A population-based analysis of the clinical course of 10,304 patients with acute cholecystitis, discharged without cholecystectomy. J Trauma Acute Care Surg. 2013;74:26-30; discussion 30-31. [PMID: 23271073 DOI: 10.1097/ta.0b013e3182788e4d]

Predictors of bile tree pathology in patients presenting with gallbladder disease

BACKGROUND

Patients with gallstone disease can present with elevated liver function tests (LFTs). It is often challenging to differentiate those with a common bile duct (CBD) stone from those without a CBD stone on the basis of the LFTs levels. In this study, we aim to evaluate the predictors of a CBD stones among patients presenting with symptomatic gallbladder disease and elevated LFTs.

PATIENTS AND METHODS

We retrospectively examined all patients who had undergone a cholecystectomy between January 2010 and December 2015. Patients with symptomatic cholelithiasis and increased LFTs were included. Patient characteristics, imaging findings, lab findings, endoscopic interventions, and operative report were recorded and evaluated. The diagnosis of CBD stones was made on the basis of ERCP and IOC findings.

RESULTS

We included 354 patients in the final analysis. Of these, 113 (32%) had confirmed choledocholithiasis. The prevalence of CBD stones among biliary colic, acute cholecystitis, and pancreatitis patients was 47, 25, and 26%, respectively. γ-Glutamyl transferase and direct bilirubin had the highest sensitivities for CBD stones among these patients (83 vs. 79%). In the setting of biliary colic, total bilirubin was highly predictive of CBD stones with a positive predictive value of 85%. In the setting of acute cholecystitis, elevated LFTs were even less significant in predicting stones, with a positive predictive value of less than 40% for most.

CONCLUSION

Although γ-glutamyl transferase and bilirubin levels showed a relatively higher sensitivity for CBDS compared with the other LFTs, these were not reliable enough because of high false-positive as well as false-negative values, especially in patients presenting with acute cholecystitis.

Acute care surgery: a means for providing cost-effective, quality care for gallstone pancreatitis

Background

Modern practice guidelines recommend index cholecystectomy (IC) for patients admitted with gallstone pancreatitis (GSP). However, this benchmark has been difficult to widely achieve. Previous work has demonstrated that dedicated acute care surgery (ACS) services can facilitate IC. However, the associated financial costs and economic effectiveness of this intervention are unknown and represent potential barriers to ACS adoption. We investigated the impact of an ACS service at two hospitals before and after implementation on cost effectiveness, patient quality-adjusted life years (QALY) and impact on rates of IC.

Methods

All patients admitted with non-severe GSP to two tertiary care teaching hospitals from January 2008–May 2015 were reviewed. The diagnosis of GSP was confirmed upon review of clinical, biochemical and radiographic criteria. Patients were divided into three time periods based on the presence of ACS (none, at one hospital, at both hospitals). Data were collected regarding demographics, cholecystectomy timing, resource utilization, and associated costs. QALY analyses were performed and incremental cost effectiveness ratios were calculated comparing pre-ACS to post-ACS periods.

Results

In 435 patients admitted for GSP, IC increased from 16 to 76% after implementing an ACS service at both hospitals. There was a significant reduction in admissions and emergency room visits for GSP after introduction of ACS services (p < 0.001). There was no difference in length of stay or conversion to an open operation. The implementation of the ACS service was associated with a decrease in cost of $1162 per patient undergoing cholecystectomy, representing a 12.6% savings.

The time period with both hospitals having established ACS services resulted in a highly favorable cost to quality-adjusted life year ratio (QALY gained and financial costs decreased).

Conclusions

ACS services facilitate cost-effective management of GSP. The result is improved and timelier patient care with decreased healthcare costs. Hospitals without a dedicated ACS service should strongly consider adopting this model of care.

