COMMENTSDear Editor:We have read with interest the recently research published by Nunes EC et al
and we believe that this is a very interesting study considering how prevalent is
gallbladder calculus disease in Latin America. However, we would like to make some
comments, as there are some aspects that can be discussed.Can cholecystitis and cholelithiasis be integrated into the same universe? We
believe not. The first is an emergency condition and requires, according to its
state at the time of admission, previous medical treatment and surgery, which can
be postponed and re-enter in some other time; the second is an elective admission.
Cholecystitis will be more likely to have more hospitalizations than
cholelithiasis, surgical solution decreases the number of hospitalizations.The authors refer to, as one of the variables of the study, the total number of
hospitalizations, but it is not well understood why the "hospitalization/general
population" indicator, as the proportional difference of this relative frequency
is the same as the absolute number. It is more convenient to measure the specific
rate of hospitalizations by age group that makes the economic analysis of the
in-hospital stay more realistic. It is also useful to measure the concentration of
hospitalizations by case and adjust it by variables that may be confusing such as
socioeconomic status, educational level, purchasing power, nutrition education,
adherence to treatment; the latter is at the same time influenced by work
schedule, food culture, and the ability to decide the home meal. These variables
that could be intervening are not being analyzed in the study: the number of times
of in-patient admission, and the hospital stay. For a more updated economic
analysis, medical expenses are no longer made on the basis of an event but on the
basis of a case, therefore it is necessary to differentiate hospitalizations per
incident case to not confuse hospitalizations of prevalent cases. This improves
the economic analysis and allows to propose interventions on the issue of costs of
hospitalization for cholecystitis and cholelithiasis.Regarding the severity of gallbladder calculus disease, the authors hypothesize
that gravity would be associated with the anthropometric characteristics,
distribution of body fat and pain threshold; however, on this point there are
other variables that may explain the severity conditions in patients coming to the
emergency services and these are due to other variables such as self-medication,
access to health services, patients' idiosyncrasies, among others; which often
involve a delay in attending a hospital with a consequent increase in the severity
of cholecystitis.In terms of mortality, this was elevated in the elderly; probably associated with
comorbidity, greater severity of the disease at hospital admission and less
physiologic reserve, feature of this patient group; on the other hand there wasn't
any exclusion criteria, which means there were mixed diagnoses such as
cholangitis, gallbladder cancer, acute pancreatitis, among others. Additionally,
early cholecystectomy in these patients could result in morbidity up to 41% and
perioperative mortality up to 18%
.Considering the surgical average time of the open and laparoscopic
cholecystectomy, it is claimed to be similar between the elderly and the young;
however, we must differentiate between an elective or an emergency surgery for
these groups of people; it is known that the elderly have an increased presence of
risk factors for conversion of laparoscopic cholecystectomy to open surgery as
fibrosis of the gallbladder wall due to repetitive cholecystitis which likewise
causes a retracted gallbladder, increased likelihood of adherence syndrome by the
history of previous surgeries
.There was restriction on the study to not established if the surgery was performed
on the context of an elective or emergency surgery, the study refers or
distinguishes cholecystitis and cholelithiasis, so that could indirectly approach
more accurate data distribution, which means that the patients with cholelithiasis
are candidates for elective surgery and patients with acute conditions, meaning
cholecystitis go to emergency surgery; an analysis from this point of view would
have been more enlightening and not analyze it as a whole. The study doesn't
classify patients according its severity, i.e. Acute Cholecystitis grade I, II or
III according to Tokyo guidelines, therefore we cannot tell whether the treatment
was early, late or in between, which may affect mortality.It is referred that there was a major expense on children under 4 years coursed
with cholelithiasis or cholecystitis, probably due to the oddness of thinking of
cholelithiasis as a diagnosis in this group and it also requires further studies
and a more complex treatment than adults
.Dear Editor:In response to the comments and issues raised for discussion by Caballero, Tresierra and
Diaz, respecting the same order of presentation of the items, we have to consider that:Our focus approached hospitalizations for cholecystitis (ICD-10 K80) and
cholelithiasis (ICD-10 K81) considering both part of the same universe of
gallbladder disease. As the immense majority of cases of cholecystitis is due
to obstruction of the bile duct by the appearance of gallstones
(cholelithiasis), it seemed appropriate to present together the panorama of
hospitalizations for both diseases.We agree that other variables may be incorporated in the analysis. However, our
data source was the Hospital Information System of the Brazilian National
Health System (SIH/SUS, in Portuguese). This information system was developed
in the 1980s based on the payment of all hospital bills of the Brazilian public
system. This system is of mandatory use by all service providers in the country
and has an average of 11 million hospitalizations per year. The data are
administrative, secondary, and are publicly available on the internet.Given their purpose, their unit of analysis is the hospitalization and not the
patient. Due to their database structure, it lacks several variables such as
the number of times of in-patient admission, socioeconomic status, educational
level, purchasing power, nutrition education, adherence to treatment of each
patient. We understand that in Table 2 we present specific indicators by age
(admissions per 10,000 people/year).In fact, other variables could explain the severity of the condition. At this
point, we quote only the reference of Peron, Schliemann and Almeida.
Understanding the reasons for the refusal of cholecystectomy in patients with
cholelithiasis: how to help them in their decision? ABCD Arq. Bras. Cir. Dig.
2014 Apr-Jun; 27 (2): 114-19.The SIH/SUS does not have data on comorbidities of hospitalized patients.
However, considering that they are about 20,000 hospitalizations per year for
ICD-10 K80 and K81 for a three-year period, all performed by the Brazilian
public system in Rio Grande do Sul, we understand that this number is
representative of population profile that we intended to present.This study did not aimed to examine differences between elective or emergency
admissions, which could be further realized.The SIH/SUS does not have data such as the classification of patients according
to Tokyo guidelines. These data are in the medical records of the patients and
not in the secondary database that was built for all kinds of stay and not just
cholelithiasis and cholecystitis.We agree, but as mentioned, the SIH/SUS does not have these variables. To
obtain such data requires a designed study for the use of primary data. This is
not the case of our article, which uses secondary data publicly available on
the internet.Finally, we would like to thank the comments made. They contributed to further
examination of the matter in question from other perspectives.Emeline C Nunes, Roger S Rosa and Ronaldo Bordin