A National Survey of Current Surgical Treatment of Acute Gallstone Disease

Evaluation of socioeconomic and healthcare disparities on same admission cholecystectomy after endoscopic retrograde cholangiopancreatography among patients with acute gallstone pancreatitis

BACKGROUND

Despite literature and guidelines recommending same admission cholecystectomy (CCY) after endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute gallstone pancreatitis, clinical practice remains variable. The aim of this study was to investigate the role of clinical and socio-demographic factors in the management of acute gallstone pancreatitis.

METHODS

Patients with acute gallstone pancreatitis who underwent ERCP during hospitalization were reviewed from the U.S. Nationwide Inpatient Sample database between 2008 and 2014. Patients were classified by treatment strategy: ERCP + same admission CCY (ERCP + CCY) versus ERCP alone. Measured variables including age, race/ethnicity, Charlson Comorbidity Index (CCI), hospital type/region, insurance payer, household income, length of hospital stay (LOS), hospitalization cost, and in-hospital mortality were compared between cohorts using χ² and ANOVA. Multivariable logistic regression was performed to identify specific predictors of same admission CCY.

RESULTS

A total of 205,012 patients (ERCP + CCY: n = 118,318 versus ERCP alone: n = 86,694) were analyzed. A majority (53.4%) of patients that did not receive same admission CCY were at urban-teaching hospitals. LOS was longer with higher associated costs for patients with same admission CCY [(6.8 ± 5.6 versus 6.4 ± 6.5 days; P < 0.001) and ($69,135 ± 65,913 versus $52,739 ± 66,681; P < 0.001)]. Mortality was decreased significantly for patients who underwent ERCP + CCY versus ERCP alone (0.4% vs 1.1%; P < 0.001). Multivariable regression demonstrated female gender, Black race, higher CCI, Medicare payer status, urban-teaching hospital location, and household income decreased the odds of undergoing same admission CCY + ERCP (all P < 0.001).

CONCLUSION

Based upon this analysis, multiple socioeconomic and healthcare-related disparities influenced the surgical management of acute gallstone pancreatitis. Further studies to investigate these disparities are indicated.

Efficacy and safety of early cholecystectomy for comorbid acute cholecystitis and acute cholangitis: Retrospective cohort study

Background

This study investigated the optimal timing and usefulness of early cholecystectomy for acute cholecystitis in patients with comorbid acute cholangitis.

Materials and methods

In 2011–2016, 252 patients who underwent early cholecystectomy for acute cholecystitis and 7 who underwent delayed cholecystectomy were enrolled and compared. Patients with comorbid acute cholangitis were then divided into those who underwent urgent cholecystectomy (within 72 h after symptom onset), semi-urgent cholecystectomy (3–14 days after symptom onset), or delayed cholecystectomy (3 months after symptom onset).

Results

There were no significant intergroup differences in postoperative complication rate (p = 0.561), operation time (p = 0.496), or intraoperative blood loss (p = 0.151) between those with and those without acute cholangitis. Postoperative stays were significantly longer in the comorbid acute cholangitis group (p = 0.004). In the patients with acute cholangitis, the urgent cholecystectomy, semi-urgent, and delayed cholecystectomy groups had comparable intra- and postoperative outcomes.

Conclusion

Early cholecystectomy within 14 days after symptom onset was safely performed for patients with concomitant acute cholecystitis and acute cholangitis after the successful treatment of acute cholangitis.

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Feasibility and safety of early cholecystectomy for concomitant acute cholecystitis with acute cholangitis within 14 days after symptom onset.

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Upfront treatment for acute cholangitis is essential for achieving low postoperative mortality in case of concomitant acute cholecystitis and acute cholangitis.

Current status of laparoscopy for acute abdomen in Italy: a critical appraisal of 2012 clinical guidelines from two consecutive nationwide surveys with analysis of 271,323 cases over 5 years

BACKGROUND

Several authors have demonstrated the safety and feasibility of laparoscopy in selected cases of abdominal emergencies. The aim of the study was to analyse the current Italian practice on the use of laparoscopy in abdominal emergencies and to evaluate the impact of the 2012 national guidelines on the daily surgical activity.

METHODS

Two surveys (42 closed-ended questions) on the use of laparoscopy in acute abdomen were conducted nationwide with an online questionnaire, respectively, before (2010) and after (2014) the national guidelines publication. Data from two surveys were compared using Chi-square or Fisher's exact test, and data were considered significant when p < 0.05.

