Time to interval cholecystectomy and associated outcomes in a population aged 50 and above with mild gallstone pancreatitis

BACKGROUND

Cholecystectomy on index admission for mild gallstone pancreatitis (GSP) is recommended, although not always feasible. This study examined rates and outcomes of people aged ≥ 50 years who underwent interval (delayed) cholecystectomy at increasing time points.

METHODS

Hospitalisation and death data were linked for individuals aged ≥ 50 years admitted to hospital in New South Wales, Australia with mild GSP between 2008-2018. Primary outcome was interval cholecystectomy timing. Secondary outcomes included mortality, emergency readmission for gallstone-related disease (GSRD) (28 and 180-day), and length of stay (LOS) (index admission and total six-month GSRD).

RESULTS

3,003 patients underwent interval cholecystectomy: 861 (28.6%) at 1-30, 1,221 (40.7%) at 31-90 and 921 (30.7%) at 91-365 days from index admission. There was no difference in 365-day mortality between groups. Longer delay to cholecystectomy was associated with increased 180-day emergency GSRD readmission (17.5% vs 15.8% vs 19.9%, p < 0.001) and total six-month LOS (5.9 vs 8.4 vs 8.3, p < 0.001). Endoscopic retrograde cholangiopancreatography (ERCP) was increasingly required with cholecystectomy delay (14.5% vs 16.9% vs 20.4%, p < 0.001), as were open cholecystectomy procedures (4.8% vs 7.6% vs 11.3%, p < 0.001). Extended delay was associated with patients of lower socioeconomic status, regional/rural backgrounds or who presented to a low volume or non-tertiary hospital (p < 0.001).

CONCLUSION

Delay to interval cholecystectomy results in increased rates of emergency readmission, overall LOS, risks of conversion to open surgery and need for ERCP. Index admission cholecystectomy is still recommended, however when not possible, interval cholecystectomy should be performed within 30 days to minimise patient risk and healthcare burden.

Factors Affecting Early Cholecystectomy for Acute Cholecystitis in Older People-A Population-Based Study

OBJECTIVES

Acute cholecystitis is one of the most common surgical presentations in Australia and increases with age. Guidelines recommend early laparoscopic cholecystectomy (within 7 days), as it results in shorter length of stay, reduced costs and readmission rates. Despite this, there is a perception that early cholecystectomy may result in higher morbidity and conversion to open surgery in older patients. Our objective is to report the proportion of early versus delayed cholecystectomy in older patients in New South Wales (NSW), Australia, and to compare health outcomes and factors influencing variation.

DESIGN

This is a retrospective population-based cohort study of all cholecystectomies for primary acute cholecystitis in NSW residents aged >50, between 2009 and 2019. The primary outcome was the proportion of early versus delayed cholecystectomy. We used multilevel multivariable logistic regression analyses adjusted for age, sex, comorbidities, insurance status, socio-economic status and hospital characteristics.

RESULTS

A high rate (85%) of the 47,478 cholecystectomies in older patients were performed within 7 days of admission. Delayed surgery was associated with increasing age and comorbidity, male sex, Medicare-only insurance and surgery in low- or medium-volume centres. Early surgery was associated with shorter overall length of stay, fewer readmissions, less conversion to open surgery and lower bile duct injury rates.

CONCLUSION

A high proportion of adults with cholecystitis are undergoing early cholecystectomy in NSW. Our results support the efficacy of early cholecystectomy in older patients and identify potentially modifiable factors relevant to health care professionals and policymakers.

Cholecystectomy for people aged 50 years or more with mild gallstone pancreatitis: predictors and outcomes of index and interval procedures

Objectives

To estimate the proportions of people aged 50 years or more with mild gallstone pancreatitis who undergo index cholecystectomy (during their initial hospital admission) or interval cholecystectomy (during a subsequent admission); to compare outcomes following index and interval cholecystectomy; and to identify factors associated with undergoing interval cholecystectomy.

Design, setting, participants

Analysis of linked hospitalisation and deaths data for all people aged 50 years or more with mild gallstone pancreatitis who underwent cholecystectomy in New South Wales within twelve months of their index admission, 1 July 2008 ‒ 30 June 2018.

