Accuracy of surgeon-performed gallbladder ultrasound

Natural history of asymptomatic gallbladder stones in clinic without beds: A long-term prognosis over 10 years

BACKGROUND

Several studies have explored the long-term prognosis of patients with asymptomatic gallbladder stones. These reports were primarily conducted in facilities equipped with beds for addressing symptomatic cases.

AIM

To report the long-term prognosis of patients with asymptomatic gallbladder stones in clinics without bed facilities.

METHODS

We investigated the prognoses of 237 patients diagnosed with asymptomatic gallbladder stones in clinics without beds between March 2010 and October 2022. When symptoms developed, patients were transferred to hospitals where appropriate treatment was possible. We investigated the asymptomatic and survival periods during the follow-up.

RESULTS

Among the 237 patients, 214 (90.3%) remained asymptomatic, with a mean asymptomatic period of 3898.9279 ± 46.871 d (50-4111 d, 10.7 years on average). Biliary complications developed in 23 patients (9.7%), with a mean survival period of 4010.0285 ± 31.2788 d (53-4112 d, 10.9 years on average). No patient died of biliary complications.

CONCLUSION

The long-term prognosis of asymptomatic gallbladder stones in clinics without beds was favorable. When the condition became symptomatic, the patients were transferred to hospitals with beds that could address it; thus, no deaths related to biliary complications were reported. This finding suggests that follow-up care in clinics without beds is possible.

The Accuracy of Point-of-Care Ultrasound (POCUS) in Acute Gallbladder Disease

There is increasing recognition that point-of-care ultrasound (POCUS), performed by the clinician at the bedside, can be a natural extension of the clinical examination—the modern abdominal “stethoscope” and provides an opportunity to expedite the care pathway for patients with acute gallbladder disease. The primary aims of this study were to benchmark the accuracy of surgeon-performed POCUS in suspected acute gallbladder disease against standard radiology or pathology reports and to compare time to POCUS diagnosis with time to definitive imaging. This prospective single-arm observational cohort study was conducted in four hospitals in Ireland, Italy, and Portugal to assess the accuracy of POCUS against standard radiology in patients with suspected acute biliary disease (ClinicalTrials.govIdentifier: NCT02682368). The findings of surgeon-performed POCUS were compared with those on definitive imaging or surgery. Of 100 patients recruited, 89 were suitable for comparative analysis, comparing POCUS with radiological findings in 84 patients and with surgical/histological findings in five. The overall global accuracy of POCUS was 88.7% (95% CI, 80.3–94.4%), with a sensitivity of 94.7% (95% CI, 85.3–98.9%), a specificity of 78.1% (95% CI, 60.03–90.7%), a positive likelihood ratio (LR+) of 4.33 and negative likelihood ratio (LR) of 0.07. The mean time from POCUS to the final radiological report was 11.9 h (range 0.06–54.9). In five patients admitted directly to surgery, the mean time between POCUS and incision was 2.30 h (range 1.5–5), which was significantly shorter than the mean time to formal radiology report. Sixteen patients were discharged from the emergency department, of whom nine did not need follow-up. Our study is one of the very few to demonstrate a high concordance between surgeon-performed POCUS of patients without a priori radiologic diagnosis of gallstone disease and shows that the expedited diagnosis afforded by POCUS can be reliably leveraged to deliver earlier definitive care for patients with acute gallbladder pathology, as the general surgeon skilled in POCUS is uniquely positioned to integrate it into their bedside assessment.

A systematic review of point-of-care abdominal ultrasound scans performed by general surgeons

BACKGROUND

Ultrasound is an established imaging modality in general surgery. With the increasing use of bedside point-of-care ultrasounds, general surgeons have been incorporating this skill into their clinical practice. This systematic review provides an up-to-date summary of the evidence for abdominal ultrasound scans performed by general surgeons to diagnose intra-abdominal pathology.

METHODS

Two independent reviewers searched the PubMed database between 1 January 1980 and 1 June 2020. Articles about surgeon-performed abdominal ultrasound in adult patients were included. Studies on trauma and vascular surgery were excluded.

