An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK

Outcomes after index cholecystectomy: a UK longitudinal multi-centre cohort Study

PURPOSE

International guidelines for management of acute biliary pathology recommend emergency cholecystectomy (EmC), citing improved outcomes compared to elective cholecystectomy (ElC) based on trials which may not reflect the capacity constraints in clinical practice, nor selection based on multiple prior attendances with emergency biliary pathology or attendances following a decision for ElC. We therefore conducted a longitudinal retrospective study evaluating all attendances with biliary pathology prior to cholecystectomy with the aim of assessing whether EmC is justified in this context.

METHODS

Data was collected on patients undergoing cholecystectomy between 2016 and 2021 at four centres. Patients who had an emergency presentation with a biliary pathology prior to cholecystectomy up to 2010 were included. Patients were divided into EmC and ElC groups, EmC was defined as cholecystectomy occurring during an emergency admission with biliary pathology. Multilevel regression modelling was used to identify independent predictors for time to surgery from index presentation, number of re-attendances and length of stay (LoS).

RESULTS

2,056 patients were included: 1,786 (86.9%) had ElC and 270 (13.1%) EmC. EmC was independently associated with a reduction in time to surgery (-112.32 days [95% CI -140.22 to -84.42]). However, there was a significant increase in both post-operative and overall LoS (+ 3.34 days [95% CI 1.81-4.86]) across all admissions with EmC. EmC did not significantly reduce rates of emergency re-attendance prior to surgery overall.

CONCLUSION

Although EmC reduces time to surgery, it does not reduce the number of emergency re-attendances and increases LoS. In the context of limited emergency theatre capacity, it may be beneficial to prioritise those who benefit most from EmC.

Temporal Analysis of the Incidence, Mortality and Disability-Adjusted Life Years of Benign Gallbladder and Biliary Diseases in High-Income Nations, 1990-2019

Objective

The aim of this observational study was to analyze trends in the incidence, mortality, and disability-adjusted life years (DALYs) of benign gallbladder and biliary diseases across high-income countries between 1990 and 2019.

Background

Benign gallbladder and biliary diseases place a substantial burden on healthcare systems in high-income countries. Accurate characterization of the disease burden may help optimize healthcare policy and resource distribution.

Materials and methods

Age-standardized incidence rates (ASIRs), age-standardized mortality rates (ASMRs), and DALYs data for gallbladder and biliary diseases in males and females were extracted from the 2019 Global Burden of Disease (GBD) study. A mortality-incidence index (MII) was also calculated. Joinpoint regression analysis was performed.

Results

The median ASIRs across the European Union 15+ countries in 2019 were 758/100,000 for females and 282/100,000 for males. Between 1990 and 2019 the median percentage change in ASIR was +2.49% for females and +1.07% for males. The median ASMRs in 2019 were 1.22/100,000 for females and 1.49/100,000 for males with a median percentage change over the observation period of -21.93% and -23.01%, respectively. In 2019, the median DALYs was 65/100,000 for females and 37/100,000 among males, with comparable percentage decreases over the observation period of -21.27% and -19.23%, respectively.

Conclusions

International variation in lifestyle factors, diagnostic and management strategies likely account for national and sex disparities. This study highlights the importance of ongoing clinical efforts to optimize treatment pathways for gallbladder and biliary diseases, particularly in the provision of emergency surgical services and efforts to address population risk factors.

