No need to wait: an analysis of the timing of cholecystectomy during admission for acute cholecystitis using the American College of Surgeons National Surgical Quality Improvement Program database

Surgeons' prioritization of emergency abdominal surgery and its impact on postoperative outcomes

BACKGROUND

Emergency general abdominal surgery (EGS) is associated with high morbidity and mortality. Timely intervention and effective triage systems are crucial to improve outcomes. This study evaluates the impact of surgeons' prioritization and adherence to a triage protocol on postoperative outcomes.

METHODS

Single-center retrospective analysis of patients undergoing EGS at Bern University Hospital from 03/2015-12/2022. Patients were categorized into four triage levels based on the urgency of surgery (level 1 within 1 h, level 2 within 6 h, level 3 within 12 h, and level 4 within 24 h). "Protocol violation" was defined in cases where the delay to surgery exceeded the triage level. Primary endpoint included complications according to Clavien-Dindo classification in patients with versus without "protocol violation".

RESULTS

A total of 1'947 patients were included. The mean overall delay from admission to surgery was in triage level 1 69.5 ± 127.5 min., in triage level 2 206.5 ± 178.0 min., in triage level 3 350.6 ± 282.6 min. and in triage level 4 693.4 ± 354.8 min.. Triage levels 1 and 2 correlated significantly with increased complication rates compared to triage level 3 and 4 (64% vs. 43% vs. 11% vs. 10%, p < 0.001). Similarly, mortality rates decreased significantly from triage level 1 through 4 (26% vs. 7% vs. 1% vs. 2%, p < 0.001). "Protocol violation" occurred in a total of 13% of patients with decreasing proportions from triage level 1 to 4 (37% vs. 13% vs. 12% vs. 0%, p < 0.001). "Protocol violation" did not statistically affect overall morbidity and mortality in most of the diagnoses. In patients with intestinal ischemia or abdominal abscesses, mortality was significantly higher in patients with "protocol violation". In contrast, in patients suffering from acute inguinal hernias or gastrointestinal bleeding, morbidity was significantly higher in patients without "protocol violation". A significantly shorter hospital length of stay (HLOS) was shown in triage level 2 and triage level 3 when patients were treated without "protocol violation" (8.6 ± 10.0 days vs. 13.5 ± 17.3 days, p = 0.022 and 5.3 ± 8.7 days vs. 6.4 ± 6.7 days, p < 0.001, respectively).

CONCLUSION

Surgeons' triage levels significantly correlated with mortality and morbidity. Moreover, "protocol violation" resulted in higher mortality in patients suffering from mesenteric ischemia and abdominal abscesses and resulted in prolonged HLOS. Further incorporating objective parameters into triage decisions in the EGS population may enhance prioritization accuracy, patient safety and resource utilization.

Clinical update on acute cholecystitis and biliary pancreatitis: between certainties and grey areas

Acute calculous cholecystitis (ACC) and acute biliary pancreatitis (ABP) are significant complications of gallstone disease. This review aims to provide a comprehensive analysis of current management practices for ACC and ABP. The Tokyo Guidelines (TG) and World Society of Emergency Surgery (WSES) guidelines recommend early laparoscopic cholecystectomy (ELC) as the treatment of choice for ACC. High-risk patients may benefit from alternative treatments like biliary drainage, with emerging techniques such as endoscopic drainage showing promise. ABP requires prompt diagnosis and intervention. The Revised Atlanta Classification (RAC) criteria are used for diagnosis, with endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy as primary treatments. Minimally invasive approaches are preferred for managing complications like infected pancreatic necrosis, with the endoscopic step-up method showing superior outcomes. The management of ACC and ABP continues to evolve. Future research is needed to refine guidelines further and address existing controversies, ultimately improving patient outcomes in these acute biliary conditions.

Intraoperative transcystic laparoscopic common bile duct stone clearance with SpyGlass™ discover during emergency and elective cholecystectomy: a single-center case series

BACKGROUND AND STUDY AIM

The development of a new cholangioscope, the SpyGlass™ Discover (Boston Scientific), has allowed the laparoscopic transcystic common bile duct exploration and stone clearance. The possibility of simultaneous treatment of choledocholithiasis during early laparoscopic cholecystectomy offers the opportunity to enormously reduce the time between acute cholecystitis diagnosis and the execution of cholecystectomy with better outcomes for patients. Furthermore, an altered anatomy of the gastrointestinal tract is not an obstacle to this technique. The aim of the study was to determine whether this new procedure is feasible, safe, and effective.

PATIENTS AND METHODS

The investigation employs a retrospective case series study including all consecutive patients with a diagnosis of common bile duct stones undergoing cholecystectomy and intraoperative laparoscopic common bile duct clearance using SpyGlass™ Discover at IRCCS Policlinico San Matteo in Pavia (Italy). Eighteen patients were included from May 2022 to May 2023.