RESULTS

26 articles met the inclusion criteria, presented as a narrative analysis. There was good evidence for the use of surgeon-performed ultrasound, particularly in gallstone-related diseases and moderate evidence for the use of ultrasound in appendicitis. Further evidence is required for point-of-care ultrasounds for other pathologies such as diverticulitis and groin hernias. Ultrasound training for general surgeons is variable with notable heterogeneity across studies.

CONCLUSION

A standardised training programme for general surgeons will greatly improve confidence and skill. There is good evidence for the use of bedside ultrasound by general surgeons in the acute and elective setting with reduced time to definitive treatment and fewer unnecessary hospital admissions.

Surgeon-Performed Ultrasound in Diagnosing Acute Cholecystitis and Appendicitis

BACKGROUND

The use of ultrasound (US) outside the radiology department has increased the last decades, but large studies assessing the quality of bedside US are still lacking. This study evaluates surgeon-performed US (SPUS) and radiologist-performed US (RPUS) with respect to biliary disease and appendicitis.

METHODS

Between October 2011 and November 2012, 300 adult patients, with a referral for an abdominal US, were prospectively enrolled in the study and examined by a radiologist as well as a surgeon. The surgeons had undergone a 4-week-long US education. US findings of the surgeon and of the radiologist were compared to final diagnosis, set by an independent external observer going through each patient's chart.

RESULTS

Among 183 patients with suspected biliary disease, 74 had gallstones and 21 had acute cholecystitis. SPUS and RPUS diagnosed gallstones with a sensitivity of 87.1 versus 97.3%. Specificity was 96.0 versus 98.9%, and the accuracy 92.3 versus 98.2%. The sensitivity, specificity and accuracy for acute cholecystitis by SPUS and RPUS were: 60.0 versus 80.0%, 98.6 versus 97.8% and 93.9 versus 95.6%, respectively. Among 58 patients with suspected appendicitis, 15 had the disease. The sensitivity, specificity and accuracy for appendicitis by SPUS and RPUS were: 53.3 versus 73.3%, 89.7 versus 93.3% and 77.3 versus 86.7%, respectively.

CONCLUSION

SPUS is reliable in diagnosing gallstones. Diagnosing cholecystitis and appendicitis with US is more challenging for both surgeons and radiologists.

TRIAL REGISTRATION NUMBER

The study was registered at clinicaltrials.gov. Registration number: NCT02469935.

Otolaryngologist-performed head and neck ultrasound: outcomes and challenges in learning the technique

Objective:

To assess the feasibility and accuracy of otolaryngologist-performed ultrasound in evaluating head and neck pathology.

Method:

An ENT trainee, who had undergone basic training in neck ultrasonography, performed this on patients referred with suspected neck pathology. The trainee recorded the presence and nature of any abnormality. Findings were compared with those from a repeated scan performed by an experienced head and neck radiologist.

Results:

The study included 250 patients. The absence or presence of lesion as reported by the trainee correlated with the radiologist's findings in 207 cases (83 per cent). There were 144 true positives, 63 true negatives, 32 false negatives and 11 false positives, yielding a sensitivity of 82 per cent, specificity of 85 per cent and accuracy of 83 per cent. Of the 144 true positive lesions, 81 per cent were interpreted concordantly with the radiologist.

Conclusion:

Neck ultrasonography performed by an otolaryngologist is less accurate than that performed by an experienced radiologist, but is still a useful adjunct to clinical assessment, facilitating assessment in a ‘one-stop’ clinical setting.

Surgeon-performed ultrasound at the bedside for the detection of appendicitis and gallstones: systematic review and meta-analysis

BACKGROUND

We undertook a systematic review and meta-analysis to compare surgeon-performed ultrasound (SPUS) for suspected appendicitis or gallstone disease to the "gold standard" of pathological examination or radiologist-performed ultrasound (RPUS).

