[ca] INTRODUCCIÓ: la colecistitis aguda litiàsica (CAL) es la segona patologia més freqüent a urgències quirúrgiques. Presenta una elevada tassa de complicacions (15-25%) i mortalitat (0,5-6%). El tractament d'elecció es quirúrgic, però no tots els pacients es beneficien de la cirurgia d'inici. Les Tokyo Guidelines (TG18) classifiquen als pacients en 3 grups i barregen diferents tractaments a un mateix grup creant confusió. No hi ha consens a la literatura per a definir qui es el pacient d'alt risc quirúrgic. JUSTIFICACIÓ CIENTÍFICA: a l'Hospital del Mar la tassa de mortalitat als pacients amb CAL va disminuir fins al 1,9% a l'any 2014, no obstant a l'any 2.015 va incrementar al 3,3%. Diverses discussions sobre el tractament de la CAL van incentivar l'inici d'aquest projecte, una línia d'investigació centrada únicament en els factors de risc per complicacions y mortalitat. HIPÓTESI: partint de la pregunta clínica: estem oferint millor tractament a tots els pacients amb diagnòstic de CAL? Hem formulat la següent hipòtesi: un estudi retrospectiu unicèntric d'una població de quasi 1.000 colecistitis agudes serà capaç d'aïllar els factors de risc per identificar als pacients que es podrien beneficiar d'un tractament alternatiu a la colecistectomia urgent. OBJETIUS:1) Analitzar els factors de risc per complicacions. 2) Analitzar els factors de risc per mortalitat. 3) Facilitar la identificació del pacient d'alt risc quirúrgic. 4) Simplificar el tractament de la colecistitis aguda. DISENY DE L'ESTUDI: estudi retrospectiu en 963 pacients amb colecistitis aguda. Es van seleccionar 725 pacients amb CAL"pura", i es van analitzar 166 variables que contenen els factors de risc recomanats a les TG18.Mitjançant el Propensity Score Matching(PSM), es van seleccionar subgrups amb idèntics factors de risc per estudiar les complicacions i mortalitat segons el tractament realitzat. El Failure-to-Rescue es va utilitzar com a indicador de qualitat del tractament de la CAL. Els estudis d'aquesta tesi doctoral estan registrats a Clinical Trials: NCT04744441 y NCT05135299. renal. El Failure-to-Rescue va ser del 8%, amb major percentatge als pacients no intervinguts (32% vs. 7%; P=0,002). Mitjançant el PSM, es van seleccionar 2 subgrups amb idèntics factors de risc per a complicacions greus, els pacients colecistectomitzats van presentar una tasa de complicacions del 48,5% vs. el 62,5% dels pacients no intervinguts (P=0,21). La tassa de mortalitat va ser del 3,6% i es va associar a major edat (83 anys + RIQ 5,5), i CCI (3,5 + 5,3). Es van aïllar quatre factors de risc que van estimar la mortalitat en un 92% dels pacients: MPOC (OR 4,66 95% IC 1,7-12,8;P=0,001), demència (OR 4,12; 95% IC 1,34-12,7;P=0,001), edat >80 anys (OR 1,12: 95% IC 1,02-1,21;P=0,001) y la necessitat de tractament amb amines vasoactives (OR 9,9: 95% IC 3,5-28,3;P=0,001). Mitjançant el PSM, es va analitzar un subgrup de pacients amb idèntics factors de risc per a mortalitat segons TG18;els pacients no intervinguts van presentar el doble de mortalitat que els intervinguts quirúrgicament (10,5% vs. 26,2%;P=0,248). CONCLUSIONS: Només tres de tots els factors de risc redactats a les TG18 van ser variables independents per a predir complicacions greus. El Failure-to-Rescue es menor en els pacients intervinguts quirúrgicament. MPOC, demencia, edat > 80 anys i la necessitat d'amines vasoactives son factors de risc independents per la mortalitat.

[en] INTRODUCTION: acute calculous cholecystitis (ACC) is the second most frequent pathology in the emergency department, nevertheless, it has a high rate of complications (15-25%) and mortality (0,5-6%. The treatment of choice is the cholecystectomy, but not all patients could benefit initially. The Tokyo Guidelines (TG18) classify patients into 3 groups and combine different treatments in the same group creating confusion. There is no consensus on the definition of who is the high-risk surgical patient in the literature. SCIENTIFIC JUSTIFICATION: in Hospital del Mar, the mortality rate in patients who required an urgent cholecystectomy decreased to 1.9% in 2014, however, it increased suddenly to a 3.3% in 2015. After several clinical discussions on the best treatment for the ACC started this project, research focused only in studying the risk factors for complications and mortality in ACC. HYPOTHESIS: starting from the clinical question, are we offering the optimal treatment to all patients with an ACC? We have formulated the following hypothesis: a single-center retrospective study of a population about 1,000 ACCs will be able to isolate the risk factors to identify who could benefit from an alternative treatment than urgent cholecystectomy. OBJECTIVES: 1) To analyze risk factors for complications in ACC. 2) To analyze risk factors for mortality in ACC. 3) To facilitate the identification of who is the high-risk surgical patient. 4) To simplify the treatment in ACC. STUDY DESIGN: retrospective study with 963 patients with an ACC. 725 patients were selected as a "pure" ACC, and 166 variables were studied including the risk factors recommended by the TG18. Using a Propensity Score Matching (PSM) subgroups with identical risk factors for mortality and complications were selected. The Failure-to-Rescue was applicated as an indicator of quality assessment. The 2 journal articles of this thesis are recorded in Clinical Trials: NCT04744441 and NCT05135299. RESULTS: the median age was 69 years old. The 21% of the ACC was mild, 39% moderate and 40% severe. Surgical treatment was performed in the 95% of the series. A 43% of the patients had any complication (76% mild and 24% severe). The independent factors for severe complications were ASA >II, solid tumor without metastases and renal failure. The Failure-to-Rescue was an 8%, with a higher percentage in non-surgical treatment (32% vs. 7%;P=0.002). With the PSM, a selected subgroup with equal risk factors for severe complication were studied: the was no differences on which treatment was applied, surgical patients had a 48,5% of complications and non-surgical patients had a 62,5% (P=0.21). The mortality was a 3,6% and was associated with higher age (83 + IQR 5.5) and higher CCI (3.5 + IQR5.3). Four risk factors were isolated as a risk factor for mortality, and predicted the 92% of the deaths: COPD (OR 4.66; 95%CI 1.7-12.8; P=0.001), Dementia (OR 4.12; 95%CI 1.34-12.7; P=0.001), age > 80 years old (OR 1.12; 95%CI 1.02-1.21; P=0.001) and the need for vasoactive amines (OR 9.9; 95%CI 3.5-28.3; P=0.001) Using the PSM, the subgroup with high-risk factors for mortality according to TG18 was analyzed and the non-surgical patients had twice the mortality of surgical patients (26,2% vs. 10,5%; P=0,248) CONCLUSIONS: only three of all the risk factors recommended in the TG18 are independent factors to predict severe complications. The Failure-to-Rescue is higher in patients with non-surgical treatment. COPD, Dementia, age > 80 years old and the need of vasoactive amines are independent risk factors for mortality.