RESULTS

A complete clearance of the common bile duct was obtained in 88.9% of patients. The mean postoperative length of stay was 3 days. No major complications occurred. After a median follow-up of 8 months, no recurrence of biliary events or readmissions occurred.

CONCLUSION

This procedure has proven to be feasible, safe, and effective.

Prospective validation of the Israeli Score for the prediction of common bile duct stones in patients with acute calculous cholecystitis

BACKGROUND

Existing guidelines for predicting common bile duct stones (CBDS) are not specific for acute calculous cholecystitis (ACC). This paper is a posthoc analysis of the S.P.Ri.M.A.C.C study aiming to prospectively validate on a large independent cohort of patients the Israeli Score (IS) in predicting CBDS in patients with ACC.

METHODS

The S.P.Ri.M.A.C.C. study is an observational multicenter prospective study endorsed by the World Society of Emergency Surgery (WSES). Between September 1st, 2021, and September 1st, 2022, 1201 participants were included. The Chi-Square test was used to compare categorical data. A Cochran-Armitage test was run to determine whether a linear trend existed between the IS and the presence of CBDS. To assess the accuracy of the prediction model, the receiver operating characteristic (ROC) curve was generated, and the area under the ROC curve (AUC) was calculated. Logistic regression was run to obtain Odds Ratio (OR). A two-tailed p < 0.05 was considered statistically significant.

RESULTS

The rate of CBDS was 1.8% in patients with an IS of 0, 4.2% in patients with an IS of 1, 24.5% in patients with 2 and 56.3% in patients with 3 (p < 0.001). The Cochran-Armitage test of trend showed a statistically significant linear trend, p < 0.001. Patients with an IS of 3 had 64.4 times (95% CI 24.8-166.9) higher odds of having associated CBDS than patients with an IS of 0. The AUC of the ROC curve of IS for the prediction of CBDS was 0.809 (95% CI 0.752-0.865, p < 0.001). By applying the highest cut-off point (3), the specificity reached 99%, while using the lowest cut-off value (0), the sensitivity reached 100%.

CONCLUSION

The IS is a reliable tool to predict CBDS associated with ACC. The algorithm derived from the IS could optimize the management of patients with ACC.

Timing of Early Cholecystectomy for Acute Calculous Cholecystitis: A Multicentric Prospective Observational Study

The definition of Early Cholecystectomy (EC) is still debatable. This paper aims to find whether the timing of EC affects outcomes. The article reports a multicentric prospective observational study including patients with acute calculous cholecystitis (ACC) who had cholecystectomy within ten days from the onset of symptoms. Kruskall-Wallis test, Fisher's Exact test, and Spearman rank correlation were used for statistical analysis. The patients were divided into three groups depending on the timing of the operation: 0-3 days, 4-7 days, or 8-10 days from the onset of symptoms. 1117 patients were studied over a year. The time from the onset of symptoms to EC did not affect the post-operative complications and mortality, the conversion, and the reintervention rate. The time represented a significant risk factor for intraoperative complications (0-3 days, 2.8%; 4-7 days, 5.6%; 8-10 days, 7.9%; p = 0.01) and subtotal cholecystectomies (0-3 days, 2.7%; 4-7 days, 5.6%; 8-10 days, 10.9%; p < 0.001). ACC is an evolutive inflammatory process and, as the days go by, the local and systemic inflammation increases, making surgery more complex and difficult with a higher risk of intraoperative complications. We recommend performing EC for ACC as soon as possible, within the first ten days of the onset of symptoms.

The Optimal Timing of Laparoscopic Cholecystectomy in Acute Cholecystitis: A Single-Center Study

Introduction Early laparoscopic cholecystectomy (ELC) is a treatment option for acute cholecystitis (AC). However, the timing of ELC is controversial. Delayed laparoscopic cholecystectomy (DLC) continues to be a common practice. This study aims to determine the optimal timing of ELC in AC. Materials and methods Patients who underwent surgery for AC between 2014 and 2020 were divided into three groups: immediate laparoscopic cholecystectomy (ILC), prolonged ELC (pELC), and DLC. The demographic, laboratory, radiological findings, and postoperative results of all patients were retrospectively reviewed. Results The study included 178 patients, with 63 in the ILC group, 27 in the pELC group, and 88 in the DLC group. Postoperative outcomes, excluding hospital stay, were similar between the groups. The total hospital stay was significantly longer in the pELC and DLC groups (p<0.05). In addition, postoperative hospital stay was longer in the pELC group (p<0.05), and 17.7% of the patients who waited for delayed surgery experienced recurrent attacks during the interval period. Conclusion ILC is recommended in AC to minimize hospital stays.