RESULTS

Two-hundred and one and 234 surgical units answered to the surveys in 2010 and 2014, respectively. Out of 144,310 and 127,013 overall surgical procedures, 23,407 and 20,102, respectively, were abdominal emergency operations. Respectively 24.74 % (in 2010) versus 30.27 % (in 2014) of these emergency procedures were approached laparoscopically, p = 0.42. The adoption of laparoscopy increased in all the considered clinical scenarios, with statistical significance in acute appendicitis (44 vs. 64.7 %; p = 0.004). The percentage of units approaching Hinchey III acute diverticulitis with laparoscopy in 26-75 % of cases (14.0 vs. 29.7 %; p = 0.009), those with >25 % of surgeons confident with laparoscopic approach to acute diverticulitis (29.9 vs. 54 %; p = 0.0009), the units with >50 % of surgeons confident with laparoscopic approach to acute appendicitis, cholecystitis and perforated duodenal ulcer, all significantly increased in the time frame. The majority of respondents declared that the 2012 national guidelines influenced their clinical practice.

CONCLUSIONS

The surveys showed an increasing use of laparoscopy for patients with abdominal emergencies. The 2012 national guidelines profoundly influenced the Italian surgical practice in the laparoscopic approach to the acute abdomen.

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.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Scoring System for the Management of Acute Gallstone Pancreatitis: Cost Analysis of a Prospective Study

Predicting the presence of a persistent common bile duct (CBD) stone is a difficult and expensive task. The aim of this study is to determine if a previously described protocol-based scoring system is a cost-effective strategy. The protocol includes all patients with gallstone pancreatitis and stratifies them based on laboratory values and imaging to high, medium, and low likelihood of persistent stones. The patient's stratification then dictates the next course of management. A decision analytic model was developed to compare the costs for patients who followed the protocol versus those that did not. Clinical data model inputs were obtained from a prospective study conducted at The Mount Sinai Medical Center to validate the protocol from Oct 2009 to May 2013. The study included all patients presenting with gallstone pancreatitis regardless of disease severity. Seventy-three patients followed the proposed protocol and 32 did not. The protocol group cost an average of $14,962/patient and the non-protocol group cost $17,138/patient for procedural costs. Mean length of stay for protocol and non-protocol patients was 5.6 and 7.7 days, respectively. The proposed protocol is a cost-effective way to determine the course for patients with gallstone pancreatitis, reducing total procedural costs over 12 %.

Open versus laparoscopic cholecystectomy in acute cholecystitis. Systematic review and meta-analysis

INTRODUCTION

Laparoscopic cholecystectomy (LC) has become a popular alternative to open cholecystectomy (OC) in the treatment of acute cholecystitis (AC). Laparoscopic cholecystectomy (LC) is now considered the gold standard of therapy for symptomatic cholelithiasis and chronic cholecystitis. However no definitive data on its use in AC has been published. CIAO and CIAOW studies demonstrated 48.7% of AC were still operated with the open technique. The aim of the present meta-analysis is to compare OC and LC in AC.

MATERIAL AND METHODS

A systematic-review with meta-analysis and meta-regression of trials comparing open vs. laparoscopic cholecystectomy in patients with AC was performed. Electronic searches were performed using Medline, Embase, PubMed, Cochrane Central Register of Controlled Trials (CCTR), Cochrane Database of Systematic Reviews (CDSR) and CINAHL.

RESULTS

Ten trials have been included with a total of 1248 patients: 677 in the LC and 697 into the OC groups. The post-operative morbidity rate was half with LC (OR = 0.46). The post-operative wound infection and pneumonia rates were reduced by LC (OR 0.54 and 0.51 respectively). The post-operative mortality rate was reduced by LC (OR = 0.2). The mean postoperative hospital stay was significantly shortened in the LC group (MD = -4.74 days). There were no significant differences in the bile leakage rate, intraoperative blood loss and operative times.

CONCLUSIONS

In acute cholecystitis, post-operative morbidity, mortality and hospital stay were reduced by laparoscopic cholecystectomy. Moreover pneumonia and wound infection rate were reduced by LC. Severe hemorrhage and bile leakage rates were not influenced by the technique. Cholecystectomy in acute cholecystitis should be attempted laparoscopically first.