Audit of Emergency Laparoscopic Cholecystectomy in a District General Hospital

Introduction  Acute gallstone diseases are common surgical emergencies, accounting for approximately one-third of emergency surgical admissions. Laparoscopic cholecystectomy is the standard choice of treatment for gallstone diseases and is currently one of the most commonly performed surgical procedures in the United Kingdom. Majority of these procedures are carried out as elective cases. National Institute of Clinical Excellence (NICE) guidelines and other upper gastrointestinal surgery specialty bodies encourage early emergency surgery in acute symptomatic gallstone disease. We assessed emergency laparoscopic cholecystectomies performed at Birmingham Heartlands Hospital, United Kingdom and compared the practice against NICE and British Benign Upper Gastrointestinal Surgery Society (BBUGSS) recommendations. Methods This is a snapshot retrospective audit, assessing emergency laparoscopic cholecystectomy practice over a nine-month period from November 2022 to July 2023. Variables assessed were demographics, duration of symptoms prior to surgery, imaging modality, indications, C-reactive protein (CRP) levels, operative difficulty, intraoperative and postoperative complications, length of hospital stay and readmission rates. These variables were compared against both NICE and BBUGSS standards. We aimed to establish baseline data to encourage emergency laparoscopic cholecystectomies in our hospital and reduce repeated hospital visits for patients with acute gallbladder disease. Results Forty-eight patients had emergency laparoscopic cholecystectomy in the period reviewed, mean age was 44.3 years and females accounted for approximately 71% (n=34) of the group. 66.7% (n=32) of patients had their surgery within seven days of diagnosis with acute gallstone disease; 50% (n=24) of patients had no adverse intraoperative event. No patient had biliary tract injury despite a high number of difficult cases. Overall there was no correlation between duration before surgery and intraoperative difficulty or readmission rates.

Tackling a Post-COVID-19 Cholecystectomy Waiting List: Are We Meeting the Challenge?

Background and Objectives: The COVID-19 pandemic has led to a tremendous backlog in elective surgical activity. Our hospital trust adopted an innovative approach to dealing with elective waiting times for cholecystectomy during the recovery phase from COVID-19. This study aimed to evaluate trends in overall cholecystectomy activity and the effect on waiting times. Materials and Methods: A prospective observational study was undertaken, investigating patients who received a cholecystectomy at a large United Kingdom hospital trust between February 2021 and February 2022. There were multiple phased strategies to tackle a 533-patient waiting list: private sector, multiple sites including emergency operating, mobile theatre, and seven-day working. The correlation of determination (R2) and Kruskal-Wallis analysis were used to evaluate trends in waiting times across the study period. Results: A total of 657 patients underwent a cholecystectomy. The median age was 49 years, 602 (91.6%) patients had an ASA of 1-2, and 494 (75.2%) were female. A total of 30 (4.6%) patients were listed due to gallstone pancreatitis, 380 (57.8%) for symptomatic cholelithiasis, and 228 (34.7%) for calculous cholecystitis. Median waiting times were reduced from 428 days (IQR 373-508) to 49 days (IQR 34-96), R2 = 0.654, p < 0.001. For pancreatitis specifically, waiting times had decreased from a median of 218 days (IQR 139-239) to 28 (IQR 24-40), R2 = 0.613, p < 0.001. Conclusions: This study demonstrates the methodology utilised to safely and effectively tackle the cholecystectomy waiting list locally. The approach utilised here has potential to be adapted to other units or similar operation types in order to reduce elective waiting times.

Endoscopic Ultrasound-Guided Gallbladder Drainage versus Percutaneous Gallbladder Drainage for Acute Cholecystitis: A Systematic Review and Meta-Analysis

Background: Percutaneous transhepatic gallbladder drainage (PT-GBD) has been the treatment of choice for acute cholecystitis patients who are not suitable for surgery. The effectiveness of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) as an alternative to PT-GBD is not clear. In this meta-analysis, we have compared their efficacy and adverse events. Methods: We adhered to the PRISMA statement to conduct this meta-analysis. Online databases were searched for studies that compared EUS-GBD and PT-GBD for acute cholecystitis. The primary outcomes of interest were technical success, clinical success, and adverse events. The pooled odds ratio (OR) with a 95% confidence interval (CI) was calculated using the random-effects model. Results: A total of 396 articles were screened, and 11 eligible studies were identified. There were 1136 patients, of which 57.5% were male, 477 (mean age 73.33 ± 11.28 years) underwent EUS-GBD, and 698 (mean age 73.77 ± 8.7 years) underwent PT-GBD. EUS-GBD had significantly better technical success (OR 0.40; 95% CI 0.17-0.94; p = 0.04), fewer adverse events (OR 0.35; 95% CI 0.21-0.61; p = 0.00), and lower reintervention rates (OR 0.18; 95% CI 0.05-0.57; p = 0.00) than PT-GBD. No difference in clinical success (OR 1.34; 95% CI 0.65-2.79; p = 0.42), readmission rate (OR 0.34; 95% CI 0.08-1.54; p = 0.16), or mortality rate (OR 0.73; 95% CI 0.30-1.80; p = 0.50) was noted. There was low heterogeneity (I2 = 0) among the studies. Egger's test showed no significant publication bias (p = 0.595). Conclusion: EUS-GBD can be a safe and effective alternative to PT-GBD for treating acute cholecystitis in non-surgical patients and has fewer adverse events and a lower reintervention rate than PT-GBD.