Impact of inter-hospital transfer on outcomes of urgent cholecystectomy

BACKGROUND

This study used a national cohort to characterize the impact of inter-hospital transfer status on outcomes following nonelective cholecystectomy for cholecystitis.

METHODS

Nonelective cholecystectomies were identified using the 2016-2019 National Inpatient Sample. Multivariable models adjusting for patient and hospital characteristics were utilized to assess outcomes of interest.

RESULTS

Of an estimated 530,696 patients, 5.3% were transferred. Transferred patients were older, more often male, and more likely to report income in the 0^th-25th percentile, compared to others. After adjustment, transfer was associated with increased odds of infectious complications (AOR 1.31, 95%CI 1.06-1.60) and non-home discharge (AOR 1.59, 95%CI 1.45-1.74), but not mortality. Transfer was linked to a $600 cost decrement at the operating hospital (95%CI -$880-330).

CONCLUSIONS

Transfer status is associated with greater postoperative infection, but not mortality. Given that disparities may play a role in transfer decisions, more work must be done to identify transfer drivers and improve patient outcomes.

The Need for Standardizing Diagnosis, Treatment and Clinical Care of Cholecystitis and Biliary Colic in Gallbladder Disease

Gallstones affect 20% of the Western population and will grow in clinical significance as obesity and metabolic diseases become more prevalent. Gallbladder removal (cholecystectomy) is a common treatment for diseases caused by gallstones, with 1.2 million surgeries in the US each year, each costing USD 10,000. Gallbladder disease has a significant impact on the logistics and economics of healthcare. We discuss the two most common presentations of gallbladder disease (biliary colic and cholecystitis) and their pathophysiology, risk factors, signs and symptoms. We discuss the factors that affect clinical care, including diagnosis, treatment outcomes, surgical risk factors, quality of life and cost-efficacy. We highlight the importance of standardised guidelines and objective scoring systems in improving quality, consistency and compatibility across healthcare providers and in improving patient outcomes, collaborative opportunities and the cost-effectiveness of treatment. Guidelines and scoring only exist in select areas of the care pathway. Opportunities exist elsewhere in the care pathway.

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

Timing of cholecystectomy for acute cholecystitis impacts surgical morbidity and mortality: an NSQIP database analysis

The aim of this study is to identify the optimal timing for cholecystectomy for acute cholecystitis. Patients undergoing cholecystectomy for acute cholecystitis from the National Surgery Quality Improvement Program database between 2014 and 2016 were included. The patients were divided into 4 groups, those who underwent surgery at days 0, 1, 2, or 3+ days. The primary outcome was short-term surgical morbidity and mortality. A total of 21,392 patients were included. After adjusting for confounders, compared to day 0 patients, those who underwent surgery at day 1 and day 2 had lower composite morbidity rate, while day 3+ patients had significantly higher bleeding and mortality rate. Subgroup analysis shows this trend to be more significant in the elderly and in diabetic patients who were delayed. Delay in cholecystectomy for over 72 h from admission is associated with statistically significant increase in bleeding and mortality.

Patients with acute cholecystitis should be admitted to a surgical service

BACKGROUND

In bowel obstruction and biliary pancreatitis, patients receive more expedient surgical care when admitted to surgical compared with medical services. This has not been studied in acute cholecystitis.

METHODS

Retrospective analysis of clinical and cost data from July 2013 to September 2015 for patients with cholecystitis who underwent laparoscopic cholecystectomy in a tertiary care inpatient hospital. One hundred ninety lower-risk (Charlson-Deyo) patients were included. We assessed admitting service, length of stay (LOS), time from admission to surgery, time from surgery to discharge, number of imaging studies, and total cost.

RESULTS

Patients admitted to surgical (n = 106) versus medical (n = 84) service had shorter mean LOS (1.4 days vs. 2.6 days), shorter time from admission to surgery (0.4 days vs. 0.8 days), and shorter time from surgery to discharge (0.8 days vs. 1.1 days). Surgical service patients had fewer CT (38% vs. 56%) and magnetic resonance imaging (MRI) (5% vs. 16%) studies. Cholangiography (30% vs. 25%) and endoscopic retrograde cholangiopancreatography (ERCP) (3 vs. 8%) rates were similar. Surgical service patients had 39% lower median total costs (US $7787 vs. US $12572).

CONCLUSION

Nonsurgical admissions of patients with cholecystitis are common, even among lower-risk patients. Routine admission to the surgical service should decrease LOS, resource utilization and costs.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Operative complications and economic outcomes of cholecystectomy for acute cholecystitis

BACKGROUND

Recent management of acute cholecystitis favors same admission (SA) or emergent cholecystectomy based on overall shorter hospital stay and therefore cost savings. We adopted the practice of SA cholecystectomy for the treatment of acute cholecystitis at our tertiary care center and wanted to evaluate the economic benefit of this practice. We hypothesized that the existence of complications, particularly among patients with a higher degree of disease severity, during SA cholecystectomy could negate the cost savings.