Gallstone pancreatitis: a review

Gallstone disease is the most common cause of acute pancreatitis in the Western world. In most cases, gallstone pancreatitis is a mild and self-limiting disease, and patients may proceed without complications to cholecystectomy to prevent future recurrence. Severe disease occurs in about 20% of cases and is associated with significant mortality; meticulous management is critical. A thorough understanding of the disease process, diagnosis, severity stratification, and principles of management is essential to the appropriate care of patients presenting with this disease. This article reviews these topics with a focus on surgical management, including appropriate timing and choice of interventions.

Multivariate analysis of factors influencing length of hospitalization and medical costs of cholecystectomy for acute cholecystitis in Japan: a national database analysis

Little information is available on the factors influencing length of stay (LOS) in hospital and medical costs during hospitalization associated with cholecystectomy for acute cholecystitis. We determined the independent factors affecting LOS and medical costs of patients who underwent cholecystectomy for acute cholecystitis based on data from the Diagnosis Procedure Combination (DPC) database. In 2008, a total of 2176 patients with acute cholecystitis were referred for cholecystectomy to 624 hospitals in Japan. We collected patient characteristics and data on treatments for acute cholecystitis using the DPC database and identified independent factors affecting LOS and medical costs during hospitalization using multiple linear regression models. Analysis revealed that early cholecystectomy was significantly associated with a decrease in LOS, whereas longer preoperative antimicrobial therapy was significantly associated with an increase of LOS: the standardized coefficient for early cholecystectomy was -0.372 and that for preoperative antimicrobial therapy was 0.353 (P < 0.001). These procedures were also significant independent factors with regard to medical costs during hospitalization: the standardized coefficient for early cholecystectomy was -0.391 and that for preoperative antimicrobial therapy was 0.335 (P < 0.001). Early cholecystectomy significantly reduces the LOS and medical costs of cholecystectomy for acute cholecystitis, while preoperative antimicrobial therapy increases LOS and medical costs during hospitalization. These results highlight the need for health care implementations such as promotion of early cholecystectomy, appropriate use of antimicrobial drugs, and centralization of patients with cholecystectomy for acute cholecystitis in Japan.

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.

Population-based analysis of 4113 patients with acute cholecystitis: defining the optimal time-point for laparoscopic cholecystectomy

OBJECTIVE

To compare clinical outcomes after laparoscopic cholecystectomy (LC) for acute cholecystitis performed at various time-points after hospital admission.

BACKGROUND

Symptomatic gallstones represent an important public health problem with LC the treatment of choice. LC is increasingly offered for acute cholecystitis, however, the optimal time-point for LC in this setting remains a matter of debate.

METHODS

Analysis was based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery and included patients undergoing emergency LC for acute cholecystitis between 1995 and 2006, grouped according to the time-points of LC since hospital admission (admission day (d0), d1, d2, d3, d4/5, d ≥6). Linear and generalized linear regression models assessed the effect of timing of LC on intra- or postoperative complications, conversion and reoperation rates and length of postoperative hospital stay.

RESULTS

Of 4113 patients, 52.8% were female, median age was 59.8 years. Delaying LC resulted in significantly higher conversion rates (from 11.9% at d0 to 27.9% at d ≥6 days after admission, P < 0.001), surgical postoperative complications (5.7% to 13%, P < 0.001) and re-operation rates (0.9% to 3%, P = 0.007), with a significantly longer postoperative hospital stay (P < 0.001).

CONCLUSIONS

Delaying LC for acute cholecystitis has no advantages, resulting in significantly increased conversion/re-operation rate, postoperative complications and longer postoperative hospital stay. This investigation-one of the largest in the literature-provides compelling evidence that acute cholecystitis merits surgery within 48 hours of hospital admission if impact on the patient and health care system is to be minimized.

Gallstone pancreatitis in older patients: Are we operating enough?

BACKGROUND

The recommended therapy for mild gallstone pancreatitis is cholecystectomy on initial hospitalization.

METHODS

Using a 5% national Medicare sample (1996-2005), we evaluated adherence to current recommendations for gallstone pancreatitis (cholecystectomy rates on initial hospitalization and the use of endoscopic retrograde cholangiopancreatography [ERCP]/sphincterotomy). We evaluated predictors of cholecystectomy, gallstone-related readmissions, and 2-year mortality.