Specialist-led urgent cholecystectomy for acute gallstone disease

BACKGROUND

Despite overwhelming evidence of the clinical and financial benefit of urgent cholecystectomy, there is variable enthusiasm and uptake across the UK. In 2014, following the First National Emergency Laparotomy Audit Organisational Report, we implemented a specialist-led urgent surgery service, whereby all patients with gallstone-related pathologies were admitted under the direct care of specialist upper gastrointestinal surgeons. We have analysed 5 years of data to investigate the results of this service model.

METHODS

Computerised operating theatre records were interrogated to identify all patients within a 5-year period undergoing cholecystectomy. Patient demographics, admission details, length of stay, duration of surgery, and complications were analysed.

RESULTS

Between 01/01/2016 and 31/12/2020, a total of 4870 cholecystectomies were performed; 1793 (36.8%) were urgent cases and 3077 (63.2%) were elective cases. All cases were started laparoscopically; 25 (0.5%) were converted to open surgery-14 of 1793 (0.78%) urgent cases and 11 of 3077 (0.36%) elective cases. Urgent cholecystectomy took 20 min longer than elective surgery (median 74 versus 52 min). No relevant difference in conversion rate was observed when urgent cholecystectomy was performed within 2 days, between 2 and 4 days, or greater than 4 days from admission (P = 0.197). Median total hospital stay was 4 days.

CONCLUSION

Urgent laparoscopic cholecystectomy is safe and feasible in most patients with acute gall bladder disease. Surgery under the direct care of upper gastrointestinal specialist surgeons is associated with a low conversion rate, low complication rate, and short hospital stay. Timing of surgery has no effect on conversion rate or complication rate.

Which octogenarian patients are at higher risk after cholecystectomy for symptomatic gallstone disease? A single center cohort study

BACKGROUND

Incidence of gallstones in those aged ≥ 80 years is as high as 38%-53%. The decision-making process to select those oldest old patients who could benefit from cholecystectomy is challenging.

AIM

To assess the risk of morbidity of the "oldest-old" patients treated with cholecystectomy in order to provide useful data that could help surgeons in the decision-making process leading to surgery in this population.

METHODS

A retrospective study was conducted between 2010 and 2019. Perioperative variables were collected and compared between patients who had postoperative complications. A model was created and tested to predict severe postoperative morbidity.

RESULTS

The 269 patients were included in the study (193 complicated). The 9.7% of complications were grade 3 or 4 according to the Clavien-Dindo classification. Bilirubin levels were lower in patients who did not have any postoperative complications. American Society of Anesthesiologists scale 4 patients, performing a choledocholithotomy and bilirubin levels were associated with Clavien-Dindo > 2 complications (P < 0.001). The decision curve analysis showed that the proposed model had a higher net benefit than the treating all/none options between threshold probabilities of 11% and 32% of developing a severe complication.

CONCLUSION

Patients with American Society of Anesthesiologists scale 4, higher level of bilirubin and need of choledocholithotomy are at the highest risk of a severely complicated postoperative course. Alternative endoscopic or percutaneous treatments should be considered in this subgroup of octogenarians.