AIM

To compare complication rates and hospital costs between SA vs delayed cholecystectomy among patients admitted emergently for acute cholecystitis.

METHODS

Under an IRB-approved protocol, complications and charges for were obtained for SA, later after conservative management (Delayed), or elective cholecystectomies over an 8.5-year period. Patients were identified using the acute care surgery registry and billing database. Data was retrieved via EMR, operative logs, and Revenue Cycle Operations. The severity of acute cholecystitis was graded according to the Tokyo Guidelines. TG18 categorizes acute cholecystitis by Grades 1, 2, and 3 representing mild, moderate, and severe, respectively. Comparisons were analyzed with χ², Fisher’s exact test, ANOVA, t-tests, and logistic regression; significance was set at P < 0.05.

RESULTS

Four hundred eighty-six (87.7%) underwent a SA while 68 patients (12.3%) received Delayed cholecystectomy. Complication rates were increased after SA compared to Delayed cholecystectomy (18.5% vs 4.4%, P = 0.004). The complication rates of patients undergoing delayed cholecystectomy was similar to the rate for elective cholecystectomy (7.4%, P = 0.35). Mortality rates were 0.6% vs 0% for SA vs Delayed. Patients with moderate disease (Tokyo 2) suffered more complications among SA while none who were delayed experienced a complication (16.1% vs 0.0%, P < 0.001). Total hospital charges for SA cholecystectomy were increased compared to a Delayed approach ($44500 ± $59000 vs $35300 ± $16700, P = 0.019). The relative risk of developing a complication was 4.2x [95% confidence interval (CI): 1.4-12.9] in the SA vs Delayed groups. Among eight patients (95%CI: 5.0-12.3) with acute cholecystitis undergoing SA cholecystectomy, one patient will suffer a complication.

CONCLUSION

Patients with Tokyo Grade 2 acute cholecystitis had more complications and increased hospital charges when undergoing SA cholecystectomy. This data supports a selective approach to SA cholecystectomy for acute cholecystitis.

A predictive grading scale for acute cholecystitis

Background

Acute cholecystitis presents in a spectrum of severity, where acute disease may be complicated by severe inflammation, gangrene, and perforation. The goal of this study is to outline an evidence-based grading scale that predicts patient outcomes after laparoscopic cholecystectomy (LC).

Methods

A retrospective review of all patients with a preoperative diagnosis of acute cholecystitis who underwent LC from August 2011 until June 2015 at a tertiary-level hospital was performed. Patients who underwent elective cholecystectomy, incidental cholecystectomy, a planned open cholecystectomy, had gallstone pancreatitis or choledocholithiasis, and those admitted to a non-surgical service were excluded. Severity of disease was obtained from operative and pathology reports, and patients were classified according to the following grading scale:

Grade I: symptomatic cholelithiasis.

Grade II: acute/chronic cholecystitis.

Grade III: gangrenous/necrotizing cholecystitis.

Grade IV: gallbladder perforation or abscess.

The groups were compared on age, gender, body mass index, severity of gallbladder disease, presence of preoperative systemic inflammatory response syndrome, hospital length of stay, length of operation, complications within 30 days, conversion to open rate, and cost of hospitalization.

Results

During the study period, 1252 patients who underwent laparoscopic cholecystectomy were analyzed; 677 met inclusion criteria. The most common grade was grade 2, which was present in 80% of patients, followed by grade 3, which was found in 16% of patients. Grade 4 cholecystitis occurred in 1.2% of patients and grade 1 occurred in 3.2% of patients. There were statistically significant increases in age, presence of preoperative systemic inflammatory response syndrome, hospital length of stay, conversion to open rate, cost of hospitalization, and length of operation with increased cholecystitis grade.

Conclusions

The proposed grading scale is an accurate predictor of duration of operation, conversion to open rate, hospital length of stay, and cost of hospitalization.

Level of evidence

III

Study type

Prognostic

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.

2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population

Background

Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide.

Aim

The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population.

Material and methods

The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences.

Results

The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain.

Discussion and conclusions

The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

Laparoscopic Cholecystectomy is Safe Both Day and Night

BACKGROUND

It is reported that performing laparoscopic cholecystectomy (LC) at night leads to increased rates of complications and conversion to open. We hypothesize that it is safe to perform LC at night in appropriately selected patients.

MATERIALS AND METHODS

We performed a retrospective review of nonelective LC in adults at our institution performed between April 2007 and February 2015. We dichotomized the cases to either day or night.