RESULTS

Adherence to current guidelines was low. Only 57% of 8,452 Medicare beneficiaries presenting to an acute care hospital with a first episode of mild gallstone pancreatitis underwent cholecystectomy on initial hospitalization. Of the patients who did not undergo cholecystectomy, 55% were never evaluated by a surgeon. Likewise, only 28% of patients who did not undergo cholecystectomy had a sphincterotomy. The 2-year readmission rates were higher among patients who did not undergo cholecystectomy (44% vs 4%; P < .0001), and 33% of these patients required cholecystectomy after discharge. In the no cholecystectomy group, ERCP prevented readmissions (hazard ratio, 0.53; 95% confidence interval, 0.47-0.61) and when readmissions occurred they were less likely to be for gallstone pancreatitis in patients who had an ERCP (27.8% vs 53.2%; P < .0001). On multivariate analysis, patients who were older, black, admitted to a nonsurgical service, lived in certain US regions, and had specific comorbidities were less likely to undergo cholecystectomy.

CONCLUSION

Adherence to current recommendations for the management of mild gallstone pancreatitis is low in older patients. Our data suggest that >40% of patients who did not undergo cholecystectomy would have benefited from early definitive therapy. Implementation of policies to increase adherence to guidelines would prevent gallstone-related morbidity and mortality in older patients.

Timing of cholecystectomy after mild biliary pancreatitis

Background

The aim of the study was to evaluate recurrent biliary events as a consequence of delay in cholecystectomy following mild biliary pancreatitis.

Methods

Between 2004 and 2007, patients with acute pancreatitis were registered prospectively in 15 Dutch hospitals. Patients with mild biliary pancreatitis were candidates for cholecystectomy. Recurrent biliary events requiring admission before and after cholecystectomy, and after endoscopic sphincterotomy (ES), were evaluated.

Results

Of 308 patients with mild biliary pancreatitis, 267 were candidates for cholecystectomy. Eighteen patients underwent cholecystectomy during the initial admission, leaving 249 potential candidates for cholecystectomy after discharge. Cholecystectomy was performed after a median of 6 weeks in 188 patients (75·5 per cent). Before cholecystectomy, 34 patients (13·7 per cent) were readmitted for biliary events, including 24 with recurrent biliary pancreatitis. ES was performed in 108 patients during the initial admission. Eight (7·4 per cent) of these patients suffered from biliary events after ES and before cholecystectomy, compared with 26 (18·4 per cent) of 141 patients who did not have ES (risk ratio 0·51, 95 per cent confidence interval 0·27 to 0·94; P = 0·015). Following cholecystectomy, eight (3·9 per cent) of 206 patients developed biliary events after a median of 31 weeks. Only 142 (53·2 per cent) of 267 patients were treated in accordance with the Dutch guideline, which recommends cholecystectomy or ES during the index admission or within 3 weeks thereafter.

Conclusion

A delay in cholecystectomy after mild biliary pancreatitis carries a substantial risk of recurrent biliary events. ES reduces the risk of recurrent pancreatitis but not of other biliary events.

Mortality associated with the treatment of gallstone disease: a 10-year contemporary national experience

BACKGROUND

Gallstones remain a common clinical problem requiring skilled operative and nonoperative management. The aim of the present population-based study was to investigate causes of gallstone-related mortality in Scotland.

METHODS

Surgical deaths were peer reviewed between 1997 and 2006 through the Scottish Audit of Surgical Mortality (SASM); data were analyzed for patients in whom the principal diagnosis on admission was gallstone disease.

RESULTS

Gallstone disease was responsible for 790/43,271 (1.83%) of the surgical deaths recorded, with an overall mortality for cholecystectomy of 0.307% (176/57,352), endoscopic retrograde cholangiopancreatography (ERCP) of 0.313% (117/37,345), and cholecystostomy of 2.1% (12/578) across the decade. However, the majority of patients who died were elderly (47.6% ≥ 80 years or older) and were managed conservatively. Deaths following cholecystectomy usually followed emergency admission (76%) and were more likely to have been associated with postoperative medical complications (n = 189) than surgical complications (n = 36).

DISCUSSION

Although cholecystectomy is a relatively safe procedure, patients who die as a result of gallstone disease tend to be elderly, to have been admitted as emergency cases, and to have had co-morbidities. Future combined medical and surgical perioperative management may reduce the mortality rate associated with gallstones.

ERCP in acute pancreatitis: What takes place in routine clinical practice?

AIM: To evaluate the data from a survey carried out in Italy regarding the endoscopic approach to acute pancreatitis in order to obtain a picture of what takes place after the release of an educational project on acute pancreatitis sponsored by the Italian Association for the Study of the Pancreas.

METHODS: Of the 1 173 patients enrolled in our survey, the most frequent etiological category was biliary forms (69.3%) and most patients had mild pancreatitis (85.8%).