DATA SOURCES

MEDLINE, Embase, trial registries, conference proceedings, and article reference lists were searched to identify trials and/or studies comparing SPUS with pathology or RPUS as the reference standard. Data were abstracted from eligible studies to produce 2 × 2 contingency tables, permitting the calculation of pooled sensitivity and specificity values.

RESULTS

Eight studies (1,268 patients) evaluated SPUS for appendicitis. For appendicitis, SPUS had a pooled sensitivity of .92 (95% confidence interval [CI], .887-.939) and a pooled specificity of .96 (95% CI, .946-.974). SPUS for gallstones was evaluated in 8 studies (1,019 patients). The pooled sensitivity was .96 (95% CI, .934-.979), and the specificity was .99 (95% CI .983-.998).

CONCLUSIONS

SPUS achieves acceptable sensitivity and specificity for both gallstones and appendicitis. However, there was some evidence of heterogeneity. Data regarding cost-effectiveness are lacking.

Patient factors influencing the effect of surgeon-performed ultrasound on the acute abdomen

Purpose

To evaluate the effect of surgeon-performed ultrasound on acute abdomen in specific patient subgroups regarding the diagnostic accuracy and further management.

Methods

Eight hundred patients attending the emergency department at Stockholm South General Hospital, Sweden, for abdominal pain, were randomized to either receive or not receive surgeon-performed ultrasound as a complement to routine management. Patients were divided into subgroups based on patient characteristics, symptoms or first preliminary diagnosis set at the emergency department before randomization. Outcomes measured were diagnostic accuracy, admission rate and requests for further examinations. Timing of surgery was evaluated for patients with peritonitis.

Results

Increased diagnostic accuracy was seen in patients with body mass index > 25, elevated C-reactive protein, peritonitis, age 30–59 years and/or upper abdominal pain. Decreased need for further examinations and/or fewer admissions were seen in all groups except in patients with a preliminary diagnosis of appendicitis. Among patients with non-specific abdominal pain, admission frequency was decreased with 14% when ultrasound was used (P = 0.007). Among patients with peritonitis, requiring surgery, 61% in the ultrasound group were admitted for surgery directly from the emergency department compared to 19% in the control group.

Conclusion

In different ways, surgeon-performed ultrasound is helpful for the majority of patients admitted to the emergency department for abdominal pain. Taking into account other shown benefits and the lack of adverse effects, we find the method worth consideration for routine implementation.

Appraising surgeons learning sonography: measuring measurement variability

PURPOSE

Sonography is increasingly used by various clinicians in several task-specific situations. We present a method of assessing 1 aspect of a nonspecialist's ability in performing sonography, measurement variability.

METHODS

An experienced radiologist and a surgeon who had received 4 weeks of sonography training each made triplicate measurements of gallbladder dimensions in 19 adult patients undergoing abdominal sonography. The observers examined the subjects in immediate succession using the same ultrasound equipment and were blinded to each other's measurements until the end of the study. Intraobserver measurement variability rates were calculated for gallbladder length, height, and width by using analysis of variance techniques and were expressed as a within-subject standard deviation and a repeatability coefficient.

RESULTS

In terms of intraobserver measurements, the estimated within-subject standard deviations were comparable for the radiologist and the surgeon (length, 0.22 versus 0.17 cm; height, 0.14 versus 0.14 cm; and width, 0.12 versus 0.14 cm, respectively), as were the repeatability coefficients. The interobserver variability showed good agreement as well; the estimated within-subject standard deviations (and 95% limits of agreement) obtained were length, 0.47 cm (-1.08 to 1.48 cm); height, 0.34 cm (-1.08 to 0.49 cm); and width, 0.28 cm (-0.80 to 0.81 cm).

CONCLUSIONS

The ability to measure organ dimensions accurately is an essential sonographic skill that can be readily appraised. The findings from this comparison study illustrate that this 1 small aspect of sonography can be learned by various clinicians and that their ability in this task can be appraised. In a clinical setting, the small degree of variability in measurements made by the experienced radiologist and the sonography-trainee surgeon is likely to be satisfactory.