RESULTS

Five thousand two hundred four patients underwent LC, with 4628 during the day and 576 at night. There were no differences in age, body mass index, American Society of Anesthesiologists class, race, insurance type, pregnancy rate, or white blood cell count. There were also no differences in the prevalence of hypertension, diabetes, or renal failure. However, daytime patients had higher median initial total bilirubin (0.6 [0.4, 1.3] versus 0.5 [0.3, 1.0] mg/dL, P = 0.002) and lipase (33 [24, 56] versus 30 [22, 42] U/L, P < 0.001) values. There was no difference in case length, estimated blood loss, rate of conversion to open, biliary complications, length of stay (LOS) after operation, unanticipated return to the hospital in 60 d, or 60-d mortality. Daytime patients spent more time in the hospital with longer median LOS before surgery (1 [1, 2] versus 1 [0, 2] d, P < 0.001) and median total LOS (3 [2, 4] versus 2 [1, 3] d, P < 0.001) compared with night patients.

CONCLUSIONS

At our institution, we perform LC safely during day or night. The lack of complications and shorter LOS justify performing LC at any hour.

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

BACKGROUND

Evidence supports early laparoscopic cholecystectomy for acute cholecystitis. Differences in treatment patterns between the USA and UK, associated outcomes and resource utilization are not well understood.

METHODS

In this retrospective, observational study using national administrative data, emergency patients admitted with acute cholecystitis were identified in England (Hospital Episode Statistics 1998-2012) and USA (National Inpatient Sample 1998-2011). Proportions of patients who underwent emergency cholecystectomy, utilization of laparoscopy and associated outcomes including length of stay (LOS) and complications were compared. The effect of delayed treatment on subsequent readmissions was evaluated for England.

RESULTS

Patients with a diagnosis of acute cholecystitis totaled 1,191,331 in the USA vs. 288 907 in England. Emergency cholecystectomy was performed in 628,395 (52.7% USA) and 45,299 (15.7% England) over the time period. Laparoscopy was more common in the USA (82.8 vs. 37.9%; p < 0.001). Pre-treatment (1 vs. 2 days; p < 0.001) and total ( 4 vs. 7 days; p < 0.001) LOS was lower in the USA. Overall incidence of bile duct injury was higher in England than the USA (0.83 vs. 0.43%; p < 0.001), but was no different following laparoscopic surgery (0.1%). In England, 40.5% of patients without an immediate cholecystectomy were subsequently readmitted with cholecystitis. An additional 14.5% were admitted for other biliary complications, amounting to 2.7 readmissions per patient in the year following primary admission.

CONCLUSION

This study highlights management practices for acute cholecystitis in the USA and England. Despite best evidence, index admission laparoscopic cholecystectomy is performed less in England, which significantly impacts subsequent healthcare utilization.

Differentiation between gallbladder cancer with acute cholecystitis: Considerations for surgeons during emergency cholecystectomy, a cohort study

PURPOSE

Gallbladder cancer (GBCA) is an uncommon malignancy with vague and non-specific symptoms. GBCA is sometimes diagnosed after emergency cholecystectomy for acute cholecystitis. We investigated the differential diagnosis between GBCA with acute cholecystitis.

MATERIALS AND METHODS

Thirteen patients were diagnosed with GBCA after emergency cholecystectomy carried out for acute cholecystitis. A radiologist who was blinded to the final diagnoses retrospectively reviewed the computed tomography (CT) scans of the patients with GBCA and 25 patients with acute cholecystitis. We retrospectively reviewed the medical records of these patients and compared the clinical characteristics and CT findings between patients with GBCA and those with acute cholecystitis. We also investigated the prognostic factors in patients with GBCA who underwent emergency cholecystectomy.

RESULTS

Gallbladder (GB) stones were found more often in patients with acute cholecystitis (n = 17, 68%) than in patients with GBCA (n = 7, 53.8%) (p = 0.486). Patients with GBCA showed typical GB masses or focal enhanced wall thickening when compared to diffuse wall thickening in patients with acute cholecystitis. Some GBCA patients showed irregular mural thickening and GB enhancement. Differentiating carcinoma from acute cholecystitis might sometimes not possible, but the latter group of patients had significantly lower C-reactive protein (CRP) levels (p = 0.033) and less regional fat stranding (p = 0.047). Survival was significantly affected by aggressive tumor characteristics (lymphatic invasion [p = 0.025], depth of tumor invasion [p = 0.004]) or R0 resection (p = 0.013) rather than bile spillage (p = 0.112).

CONCLUSIONS

Surgeons deciding on emergency cholecystectomy for elderly patients with acute cholecystitis must suspect GBCA in patients with a low CRP level, irregular mural thickening or enhancement of GB without regional fat stranding.

Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study

BACKGROUND

Although early laparoscopic cholecystectomy is widely performed for acute cholecystitis, the optimal timing of a cholecystectomy in clinically ill patients remains controversial. This study aims to determine the best practice for the patients presenting with acute cholecystitis focused on disease severity and comorbidities.