Effect of the COVID-19 Pandemic on the Management of Acute Cholecystitis and Assessment of the Crisis Approach: A Multicenter Experience in Egypt

INTRODUCTION

The covid-19 pandemic has had a drastic impact on all medical services. Acute cholecystitis is a serious condition that accounts for a considerable percentage of general surgical acute admissions. Therefore, the Royal College of Surgeons' Commissioning guidance' recommended urgent admission to secondary care and early cholecystectomy. During the first wave of hospital admissions associated with COVID-19, most guidelines recommended conservative treatment in order to limit the admission rates and free up spaces for COVID-19-infected patients. However, reviews of this approach have not been widely done to assess the results and, in turn, planning our future management approach when future pressures on in-patient admissions are inevitable.

METHODS

Our study included all acute cholecystitis patients who needed surgical intervention in one Centre in the UK over three distinct periods (pre-COVID-19, during the first lockdown, and lockdown ease). Comparison between these groups were done regarding intraoperative and postoperative results.

RESULTS

The conservative management led to a high rate of readmission. Moreover, delayed cholecystectomy was associated with increased operative difficulties such as extensive adhesions, intraoperative blood loss, and/or complicated gall bladder pathologies such as perforated or gangrenous gall bladder (29.9%, 16.7%, and 24.8%, respectively). The resulting postoperative complications of surgical and nonsurgical resulted in a longer hospital stay (13.5 d).

CONCLUSION

The crisis approach for acute cholecystitis management failed to deliver the hoped outcome. Instead, it backfired and did the exact opposite, leading to longer hospital stays and extra burden to the patient and the healthcare system.

Percutaneous Cholecystostomy Tubes versus Medical Management for Acute Cholecystitis

BACKGROUND

Cholecystitis is one of the most common infections treated surgically in the United States. Surgical risk is prohibitive in some patients, leading to alternative therapeutic strategies, including medical management (antibiotics) with or without percutaneous cholecystostomy tube (PCT) drainage.

MATERIALS AND METHODS

Using the Healthcare Cost and Utilization Project (HCUP) National Readmission Database (NRD), we performed a retrospective review to compare medically managed patients with or without PCT placement by evaluating 60-day readmissions rates, health care costs, and hospital length of stay (LOS). Both study groups were matched using the Elixhauser comorbidity index, age, and sex. Univariate and multivariate statistical analyses were performed using STATA.

RESULTS

776,766 patients were included in the analysis. The population receiving PCT placement was on average 16 years older (69.9 vs 53.6 years; P < .01), less likely to be female (40.7% vs 59.3%; P < .01), and had almost twice as many comorbidities (3.36 vs 1.81; P < .01) compared to the population receiving medical management. After matching our data to account for these incongruities, PCT patients were still 10.4 times more likely to be readmitted, had a 11.6% increase in the cost of care, and a 37.6% increase in LOS compared to those managed medically.

DISCUSSION

Percutaneous cholecystostomy tube placement for cholecystitis is associated with a higher readmission rate, increased charges, and increased LOS compared to antibiotic therapy alone, even after correcting for age, sex, and comorbidities.

'Hot gall bladder service' by emergency general surgeons: Is this safe and feasible?

Background:

Despite NICE/AUGIS recommendations, the practice of early laparoscopic cholecystectomy (ELC) has been particularly poor in the UK offered only by 11%–20% surgeons as compared to 33%–67% internationally, possibly due to financial constraints, logistical difficulties and shortage of expertise, thus, reflecting the varied provision of emergency general surgical care. To assess whether emergency general surgeons (EGS) could provide a 'Hot Gall Bladder Service' (HGS) with an acceptable outcome.

Patients and Methods:

This was a prospective HGS observational study that was protocol driven with strict inclusion/exclusion criteria and secure online data collection in a district general hospital between July 2018 and June 2019. A weekly dedicated theatre slot was allocated for this list.

Results:

Of the 143 referred for HGS, 86 (60%) underwent ELC which included 60 (70%) women. Age, ASA and body mass index was 54* (18–85) years, II* (I-III) and 27* (20–54), respectively. 86 included 46 (53%), 19 (22%), 19 (22%) and 2 (3%) patients presenting with acute calculus cholecystitis, gallstone pancreatitis, biliary colic, and acalculus cholecystitis, respectively. 85 (99%) underwent LC with a single conversion. Grade of surgical difficulty, duration of surgery and post-operative stay was 2* (1–4) 68* (30–240) min and 0* (0–13) day, respectively. Eight (9%) required senior surgical input with no intra-operative complications and 2 (2%) 30-day readmissions. One was post-operative subhepatic collection that recovered uneventfully and the second was pancreatitis, imaging was clear requiring no further intervention.