Cost-effectiveness of emergency versus delayed laparoscopic cholecystectomy for acute gallbladder pathology

BACKGROUND

The optimal timing of cholecystectomy for patients admitted with acute gallbladder pathology is unclear. Some studies have shown that emergency cholecystectomy during the index admission can reduce length of hospital stay with similar rates of conversion to open surgery, complications and mortality compared with a 'delayed' operation following discharge. Others have reported that cholecystectomy during the index acute admission results in higher morbidity, extended length of stay and increased costs. This study examined the cost-effectiveness of emergency versus delayed cholecystectomy for acute benign gallbladder disease.

METHODS

Using data from a prospective population-based cohort study examining the outcomes of cholecystectomy in the UK and Ireland, a model-based cost-utility analysis was conducted from the perspective of the UK National Health Service, with a 1-year time horizon for costs and outcomes. Probabilistic sensitivity analysis was used to investigate the impact of parameter uncertainty on the results obtained from the model.

RESULTS

Emergency cholecystectomy was found to be less costly (£4570 versus £4720; €5484 versus €5664) and more effective (0·8868 versus 0·8662 QALYs) than delayed cholecystectomy. Probabilistic sensitivity analysis showed that the emergency strategy is more than 60 per cent likely to be cost-effective across willingness-to-pay values for the QALY from £0 to £100 000 (€0-120 000).

CONCLUSION

Emergency cholecystectomy is less costly and more effective than delayed cholecystectomy. This approach is likely to be beneficial to patients in terms of improved health outcomes and to the healthcare provider owing to the reduced costs.

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

The increasing incidence of gallbladder disease in children: A 20year perspective

OBJECTIVE

The incidence of cholecystectomy in the pediatric population has increased over the last 20years but has not been described in a Canadian population. We conducted the first province-wide study to describe the incidence of cholecystectomy in children in Ontario.

STUDY DESIGN

A population-based, retrospective cohort using administrative databases in Ontario, Canada, was conducted. We included patients less than 18years of age who underwent cholecystectomy from 1993 to 2012. Trends in rates of cholecystectomy were assessed with the Cochrane-Armitage test.

RESULTS

There were a total of 6040 pediatric cholecystectomies performed over the study period in Ontario. The mean age was 14.3years, and 79.6% of patients were females. The crude incidence per 100,000 person-years increased from 8.8 to 13.0 (p<0.001) from 1993 96-2009-12, respectively. The sex-specific incidence showed a larger increase in the female population from 14.7 to 21.1 per 100,000 person-years (p<0.001). The vast majority (82%) of surgeries were performed in 13-17year olds and were largely performed in the community (>75%).

CONCLUSIONS

There has been a significant rise in the incidence of pediatric cholecystectomy in Ontario over the last 20years. The majority of surgeries are performed in the community, and pediatricians will likely see an increase of gallbladder disease in practice.

Systematic review of antibiotic treatment for acute calculous cholecystitis

BACKGROUND

Intravenous antibiotics are frequently used in the initial management of acute calculous cholecystitis (ACC), although supportive care alone preceding delayed elective cholecystectomy may be sufficient. This systematic review assessed the success rate of antibiotics in the treatment of ACC.

METHODS

A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Primary outcomes were the need for emergency intervention and recurrence of ACC after initial non-operative management of ACC. Risk of bias was assessed. Pooled event rates were calculated using a random-effects model.

RESULTS

Twelve randomized trials, four prospective and ten retrospective studies were included. Only one trial including 84 patients compared treatment with antibiotics to that with no antibiotics; there was no significant difference between the two groups in terms of length of hospital stay and morbidity. Some 5830 patients with ACC were included, of whom 2997 had early cholecystectomy, 2791 received initial antibiotic treatment, and 42 were treated conservatively. Risk of bias was high in most studies, and all but three studies had a low level of evidence. For randomized studies, pooled event rates were 15 (95 per cent c.i. 10 to 22) per cent for the need for emergency intervention and 10 (5 to 20) per cent for recurrence of ACC. The pooled event rate for both outcomes combined was 20 (13 to 30) per cent.

CONCLUSION

Antibiotics are not indicated for the conservative management of ACC or in patients scheduled for cholecystectomy.

