenous pathology was, however, more common in male patients (45% vs. 23%; P < 0.001). The overall complication, mortality, and readmission rates were similar between the 2 groups. Males, however, had a longer postoperative length of stay (4 vs. 3 d; P = 0.001). Conclusions: Male patients with acute cholecystitis are older, have more comorbidities, and are more likely to have gangrenous cholecystitis than female patients. Despite these differences, oper- ative outcomes and postoperative morbidity and mortality are similar between male and female patients. Key Words: acute cholecystitis, gangrenous, male, female, out- comes, laparoscopic cholecystectomy (Surg Laparosc Endosc Percutan Tech 2013;23:61–65) T here are many reports previously citing male sex as a risk factor for cholelithiasis and is associated with conversion to open surgery. 1–3 Similarly, there are reports that severe acute cholecystitis occurs more commonly in men and is independently associated with conversion to open surgery. 1–3 The majority of these observations were from series that also included patients treated by delayed surgery for acute cholecystitis. It is accepted that laparoscopic surgery is the standard treatment for symptomatic cholelithiasis and for acute cholecystitis. Early operative intervention for acute chol- ecystitis is now considered preferable to a delayed approach in the majority of cases. The aim of this study was to determine whether sex is associated with differences in severity and outcomes of acute cholecystitis when treatment is performed in specialized hepatobiliary and upper gas- trointestinal surgery units, adopting an early surgical approach when possible. PATIENTS AND METHODS Patients Patients treated by cholecystectomy for suspected acute cholecystitis between November 2005 and January 2011 within specialist hepatobiliary and upper gastro- intestinal units in a tertiary hospital were identified from a prospectively maintained database and files were retro- spectively reviewed with institutional review board appro- val. An early treatment policy was advocated during this period, with patients admitted through the emergency department operated on during the same hospital admis- sion. Patients with suspected acute cholecystitis seen in the outpatient clinic were operated on the first available elective operating list or admitted directly to the hospital to undergo surgical intervention. Patients treated by percuta- neous cholecystectomy were excluded from this study. Acute cholecystitis was defined based on a histologic finding of an acute inflammatory infiltrate on examination of the gallbladder wall. Gangrenous cholecystitis was diagnosed if there was evidence of transmural necrosis involving a portion of the gallbladder wall. The length of hospital stay was defined as the time from surgery to discharge. A complication was considered any deviation from the normal postoperative course or any adverse event that required an intervention, such as reop- eration, drainage, or administration of antibiotics. Preoperative Assessment Age, sex, American Society of Anesthesiologists (ASA) classification, body mass index, associated medical conditions, preoperative symptoms and duration, timing from admission to surgery, physical examination findings, blood tests, and imaging findings were recorded. Received for publication January 17, 2012; accepted September 16, 2012. From the Department of Surgery, Austin Health, University of Melbourne, Melbourne, VIC, Australia. The authors declare no conflicts of interest. Reprints: Mehrdad Nikfarjam, MD, PhD, FRACS, Department of Surgery, Austin Health, University of Melbourne, LTB 8, Studley Rd, Heidelberg, Melbourne, VIC 3084, Australia (e-mail: mehrdad. nikfarjam@gmail.com). Copyright r 2013 by Lippincott Williams & Wilkins ORIGINAL ARTICLE Surg Laparosc Endosc Percutan Tech  Volume 23, Number 1, February 2013 www.surgical-laparoscopy.com | 61