Conclusion:

In the current climate of NHS financial crunch, COVID pandemic and significant pressure on inpatient beds: Safe and cost-effective HGS can be provided by the EGS with input from upper GI/HPB surgeons (when required) with acceptable morbidity and a satisfactory outcome.

Days of symptoms and days of hospital admission before surgery do not influence the results of cholecystectomy in moderate acute calculous cholecystitis

BACKGROUND AND AIMS

Early cholecystectomy is the gold standard treatment for acute calculous cholecystitis (AC), although for grade II, many surgeons still prefer delayed cholecystectomy, to avoid surgical complications. The aim of this study is to analyze postoperative morbidity and mortality for Tokyo Guidelines grade II AC treated with cholecystectomy, taking in to account the days of symptoms and the days since hospital admission.

MATERIALS AND METHODS

Unicentre, retrospective study based on a prospective database. Patients with grade II AC treated with cholecystectomy were selected. Patients were analyzed according to Days of Symptoms (DS) and Days of Hospital Admission (DHA) until cholecystectomy. Patients were subdivided in: < 3 days, 3-5 days, >5 days. Univariant and multivariant analysis for morbidity and mortality. Categorical variables were compared using chi square or Fischer's exact test. Continuous variables were compared using the Mann Whitney U test. Level of statistical significance was set at p < 0.05.

RESULTS

998 patients with AC diagnoses were included; 567 with grade II AC; 368 treated with cholecystectomy. Nearly 90% were treated laparoscopically; 48.1% were operated the same day of emergency admission. For DS and DHA there were no statistical differences for severe postoperative complications, although a greater number of complications were detected in >5 DS (p: 0.32) and >5 DHA (p: 0.00). Statistically differences were found in DS for mortality (p:0.04). Postoperative length of stay was longer for >5 DHA cholecystectomies, (p > 0.05). No differences for hospital readmission.

CONCLUSION

Regardless of DS or DHA until cholecystectomy, do not exist statistically significant differences related to severe postoperative complications, length of stay or mortality.

Changing trends and outcomes associated with the adoption of minimally-invasive pancreato-biliary surgery: Contemporary experience of a 'self-taught' early adopter in Southeast Asia

BACKGROUND

Minimally-invasive pancreato-biliary surgery (MIPBS) is increasingly reported worldwide. This study examines the changing trends, safety and outcomes associated with the adoption of MIPBS based on a contemporary experience of an early adopter in Southeast Asia.

METHODS

Retrospective review of 114 consecutive patients who underwent MIPBS by a single surgeon over 86 months from 2011. The study population was stratified into three equal groups of 38 patients. Comparison was also performed between minimally-invasive pancreato surgery (MIPS) and minimally-invasive biliary surgery (MIBS).

RESULTS

There were 70 MIPS and 44 MIBS. Sixty-three cases (55.3%) were performed using robotic assistance and fourteen (12.3%) were hybrid procedures with open reconstruction. Forty-four (38.6%) procedures were performed for malignancy. There were 8 (7.0%) open conversions and median operation time was 335 (range, 60-930) min. There were nine extended pancreatectomies including seven involving vascular reconstructions. Major morbidity (>Grade 2) occurred in 20 (17.5%) patients including 6 (5.3%) reoperations and there was no mortality. Comparison across the three groups demonstrated that with increasing experience, there was a significant trend in a higher proportion of higher ASA score patients, increasing frequency of procedures requiring anastomosis and increasing the use of robotic assistance without significant difference in key perioperative outcomes such as open conversion rate, morbidity and hospital stay. Comparison between MIPS and MIBS demonstrated that MIPS was associated with significantly longer operation time, increased blood loss, increased transfusion rate, longer hospital stay, increased readmission rate and increased morbidity.