Meta-analysis comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Previous studies comparing early laparoscopic cholecystectomy (ELC) with delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis were incomplete. A meta-analysis was undertaken to compare the cost-effectiveness, quality of life, safety and effectiveness of ELC versus DLC.

METHODS

PubMed, Embase, the Cochrane Library and Web of Science were searched for randomized clinical trials (RCTs) that compared ELC (performed within 7 days of symptom onset) with DLC (undertaken at least 1 week after symptoms had subsided) for acute cholecystitis.

RESULTS

Sixteen studies reporting on 15 RCTs comprising 1625 patients were included. Compared with DLC, ELC was associated with lower hospital costs, fewer work days lost (mean difference (MD) -11·07 (95 per cent c.i. -16·21 to -5·94) days; P < 0·001), higher patient satisfaction and quality of life, lower risk of wound infection (relative risk 0·65, 95 per cent c.i. 0·47 to 0·91; P = 0·01) and shorter hospital stay (MD -3·38 (-4·23 to -2·52) days; P < 0·001), but a longer duration of operation (MD 11·12 (4·57 to 17·67) min; P < 0·001). There were no significant differences between the two groups in mortality, bile duct injury, bile leakage, conversion to open cholecystectomy or overall complications.

CONCLUSION

For patients with acute cholecystitis, ELC appears as safe and effective as DLC. ELC might be associated with lower hospital costs, fewer work days lost, and greater patient satisfaction.

Implementation of an Acute Care Surgery Service Facilitates Modern Clinical Practice Guidelines for Gallstone Pancreatitis

BACKGROUND

Current practice guidelines for management of gallstone pancreatitis (GSP) recommend early cholecystectomy for patient stabilization and bile duct clearance, preferably at index admission. Historically, this has been difficult to achieve due to lack of emergency surgical resources. We investigated whether implementation of an acute care surgery (ACS) model would allow better adherence to current practice guidelines for GSP.

STUDY DESIGN

A retrospective review was conducted of all patients admitted with the diagnosis of GSP to 2 tertiary care university teaching hospitals from January 2002 to October 2013. Diagnosis was confirmed on review of clinical, biochemical, and radiographic criteria. Patients were divided into pre-ACS (2002 to 2009) and post-ACS (2010 to 2013) eras. Only 1 of the 2 hospitals implemented an ACS service in the latter era. Data were collected on demographics, admissions, cholecystectomy timing, and emergency department visits.

RESULTS

Before implementation of an ACS service, the rate of index cholecystectomy was 3% at both hospital sites. The rate of index cholecystectomy increased significantly with the addition of ACS, from 2.4% to 67% (p < 0.001). The presence of an ACS team was highly predictive of index cholecystectomy (odds ratio = 10.4; 95% CI 2.0 to 55.1). Patients who did not undergo cholecystectomy during the index admission had an overall readmission rate of 24.9% at both sites. In the ACS hospital, repeat emergency department visits decreased from 24.8% to 8.3% (p < 0.001) and readmission rate decreased from 16.8% to 7.3% (p = 0.04) in the pre-and post-ACS eras, respectively.

CONCLUSIONS

Implementation of an ACS service resulted in a higher rate of index cholecystectomy and decreased emergency department visits and readmissions for biliary disease, and allowed for increased adherence to clinical practice guidelines for GSP.

Surgical management of acute cholecystitis

BACKGROUND

Acute cholecystitis occurs in approximately 1% of patients with known gallstones. It presents as a surgical emergency and usually requires hospitalisation for treatment. It is associated with significant morbidity and mortality, particularly in the elderly. Cholecystectomy is advocated for acute cholecystitis; however, the timing of cholecystectomy and the value of the additional treatments have been a matter of debate. This review examines the available evidence regarding the optimal surgical management of patients with acute cholecystitis.

METHODS

A literature search was performed on the MEDLINE, EMBASE and WHO International Clinical Trials Registry Platform, databases for English language publications. The MeSH headings 'cholecystitis', 'acute', 'gallbladder', 'inflammation', 'surgery', 'cholecystectomy', 'laparoscopic', 'robotic', 'telerobotic' and 'computer-assisted' were used.