RESULTS: 344/1 173 (29.3%) underwent endoscopic retrograde cholangiopancreatography (ERCP). The mean interval between the onset of symptoms and ERCP was 6.7 ± 5.0 d; only 89 examinations (25.9%) were performed within 72 h from the onset of symptoms. The main indications for ERCP were suspicion of common bile duct stones (90.3%), jaundice (44.5%), clinical worsening of acute pancreatitis (14.2%) and cholangitis (6.1%). Biliary and pancreatic ducts were visualized in 305 patients (88.7%) and in 93 patients (27.0%) respectively. The success rate in obtaining a cholangiogram was statistically higher (P = 0.003) in patients with mild acute pancreatitis (90.6%) than in patients with severe disease (72.2%). Biliary endoscopic sphincterotomy was performed in 295 of the 305 patients (96.7%) with no difference between mild and severe disease (P = 0.985). ERCP morbidity was 6.1% and mortality was 1.7%; the mortality was due to the complications of acute pancreatitis and not the endoscopic procedure.

CONCLUSION: The results of this survey, as with those carried out in other countries, indicate a lack of compliance with the guidelines for the indications for interventional endoscopy.

Endoscopic treatment of acute biliary pancreatitis: a national survey among Dutch gastroenterologists

OBJECTIVE

Based on the ampullary obstruction and reflux theory, six endoscopic retrograde cholangiopancreatography (ERCP) studies have investigated the effect of (early) biliary decompression versus conservative management on the course and outcome of patients with acute biliary pancreatitis (ABP) showing inconsistent and contradictory outcomes. We investigated the opinion and attitude of Dutch gastroenterologists regarding the application of (early) ERCP in the clinical management of ABP by means of a nationwide survey.

MATERIAL AND METHODS

An anonymous questionnaire was sent to all registered consultant gastroenterologists (n = 283) across the Netherlands.

RESULTS

The response rate was 52%. The vast majority of consulting gastroenterologists declared that early ERCP may be indicated in ABP (96.6%). Fourteen percent stated that they always perform ERCP in ABP. The remainder of the respondents consider ERCP only if a concomitant condition is present such as a dilated CBD (95%), co-existent cholangitis (87%), common bile duct stone(s) (CBDS) (72%), jaundice (59%), ampullary stone (68%) or (predicted) severe ABP (35%). About half of the consultant gastroenterologists (51.4%) consider the optimal time point for ERCP in ABP to be within 24 h after admission or symptom onset. If ERCP is performed for suspected APB, 55% of the respondents perform an endoscopic sphincterotomy (ES), regardless of the findings on cholangiography.

CONCLUSIONS

The vast majority of Dutch gastroenterologists attest to a role for ERCP in ABP, but indications when to perform ERCP, its timing, and the application of ES vary greatly and are not always in line with the Dutch or other published national guidelines. The results of this survey highlight the need for additional comparative randomized studies to define the role of (early) ERCP in ABP.

Emergency laparoscopic cholecystectomy in an unselected cohort: a safe and viable option in a specialist centre

INTRODUCTION

Patients presenting acutely with symptomatic gallstone-related disease have historically had their laparoscopic cholecystectomy (LC) deferred due to perceived increased operative risks in the acute setting, particularly conversion to open surgery. The aim of this study was to compare morbidity and mortality between unselected cohorts of patients undergoing elective and 'emergency' LC in a District General Hospital.

METHODS

All gallstone-related elective and emergency admissions under the care of two specialist laparoscopic surgeons during a two-year period were included. Patients admitted acutely with a diagnosis of biliary colic, acute cholecystitis or gallstone pancreatitis underwent 'emergency' LC during the same admission. Data were collected prospectively on patient demographics, inpatient stay, post-operative course and POSSUM scores.

RESULTS

423 patients underwent LC, of which 301 (71.1%) were elective and 122 (28.9%) were 'emergency' procedures. ASA grades and POSSUM physiologic scores were similar between the two groups. The overall morbidity rates were similar in the emergency and elective groups (13.1% vs. 7.3%, p = 0.088), and there was no significant difference in the rates of major complications including conversion to open surgery (0% vs. 0.3%, NS), bile leak or re-operation between the two groups. 30-day mortality rates were similar in the two groups (0.8% vs. 0%, NS).

CONCLUSION

When performed by specialist laparoscopic surgeons, LC in the acute setting is safe with mortality and morbidity rates, including conversion to open surgery, comparable to elective LC.