Feasibility of an ultrasound service on district health care level in Botswana

OBJECTIVE

To assess the clinical benefit and financial feasibility of an ultrasound service in a district hospital in Botswana.

METHOD

An ultrasound service was established in the study hospital. Clinical and ultrasound-aided diagnoses were compared in patients who met eligibility criteria laid down in an indication list.

RESULTS

We enrolled 2309 patients over 18 months. The most frequent indications for ultrasound were pregnancy-related diagnoses followed by gynaecological and hepato-biliary disorders. Ultrasound assistance improved case management in 696 cases (30%) and led to an immediate change in management in 151 patients. Ultrasound diagnosis was used as gold standard to assess the accuracy of the clinical diagnosis of incomplete abortion (sensitivity 24%; positive predictive value, PPV 66%), pelvic mass (sensitivity 53%; PPV 69%), ectopic pregnancy (sensitivity 75%; PPV 28%), and gall bladder stones (sensitivity 30%; PPV 32%).

CONCLUSIONS

Ultrasound improved case management for a wide diversity of clinical problems encountered on district health care level. The service proved to be affordable for the Botswana health care system.

Comparison of quality and cost-effectiveness in the evaluation of symptomatic cholelithiasis with different approaches to ultrasound availability in the ED

Ultrasound is the imaging study of choice for the detection of gallstones, but ultrasound through medical imaging departments (MI Sono) is not readily available on an immediate basis in many emergency departments (EDs). Several studies have shown that emergency physicians can perform ultrasound themselves (ED Sono) to rule out gallstones with acceptable accuracy after relatively brief training periods, but there have been no studies to date specifically addressing the effect of ED Sono of the gallbladder on quality and cost-effectiveness in the ED. In this study, we investigated measures of quality and cost-effectiveness in evaluating patients with suspected symptomatic cholelithiasis during three different years with distinctly different approaches to ultrasound availability. The study retrospectively identified a total of 418 patients who were admitted for cholecystectomy or for a complication of cholelithiasis within 6 months of an ED visit for possible biliary colic. The percentage of patients who had gallstones documented at the first ED visit improved from 28% in 1993, when there was limited availability of ultrasound through the Medical Imaging Department (MI Sono), to 56% in 1995, when MI Sono was readily available, to 70% in 1997, when both MI Sono and ED Sono were readily available (P <.001). There were also significant differences over the 3 years in the mean number of days from the first ED visit to documentation of gallstones (19.7 in 1993, 10.7 in 1995, 7.4 in 1997, P <.001); the mean number of return visits for possible biliary colic before documentation of gallstones (1.67 in 1993, 1.24 in 1995, and 1.25 in 1997, P <.001); and the incidence of complications of cholelithiasis in the interval between the first ED visit for possible biliary colic and the date of documentation of cholelithiasis (6.8% in 1993, 5.9% in 1995, 1.5% in 1997, P =.049). The number of MI Sonos ordered by emergency physicians per case of symptomatic cholelithiasis identified increased from 1.7 in 1993 to 2.5 in 1995 and dropped back to 1.7 in 1997, when 4.2 ED Sonos per study case were also done. The cost of ED Sonos was more than offset by savings in avoiding calling in ultrasound technicians after regular Medical Imaging Department hours. The indeterminate rate for ED Sonos was 18%. Excluding indeterminates, the sensitivity of ED Sono for detection of gallstones was 88.6% (95% CI 83.1-92.8%), the specificity 98.2% (95% CI 96.0-99.3%), and the accuracy 94.8% (95% CI 92.5-96.5%). We conclude that greater availability of MI Sono in the ED was associated with improved quality in the evaluation of patients with suspected symptomatic cholelithiasis but also with increased ultrasound costs. The availability of ED Sono in addition to readily available MI Sono was associated with further improved quality and decreased costs. The indeterminate rate for ED Sono was relatively high, but excluding indeterminates, the accuracy of ED Sono was comparable with published reports of MI Sono.