RESULTS

Data from eight randomised controlled trails and three population-based analyses show that early cholecystectomy for acute cholecystitis performed on the index admission is safe and not associated with increased conversion rates or morbidity in comparison to conservative treatment followed by elective cholecystectomy. Delaying cholecystectomy increases readmissions for gallstone-related events, complications, hospital stay and mortality in the elderly. Early cholecystectomy is also more cost-effective. Randomised trials addressing antibiotic use in acute cholecystitis suggest that antibiotics should be stopped on the day of cholecystectomy. Insufficient trials have been performed to address the optimal analgesia regime post cholecystectomy. Similarly, a lack of trials on intraoperative cholangiography and management of common bile duct stones in patients with acute cholecystitis means that treatment of concomitant bile duct stones should be based on institutional expertise and resource availability. As regards acute cholecystitis in elderly and high-risk patients, case series and retrospective studies would suggest that cholecystectomy is more effective and of lower mortality than percutaneous cholecystostomy. There is not enough evidence to support the routine use of robotic surgery, single-incision laparoscopic cholecystectomy or natural orifice transluminal endoscopic surgery (NOTES) in the treatment of acute cholecystitis.

CONCLUSIONS

Trial evidence would favour a policy of early laparoscopic cholecystectomy following admission with acute cholecystitis. The optimal approach to support early cholecystectomy is suggested but requires evidence from further randomised trials.

Should Delayed Cholecystectomy Following Acute Calculous Cholecystitis Be Discouraged in a Resource-restricted Setting?

BACKGROUND

Early cholecystectomy for acute calculous cholecystitis (ACC) reduces hospital stay and complications during the waiting period. The purpose of this study is to establish the patterns of management of ACC at the University Hospital of the West Indies (UHWI) and to evaluate the advantages of early versus delayed cholecystectomy.

METHODS

This was a retrospective chart review of patients admitted with a diagnosis of ACC. Data collection included demographics, management strategy, timing to cholecystectomy, significant events while awaiting cholecystectomy and duration of hospital stay. Mann-Whitney U and Chi-squared tests were used for analysis. P-value of < 0.05 was considered significant.

RESULTS

A total of 102 patient charts were extracted, 59 of which were managed conservatively and 43 managed with early cholecystectomy. The mean time to surgery after conservative management was 173 days. About 30% of persons managed conservatively had significant attacks while awaiting surgery, which included need for re-admission and earlier intervention. There was a trend toward longer mean total hospital stay in the conservative group (xsx = 5.03, xCons = 6.12; p = 0.054).

CONCLUSION

Conservative management of ACC results in significant delays in definitive management and risks of complications during the waiting period. Early cholecystectomy should be encouraged even in a resource-restricted setting.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

Success of elective cholecystectomy treatment plans after emergency department visit

BACKGROUND

Differentiation between patients with acute cholecystitis and patients with severe biliary colic can be challenging. Patients with undiagnosed acute cholecystitis can incur repeat emergency department (ED) visits, which is resource intensive.

METHODS

Billing records from 2000-2013 of all adults who visited the ED in the 30 d preceding their cholecystectomy were analyzed. Patients who were discharged from the ED and underwent elective cholecystectomy were compared with those who were discharged and returned to the ED within 30 d. T-tests, chi-square tests, and multivariable analysis were used as appropriate.

RESULTS

From 2000-2013, 3138 patients (34%) presented to the ED within 30 d before surgery, 63% were women, mean age 51 y, and of those 1625 were directly admitted from the ED for cholecystectomy, whereas 1513 patients left the ED to return for an elective cholecystectomy. Patients who were discharged were younger (mean age 49 versus 54 y, P < 0.001) and had shorter ED stays (5.9 versus 7.2 h, P < 0.001) than the patients admitted immediately. Of the discharged patients, 303 (20%) returned to the ED within 30 d to undergo urgent cholecystectomy. Compared with patients with successful elective cholecystectomy after the ED visit, those who failed the pathway were more likely to have an American Society of Anesthesiologists score ≥3 and were <40 or ≥60 compared with the successful group.