CONCLUSION

MIPBS can be safely adopted today with a low open conversion rate.

Early versus delayed cholecystectomy for cholecystitis at high risk of operative difficulties: A propensity score-matching analysis

BACKGROUND

Numerous studies have demonstrated the superiority of early (EC) over delayed (DC) cholecystectomy for acute cholecystitis (AC). However, none have assessed the effect of operative difficulty when reporting on treatment outcomes.

METHODS

Outcomes of patients who underwent EC or DC between 2010 and 2019 were compared taking into account the operative difficulty evaluated by the Difficult Laparoscopic Cholecystectomy score (DiLC). For each patient, the DiLC score was retrospectively calculated and corresponded to the foreseeable operative difficulty measured on admission for AC. A propensity score was used to account for confounders. Primary endpoints were the length of stay (LOS) and the occurrence of a serious operative/post-operative event (SOE).

RESULTS

DC in patients with DiLC≥10 reduced the risk of SOE without increasing the LOS. Conversely, DC in patients with DiLC<10 increased the LOS without improving outcomes. Multivariate analysis found EC in patients with DiLC≥10 as the main independent predictor of SOE.

CONCLUSIONS

Provided prospective validation, DC for AC in patients with DiLC≥10 seems safer than EC and is not hospital-stay consuming.

Cholecystectomy for Complicated Gallbladder and Common Biliary Duct Stones: Current Surgical Management

Gallstone disease accounts for the vast majority of acute surgical admissions in the UK, with a major treatment being cholecystectomy. Practice varies significantly as to whether surgery is performed during the acute symptomatic phase, or after a period of recovery. Differences in practice relate to operative factors, patient factors, surgeon factors and hospital and trust wide policies. In this review we summarize recent evidence on management of gallstone disease, particularly with respect to whether cholecystectomy should occur during index presentation or following recovery. We highlight morbidity and mortality studies, cost, and patient reported outcomes. We speculate on barriers to change in service delivery. Finally, we propose potential solutions to optimize care.

Does the Surgeon's Caseload Affect the Outcome in Laparoscopic Cholecystectomy for Acute Cholecystitis?

BACKGROUND

This study investigated how annual caseloads and the surgeon's previous experience influence the outcome in laparoscopic cholecystectomy (LCC) for acute cholecystitis.

METHODS

A total of 892 patients treated in Helsinki University Hospital in 2013-2016 were retrospectively analyzed. Surgeons were compared regarding volume-over 5 LCCs for acute cholecystitis a year versus 5 or fewer LCCs a year, and experience-attendings versus residents.

RESULTS

High-volume surgeons (n=14) operated faster than low-volume surgeons (n=62) (91 vs. 108 min, P<0.001). Examining only procedures with an attending present, high-volume attendings (n=7) converted less (14.9% vs. 32.0%, P<0.001) and operated faster (95 vs. 110 min, P<0.001) compared with low-volume attendings (n=41). The results of residents did not significantly differ from the results of attendings.

CONCLUSIONS

Attending surgeons, performing >5 LCCs for acute cholecystitis a year, have shorter operative times and lower conversion rates.

Percutaneous cholecystostomy - An option in selected patients with acute cholecystitis