METHODS

An international multicentric retrospective observational study was conducted over a 2-year period. Patients were divided into four groups: Group A: primary cholecystectomy; Group B: cholecystectomy after gallbladder drainage; Group C: gallbladder drainage alone; and Group D: medical treatment alone.

RESULTS

The subjects of analyses were 5,329 patients. There were statistically significant differences in mortality rates between patients with Charlson comorbidity index (CCI) scores below and above 6 (P < 0.001). The shortest operative time was observed in Group A patients who underwent surgery 0-3 days after admission (P < 0.01). Multiple regression analysis revealed CCI and low body mass index <20 as predictive factors of 30-day mortality in Grade I+II patients. Also, jaundice, neurological dysfunction, and respiratory dysfunction were predictive factors of 30-day mortality in Grade III patients. In Grade III patients without predictive factors, there were no difference in mortality between Group A and Group B (0% vs. 0%), whereas Group A patients had higher mortality rates than that of Group B patients (9.3% vs. 0.0%) in cases with at least one predictive factor.

CONCLUSION

Even patients with Grade III severity, primary cholecystectomy can be performed safely if they have no predictive factors of mortality. Gallbladder drainage may have a therapeutic role in subgroups with higher CCI or higher disease severity.

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.

Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: a meta-analysis of case-control studies

BACKGROUND

Since the advent of laparoscopic cholecystectomy (LC) there has been continued debate regarding the management of acute cholecystitis with either early or delayed LC. Nearly all studies have demonstrated that early LC has a significantly shorter total length of hospital stay compared with delayed LC. Although previous randomized controlled trials and meta-analysis have shown clinical outcomes to favour early surgery, clinical practice continues to vary significantly worldwide. In addition, there is much confusion in the optimal timing for early LC with definitions of early varying from 72 h to 7 days. There have been numerous case-control studies investigating the timing of LC in acute cholecystitis. The aim of this paper is to pool the results from all case-control studies to investigate outcomes including mortality rates, complication rates, length of hospital stay and conversion rates to open procedures.

METHODS

A search of electronic databases was performed for case-control studies published between 1985-February 2015.

RESULTS

Results from 77 case-control studies showed statistically significant reductions in mortality, complications, bile duct leaks, bile duct injuries, wound infections, conversion rates, length of hospital stay and blood loss associated with early LC. Although LC within the 72-h window is optimal, patients operated after this window still benefit from early surgery compared to delayed surgery. The duration of symptoms in acute cholecystitis should not influence the surgeons' willingness to operate acutely.

CONCLUSIONS

Early LC is clearly superior to delayed LC in acute cholecystitis. The most recent evidence-based practice strongly suggests that early LC should be standard of care in the management of acute cholecystitis.

Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: a meta-analysis of case-control studies

BACKGROUND

Since the advent of laparoscopic cholecystectomy (LC) there has been continued debate regarding the management of acute cholecystitis with either early or delayed LC. Nearly all studies have demonstrated that early LC has a significantly shorter total length of hospital stay compared with delayed LC. Although previous randomized controlled trials and meta-analysis have shown clinical outcomes to favour early surgery, clinical practice continues to vary significantly worldwide. In addition, there is much confusion in the optimal timing for early LC with definitions of early varying from 72 h to 7 days. There have been numerous case-control studies investigating the timing of LC in acute cholecystitis. The aim of this paper is to pool the results from all case-control studies to investigate outcomes including mortality rates, complication rates, length of hospital stay and conversion rates to open procedures.

METHODS

A search of electronic databases was performed for case-control studies published between 1985-February 2015.

RESULTS

Results from 77 case-control studies showed statistically significant reductions in mortality, complications, bile duct leaks, bile duct injuries, wound infections, conversion rates, length of hospital stay and blood loss associated with early LC. Although LC within the 72-h window is optimal, patients operated after this window still benefit from early surgery compared to delayed surgery. The duration of symptoms in acute cholecystitis should not influence the surgeons' willingness to operate acutely.

CONCLUSIONS

Early LC is clearly superior to delayed LC in acute cholecystitis. The most recent evidence-based practice strongly suggests that early LC should be standard of care in the management of acute cholecystitis.

Acute Cholecystitis-Optimal Timing for Early Cholecystectomy: a French Nationwide Study

BACKGROUND

The recommended treatment for acute calculous cholecystitis combines antibiotics and cholecystectomy. To reduce morbidity and mortality, guidelines recommend early cholecystectomy. However, the optimal timing for surgery on first admission remains controversial. This study aims to determine the best timing for cholecystectomy in patients presenting with acute calculous cholecystitis.