Main outcome measures

Cholecystectomy classification (index or interval). Secondary outcomes: all‐cause mortality (30‒365 days), emergency re‐admissions with gallstone‐related disease (within 28 or 180 days of discharge); hospital lengths of stay (index admission, and all admissions with gallstone‐related disease over six months).

Results

A total of 1836 patients underwent index cholecystectomy (37.9%) and 3003 interval cholecystectomy (62.1%). Mortality to twelve months was similar in the two groups. Larger proportions of people who underwent interval cholecystectomy were re‐admitted within 28 days (246, 8.2% v 23, 1.3%) or 180 days (527, 17.6% v 59, 3.2%), or required open cholecystectomy (238, 7.9% v 69, 3.8%). Mean index admission length of stay was longer for index than interval cholecystectomy (7.7 [SD, 4.7] days v 5.3 [SD, 3.9] days), but six‐month total length of stay was similar (8.2 [SD, 5.6] days v 7.9 [SD, 5.8] days). Interval cholecystectomy was more likely for patients with three or more comorbid conditions (adjusted odds ratio [aOR], 1.29; 95% CI, 1.08‒1.55) or private health insurance (aOR, 1.31; 95% CI, 1.13‒1.51), and for those admitted to low surgical volume hospitals (aOR, 1.84; 95% CI, 1.03‒3.31).

Conclusions

Most NSW people over 50 with mild gallstone pancreatitis did not undergo index cholecystectomy, despite recommendations in international guidelines. Delayed cholecystectomy was associated with more frequent open cholecystectomy procedures and gallstone disease‐related emergency re‐admissions, as well as with low or medium hospital surgical volume, comorbidity, and having private insurance.

Does identifying frailty from ICD-10 coded data on hospital admission improve prediction of adverse outcomes in older surgical patients? A population-based study

BACKGROUND

frailty is a major contributor to poor health outcomes in older people, separate from age, sex and comorbidities. This population-based validation study evaluated the performance of the International Classification of Diseases, 10th revision, coded Hospital Frailty Risk Score (HFRS) in the prediction of adverse outcomes in an older surgical population and compared its performance against the commonly used Charlson Comorbidity Index (CCI).

METHODS

hospitalisation and death data for all individuals aged ≥50 admitted for surgery to New South Wales hospitals (2013-17) were linked. HFRS and CCI scores were calculated using both 2- and 5-year lookback periods. To determine the influence of individual explanatory variables, several logistic regression models were fitted for each outcome of interest (30-day mortality, prolonged length of stay (LOS) and 28-day readmission). Area under the receiving operator curve (AUC) and Akaike information criterion (AIC) were assessed.

RESULTS

of the 487,197 patients, 6.8% were classified as high HFRS, and 18.3% as high CCI. Although all models performed better than base model (age and sex) for prediction of 30-day mortality, there was little difference between CCI and HFRS in model discrimination (AUC 0.76 versus 0.75), although CCI provided better model fit (AIC 79,020 versus 79,910). All models had poor ability to predict prolonged LOS (AUC range 0.62-0.63) or readmission (AUC range 0.62-0.65). Using a 5-year lookback period did not improve model discrimination over the 2-year period.

CONCLUSIONS

adjusting for HFRS did not improve prediction of 30-mortality over that achieved by the CCI. Neither HFRS nor CCI were useful for predicting prolonged LOS or 28-day unplanned readmission.

Refining the care of patients with pancreatic cancer: the AGITG Pancreatic Cancer Workshop consensus