CONCLUSIONS

One in five patients failed the elective cholecystectomy pathway after ED discharge, leading to additional patient distress and use of resources. Further risk factor assessment may help design efficient care pathways.

Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis

OBJECTIVE

To compare the operative outcomes of early and delayed cholecystectomy for acute cholecystitis.

BACKGROUND

Randomized trials comparing early to delayed cholecystectomy for acute cholecystitis have limited contemporary external validity. Furthermore, no study to date has been large enough to assess the impact of timing of cholecystectomy on the frequency of serious rare complications including bile duct injury and death.

METHODS

This is a population-based retrospective cohort study of patients emergently admitted to hospital with acute cholecystitis and managed with cholecystectomy over the period of April 1, 2004, to March 31, 2011. We used administrative records for the province of Ontario, Canada. Patients were divided into 2 exposure groups: those who underwent cholecystectomy within 7 days of emergency department presentation on index admission (early cholecystectomy) and those whose cholecystectomy was delayed. The primary outcome was major bile duct injury requiring operative repair within 6 months of cholecystectomy. Secondary outcomes included major bile duct injury or death, 30-day postcholecystectomy mortality, completion of cholecystectomy with an open approach, conversion among laparoscopic cases, and total hospital length of stay. Propensity score methods were used to address confounding by indication.

RESULTS

From 22,202 patients, a well-balanced matched cohort of 14,220 patients was defined. Early cholecystectomy was associated with a lower risk of major bile duct injury [0.28% vs 0.53%, relative risk (RR)=0.53, 95% confidence interval [CI]: 0.31-0.90], of major bile duct injury or death (1.36% vs 1.88%, RR=0.72, 95% CI: 0.56-0.94), and, albeit non-significant, of 30-day mortality (0.46% vs 0.64%, RR=0.73, 95% CI: 0.47-1.15). Total hospital length of stay was shorter with early cholecystectomy (mean difference 1.9 days, 95% CI: 1.7-2.1). No significant differences were observed in terms, open cholecystectomy (15% vs 14%, RR=1.07, 95% CI: 0.99-1.16) or in conversion among laparoscopic cases (11% vs 10%, RR=1.02, 95% CI: 0.93-1.13).

CONCLUSIONS

These results support the benefit of early overdelayed cholecystectomy for patients with acute cholecystitis.

Early cholecystectomy for acute cholecystitis: a population-based retrospective cohort study of variation in practice

BACKGROUND

Despite evidence in favour of early cholecystectomy for most patients with acute cholecystitis, variation in practice has been reported across hospitals worldwide. We sought to characterize the extent and potential sources of variation in the performance of early cholecystectomy for acute cholecystitis within a large regional health care system.

METHODS

We used a population-based retrospective cohort design. The cohort was limited to adults with a first episode of acute cholecystitis, admitted through the emergency department. Patients were identified using administrative databases comprising all emergency department visits and hospital admissions in Ontario from 2004 to 2010. Patient and hospital characteristics associated with early cholecystectomy (within 7 d of emergency department presentation) were identified using multilevel logistic regression.

RESULTS

We identified 24 437 patients admitted to 106 hospitals with a first episode of acute cholecystitis. Most (58%, n = 14 286) underwent early cholecystectomy. Rates of early cholecystectomy varied widely across hospitals (median 51%, interquartile range [IQR] 25%-72%), even among healthy patients aged 18-49 years with uncomplicated cholecystitis (median 74%, IQR 41%-88%). Multivariable multilevel analysis showed that hospitals in the lowest quartile for volume of acute cholecystitis admissions had the lowest adjusted odds of early cholecystectomy (odds ratio 0.53, 95% confidence interval 0.35-0.78) and that hospital effects accounted for half (27%) of the explained variation (53%) in early cholecystectomy.

INTERPRETATION

Across the hospitals of a regional health care system, similar patients with acute cholecystitis did not receive comparable care. Hospital-specific initiatives should be considered to facilitate early cholecystectomy for patients with acute cholecystitis.