STUDY DESIGN

The French national health-care database was analyzed to identify all patients undergoing cholecystectomy for acute cholecystitis during the same hospital stay between January 2010 and December 2013. Data regarding patients, procedures, and hospitals characteristics were collected. The relationship between surgery's timing and clinical outcome was evaluated by multiple logistic regressions.

RESULTS

Overall, 42,452 patients from 507 hospitals were included in the study. Postoperative complications requiring invasive treatment occurred in 961 patients (2.3 %), and the mortality rate was 1.1 %. Adverse postoperative outcomes-intensive care admission, reoperation, and postoperative sepsis-were significantly lower when surgery was performed between days 1 and 3 (3-3.3, 0.5-0.6, and 3.8-4.1 %, respectively) when compared to surgery performed on the day of admission (5.6, 1.2, and 5.2 %, p < 0.001) or from day 5 onward (4.5, 1, and 6.5 %, respectively; p < 0.001). Mortality was also significantly lower in patients undergoing cholecystectomy between days 1 and 3 after admission (0.8-1 %) when compared to patients operated on the day of admission or after day 3 (1.4 % on day 0, 1.2 % on day 4, and 1.9 % from day 5: all p < 0.001).

CONCLUSION

For patients with acute calculous cholecystitis, all efforts should be made to perform cholecystectomy within 3 days after hospital admission in order to decrease morbidity and mortality.

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.

Analysis of deficiencies in care following cholecystectomy

INTRODUCTION

Failure To Rescue was first defined in patients who died due to a complication following (open) cholecystectomy but research into the relevant factors has been scarce. This study was designed to determine a chronological sequence of deficiencies in care.

METHODS

Adult patients who died under the care of a surgeon following cholecystectomy in Queensland were identified from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) database.

RESULTS

Not unexpectedly, this is a high-risk patient population: median age of the 48 patients was 74.5 years and the median number of comorbidities and American Society of Anesthesiologists class was 4. Death occurred on postoperative day 6. Most deaths occurred at the end of the week. Over 80% of deaths followed emergency cholecystectomy. In almost half the patients, there were no deficiencies in care. Most common deficiency was during postoperative management (i.e. Failure To Rescue), however, significant deficiencies also arose prior to surgical admission; choice and timing of intervention as well as intraoperative decision-making.

CONCLUSION

Surgeons who perform cholecystectomy need to be aware of the levels at which deficiencies arise given that many may be preventable.

Acute cholecystitis: risk factors for conversion to an open procedure

BACKGROUND

Laparoscopic cholecystectomy is one of the most common general surgical procedures performed. Conversion to an open procedure (CTO) is associated with increased morbidity and length of stay. Patients presenting with acute cholecystitis are at higher risk for CTO. Studies have attempted to examine risk factors for CTO in patients who undergo laparoscopic cholecystectomy for acute cholecystitis but are limited by small sample size. The aim of this study was to identify preoperative variables that predict higher risk for CTO in patients presenting with acute cholecystitis.

MATERIALS AND METHODS

Patients undergoing laparoscopic cholecystectomy for acute cholecystitis from 2005-2011 were identified from the American College of Surgeons' National Surgical Quality Improvement Program Participant Use File. Patients who underwent successful laparoscopic surgery were compared with those who required CTO. Demographics, comorbidities, and 30-d outcomes were analyzed. Multivariable logistic regression was used for variables with P value <0.1, with CTO used as the dependent variable.

RESULTS

A total of 7242 patients underwent laparoscopic cholecystectomy for acute cholecystitis. CTO was reported in 436 patients (6.0%). Those who required conversion were older (60.7 ± 16.2 versus 51.6 ± 18.0, P = 0.0001) and mean body mass index was greater (30.8 ± 7.6 versus 30.0 ± 7.3, P = 0.033) compared with those whose procedure was completed laparoscopically. Vascular, cardiac, renal, pulmonary, neurologic, hepatic disease, diabetes, and bleeding disorders were more prevalent in CTO patients. Mortality (2.3% versus 0.7%, P < 0.0001), overall morbidity (21.8% versus 6.0%, P < 0.0001), serious morbidity (14.9% versus 3.8%, P < 0.0001), reoperation (3.4% versus 1.4%, P = 0.001), and surgical site infection (9.2% versus 1.8%, P < 0.0001) rates, as well as length of stay (8.6 ± 13.0 versus 3.4 ± 6.7, P < 0.0001) were greater in those requiring CTO. The following factors were independently associated with CTO: age (odds ratio [OR], 1.01, P = 0.015), male gender (OR, 1.77, P = 0.005), body mass index (OR, 1.04, P < 0.0001), preoperative alkaline phosphatase (OR, 1.01, P = 0.0005), white blood cell count (OR, 1.06, P = 0.0001), and albumin (OR, 0.52, P = 0.0001).

CONCLUSIONS

CTO for acute cholecystitis remains low but not clinically negligible. The identified risk factors can potentially guide management and patient selection for delayed intervention for acute cholecystitis.