While urgent percutaneous cholecystostomy (PC) was introduced as an alternative to acute surgical treatment for acute cholecystitis (AC), the current place of PC in the treatment algorithm for AC is challenged. We evaluate demographics and outcomes of PC in routine clinical practice in a population-based cohort.Retrospective evaluation of consecutive patients treated with PC for AC between 2000 and 2015. The severity of cholecystitis was graded according to the 2013 Tokyo Guidelines.One hundred forty-nine patients were included (82; 55% males) (median age of 72.5 years; range, 21-92). The Tokyo Guidelines criteria of 2013 (TG13) severity grade distribution was 4%, 61.7%, and 34.2% for grades I, II, and III, respectively. No difference was observed between males and females with regard to age, American Society of Anesthesiologists (ASA) score, comorbidities, or previous history of cholecystitis. PC was successfully performed in all but 1 patient, and complications were few and minor. Less than half (48.3%) of all patients subsequently received definitive surgical treatment, mostly (83.3%) laparoscopy. No or minor complications were encountered in 58 (80.6%) patients. Operated patients were significantly younger (P = <.001) and had lower ASA scores (P = .005), less comorbidities (P < .001), and had more seldomly a severe grade 3 cholecystitis (P < .001) than non-operated patients.PC is useful in selected patients with AC. However, since only a half of the patients eventually received definitive surgical treatment, a better routine decision-making based on proper criteria may enable an improved allocation of the individual patient for tailored treatment according to the disease severity, the patient's comorbidity burden, and also to the treatment options available at the institution to prevent overutilization of a non-definitive treatment approach. Comprehension of this responsibility should be acknowledged by hospitals with an emergency surgical service, although the clinical decision-making remains a challenge of the responsible surgeon on call.

Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy

Background

Acute gallstone disease is a high-volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance.

Methods

Patients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods.

Results

Of 13 sites invited to join Chole-QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole-QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8-day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals.

Conclusion

A surgeon-led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy.

Evidence-based Reviews in Surgery: Early Cholecystectomy for Cholecystitis

QUESTION

What are the clinical outcomes of early versus delayed laparoscopic cholecystectomy (LC) in acute cholecystitis with more than 72 hours of symptoms?

DESIGN

A randomized controlled trial.

SETTING

Single center at the University Hospital of Lausanne, Switzerland.

PATIENTS

Eighty-six patients were enrolled in the study that had symptoms of acute cholecystitis lasting more than 72 hours before admission.

INTERVENTION

Patients were randomly assigned to early LC or delayed LC.

MAIN OUTCOME

Primary outcome was overall morbidity following initial diagnosis. Secondary outcomes included total length of stay, duration of antibiotic used, cost, and surgical outcome.

RESULTS

Overall morbidity was lower in early laparoscopic cholecystectomy (ELC) [6 (14%) vs 17 (39%) patients, P = 0.015]. Median total length of stay (4 vs 7 days, P < 0.001) and duration of antibiotic therapy (2 vs 10 days, P < 0.001) were shorter in the ELC group. Total hospital costs were lower in ELC (9349&OV0556; vs 12,361&OV0556;, P = 0.018). Operative time and postoperative complications were similar (91 vs 88 minutes; P = 0.910) and (15% vs 17%; P = 1.000), respectively.

CONCLUSIONS

ELC for acute cholecystitis even beyond 72 hours of symptoms is safe and associated with less overall morbidity, shorter total hospital stay, and duration of antibiotic therapy, as well as reduced cost compared with delayed cholecystectomy.

Optimum timing of emergency cholecystectomy for acute cholecystitis in England: population-based cohort study

Background

Cholecystectomy on index admission for acute cholecystitis is associated with improved patient outcomes. The timing of intervention is mainly driven by service provision. This population-based cohort study aimed to evaluate timing of emergency cholecystectomy in England.

Methods

Data from all consecutive patients undergoing surgery for acute cholecystitis on index admission in England from 1997 to 2012 were captured from the Hospital Episodes Statistics database. Data were analysed based on whether patients underwent surgery 0–3 days, 4–7 days or ≥ 8 days from admission. Outcome measures were rate of post-operative biliary complications, conversion to open and length of stay.

Results

Forty-three thousand eight hundred and seventy patients underwent emergency cholecystectomy. 64.6% of patients underwent surgery between days 0 and 3 of admission, 24.3% between days 4–7 and 11.0% had surgery after day 8. Patients undergoing early surgery had significantly reduced rates of intra-operative laparoscopic conversion to open (0–3 days: 3.6%; 4–7 days: 4.0%; ≥ 8 days 4.7%, p = 0.001), post-operative ERCP (0–3 days: 1.1%; 4–7 days: 1.5%; ≥ 8 days 1.9%, p < 0.001) and bile duct injury (0–3 days: 0.6%; 4–7 days: 1.0%; ≥ 8 days 1.8%, p < 0.001). Early cholecystectomy was also associated with a shorter post-operative length of stay (LOS) [0–3 days group: median post-operative LOS 3 days (IQR: 1–6); 4–7 days group: 3 days (IQR 2–6); ≥ 8 days group: 4 days (IQR 2–9) (p < 0.001)]. High-volume centres undertook a significantly greater proportion of cholecystectomies within 3 days of presentation (high-volume: 67.3%; medium-volume: 64.8%; low-volume: 61.2%). In multivariate analysis greater time to surgery was independently associated with increased risk of post-operative ERCP and bile duct injury.