Selective intraoperative cholangiography and risk of bile duct injury during cholecystectomy

Background

Whether intraoperative cholangiography can prevent iatrogenic bile duct injury during cholecystectomy remains controversial.

Methods

Data from the national Swedish Registry for Gallstone Surgery, GallRiks (May 2005 to December 2010), were analysed for evidence of iatrogenic bile duct injury during cholecystectomy. Patient- and procedure-related risk factors for bile duct injury with a focus on the rate of intended intraoperative cholangiography were analysed using multivariable logistic regression.

Results

A total of 51 041 cholecystectomies and 747 bile duct injuries (1·5 per cent) were identified; 9008 patients (17·6 per cent) were diagnosed with acute cholecystitis. No preventive effect of intraoperative cholangiography was seen in uncomplicated gallstone disease (odds ratio (OR) 0·97, 95 per cent c.i. 0·74 to 1·25). Operating in the presence (OR 1·23, 1·03 to 1·47) or a history (OR 1·34, 1·10 to 1·64) of acute cholecystitis, and open surgery (OR 1·56, 1·26 to 1·94), were identified as significant risk factors for bile duct injury. The intention to perform intraoperative cholangiography was associated with a reduced risk of bile duct injury in patients with concurrent (OR 0·44, 0·30 to 0·63) or a history of (OR 0·59, 0·35 to 1·00) acute cholecystitis.

Conclusion

Any proposed protective effect of intraoperative cholangiography was restricted to patients with (or a history of) acute cholecystitis.

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.

Effect of delaying same-admission cholecystectomy on outcomes in patients with diabetes

Background

Recent studies have suggested that same-admission delayed cholecystectomy is a safe option. Patients with diabetes have been shown to have less favourable outcomes after cholecystectomy, but the impact of timing of operation for acute cholecystitis during the same admission is unknown.

Methods

This was a retrospective analysis of patients undergoing laparoscopic cholecystectomy for acute cholecystitis between 2004 and 2010, from the American College of Surgeons National Surgical Quality Improvement Program database. Patients with no significant co-morbidities (American Society of Anesthesiologists grade I or II) were included. Propensity score matching (PSM) was used to match patients with diabetes with those who did not have diabetes, in a ratio of 1 : 3, to ensure homogeneity of the two groups. Logistic regression models were applied to adjust for differences between early (within 24 h) and delayed (24 h or more) surgical treatment. The primary outcome was development of local and systemic infectious complications. Secondary outcomes were duration of operation and length of hospital stay.

Results

From a total of 2892 patients, 144 patients with diabetes were matched with 432 without diabetes by PSM. Delaying cholecystectomy for at least 24 h after admission in patients with diabetes was associated with significantly higher odds of developing surgical-site infections (adjusted odds ratio 4·11, 95 per cent confidence interval 1·11 to 15·22; P = 0·034) and a longer hospital stay. For patients with no diabetes, however, delaying cholecystectomy had no impact on complications or length of hospital stay.

Conclusion

Patients with diabetes who undergo laparoscopic cholecystectomy 24 h or more after admission may have an increased risk of postoperative surgical-site infection and a longer hospital stay than those undergoing surgery within 24 h of admission.

Outpatient management of biliary colic: a prospective observational study of prescribing habits and analgesia effectiveness

BACKGROUND

Uncomplicated biliary colic presents a significant health and financial burden to hospitals and primary care services alike. There is little guidance on the correct analgesia to use on an outpatient basis. This study aimed to evaluate the effectiveness of oral analgesics on biliary colic pain and to explore the prescribing habits of community doctors.

METHODS

Consecutive patients with ultrasound proven symptomatic gallstones completed a questionnaire recording demographics and symptomatology. Pain was assessed using a visual analogue scale (VAS) based on the Biliary Symptom Score (BSS) to evaluate the effectiveness of various analgesic agents. Local General Practitioners were also surveyed to establish prescribing practices.

RESULTS

Co-Codamol had the highest mean effectiveness VAS score (6.5/10). Patients with increased BMI, short symptom duration and a BSS >70 were most likely to suffer from severe pain. Patients in a subgroup with severe pain were most likely to have their pain reduced by NSAID analgesia compared to no NSAID (OR 2.20, p = 0.027). This effect remained significant upon multivariable regression (OR 2.52, p = 0.018) in a model containing age and NSAIDs. There was wide variation in the prescribing practice of GPs and hospital doctors.

CONCLUSIONS

The range of drugs prescribed for biliary colic is extensive with little evidence base. In this study NSAIDs were the most effective analgesia for patients with severe pain. In the absence of contraindications to their use, physician education or guidance emphasizing the benefits of NSAIDs may potentially reduce symptomatic hospital presentation and admissions for biliary colic.