Conclusions

Early cholecystectomy within 3 days of admission reduces intra-operative conversion, post-operative biliary complications and length of stay. Centres undertaking the greatest numbers of emergency cholecystectomies perform a larger proportion within 3 days of admission.

GI Surgical Emergencies: Scope and Burden of Disease

Nearly 3 million patients are hospitalized every year for emergent gastrointestinal (GI) surgical problems and nearly one third of those will require surgery. This article reviews the scope of GI surgical emergencies within the context of emergency general surgery (EGS), costs of care, overview of several common GI surgical problems, and traditional and emerging treatment modalities. This article also argues for ongoing work in the area of risk assessment for EGS, and describes quality metrics as well as outcomes of care for these patients.

An Update on Iatrogenic Biliary Injuries: Identification, Classification, and Management

Common bile duct injury is a feared complication of cholecystectomy, with an incidence of 0.1% to 0.6%. A majority of injuries go unnoticed at index operation, and postoperative diagnosis can be difficult. Patient presentation can vary from vague abdominal pain to uncontrolled sepsis and peritonitis. Diagnostic evaluation typically begins with ultrasound or CT scan in the acute setting, and source control is paramount at time of presentation. In a stable patient, hepatobiliary iminodiacetic acid scan can be useful in identifying an ongoing bile leak, which requires intervention. A variety of diagnostic techniques define biliary anatomy. Treatment often requires a multidisciplinary approach.

Evolution in the management of acute cholecystitis in the elderly: population-based cohort study

BACKGROUND

Acute cholecystitis is a life-threatening emergency in elderly patients. This population-based cohort study aimed to evaluate the commonly used management strategies for elderly patients with acute cholecystitis as well as resulting mortality and re-admission rates.

METHODS

Data from all consecutive elderly patients (≥ 80 years) admitted with acute cholecystitis in England from 1997 to 2012 were captured from the Hospital Episode Statistics database. Influence of management strategies upon mortality was analyzed with adjustment for patient demographics and treatment year.

RESULTS

47,500 elderly patients were admitted as an emergency with acute cholecystitis. On the index emergency admission the majority of patients (n = 42,620, 89.7%) received conservative treatment, 3539 (7.5%) had cholecystectomy, and 1341 (2.8%) underwent cholecystostomy. In the short term, 30-day mortality was increased in the emergency cholecystectomy group (11.6%) compared to those managed conservatively (9.9%) (p < 0.001). This was offset by the long-term benefits of cholecystectomy with a reduced 1-year mortality [20.8 vs. 27.1% for those managed conservatively (p < 0.001)]. Management with percutaneous cholecystostomy had increased 30-day and 1-year mortality (13.4 and 35.0%, respectively). The annual proportion of cholecystectomies performed laparoscopically increased from 27% in 2006 to 59% in 2012. Within the cholecystectomy group, laparoscopic approach was an independent predictor of reduced 30-day mortality (OR 0.16, 95% CI 0.10-0.25). Following conservative management, there were 16,088 admissions with further cholecystitis. Only 11% of patients initially managed conservatively or with cholecystostomy received subsequent cholecystectomy.

CONCLUSION

Acute cholecystitis is associated with significant mortality in elderly patients. Potential benefits of emergency cholecystectomy in selected elderly patients include reduced rate of readmissions and 1-year mortality. Laparoscopic approach for emergency cholecystectomy was associated with an 84% relative risk reduction in 30-day mortality compared to open surgery.