A meeting of the Australasian Gastro-Intestinal Trials Group (AGITG) was held to develop a consensus statement defining when a patient with pancreatic cancer has disease that is clearly operable, is borderline, or is locally advanced/inoperable. Key issues included the need for multidisciplinary team consensus for all patients considered for surgical resection. Staging investigations, to be completed within 4 weeks of presentation, should include pancreatic protocol computed tomography, endoscopic ultrasound, and, when possible, biopsy. Given marked differences in outcomes, the operability of tumours should be clearly identified by categories: those clearly resectable by standard means (group 1a), those requiring vascular resection but which are clearly operable (group 1b), and those of borderline operability requiring vascular resection (groups 2a and 2b). Patients who may require vascular reconstruction should be referred, before exploration, to a specialist unit. All patients should have a structured pathology report with standardised reporting of all seven surgical margins, which identifies an R0 (no tumour cells within a defined distance of the margin) if all surgical margins are clear from 1 mm. Neo-adjuvant therapy is increasingly recommended for borderline operable disease, while chemotherapy is recommended as initial therapy for patients with unresectable loco-regional pancreatic cancer. The value of adding radiation after initial chemotherapy remains uncertain. A small number of patients may be downstaged by chemoradiation, and trimodality therapy should only be considered as part of a clinical trial. Instituting these recommendations nationally will be an integral part of the process of improving quality of care and reducing geographic variation between centres in outcomes for patients.

Short- and long-term outcomes of elderly patients undergoing liver resection for colorectal liver metastasis

BACKGROUND

Metastatic colorectal cancer is a disease of advancing age. Increased life expectancy has dramatically increased the number of older patients being assessed for hepatectomy. The objective of the study is to assess the safety and survival of hepatic resection in older patients, with colorectal liver metastases (CLM) and compare that with younger patients.

METHODS

All patients undergoing hepatic resection of CLM were included. Patients were divided in groups, less than 75 and 75 and over. Prospectively collected data on patient demographics and post-operative complications were retrospectively analysed. Overall survival was calculated in both groups.

RESULTS

Twenty-nine patients over the age of 75 underwent hepatic resection for CLM. A total of 158 patients under the age of 75 underwent resection. Overall, 66% of patients received neoadjuvant chemotherapy and 64% underwent major resection. Ninety-day mortality was 1 out of 29 and 1 out of 158, respectively (P = 0.15). Overall complication rate was low, 4 out of 29 and 26 out of 158 (P = 0.45). Median length of stay was similar in the older population, 8.5 versus 8 days (P = 0.65). Overall 5-year survival was 58% in the over 75 group and 56% in the under 75 group (P = 0.31).

CONCLUSION

Hepatic resection for CLM can be achieved safely in patients over the age of 75 and with equivalent short- and long-term outcomes.

Hepatic resection of non-colorectal non-endocrine liver metastases

BACKGROUND

Hepatic resection is standard treatment for liver metastases from colorectal and neuroendocrine cancers as well as primary biliary and hepatic carcinomas. The role of hepatic resection in patients with non-colorectal non-endocrine liver metastases (NCNELM) is less defined. Overall survival in this group of patients is poor with few patients surviving beyond two years, even with modern chemotherapy.

METHODS

A prospective database of all liver resections performed by a single surgeon (KSH) from January 2007 to December 2014 was maintained. Patient demographics, surgical and pathological data were collected prospectively; survival data were updated retrospectively. Patients were grouped according to pathology and analysis was performed using SPSS (version 21).

RESULTS

A total of 48 patients underwent hepatic resection for NCNELM, of which 18 were major resections. Pathologies encountered included sarcoma in 8/48, both breast and ovarian in 6/48 each and renal cell carcinoma and melanoma, each representing 5/48. A result of 38/48 patients undertook chemotherapy prior to surgery. R0 margin was achieved in 96%. Seven patients suffered complications from surgery and one peri-operative mortality. Overall survival at 1, 3 and 5 years was 93%, 83% and 61%, respectively. Forty-four percent of patients developed disease recurrence, 29% at distant sites.

CONCLUSION

Hepatic resection can be achieved safely for NCNELM. Patient selection is key, along with a standardized surgical and anaesthetic technique. Patients should be rigorously investigated to exclude disseminated disease and multidisciplinary discussion must take place prior to surgery. Patients with NCNELM should not routinely be excluded from liver resection and selected patients may benefit from resection.

Discovery of diagnostic biomarkers for pancreatic cancer in immunodepleted serum by SELDI-TOF MS

MOTIVATION

Reports of serum pancreatic cancer (PC) biomarkers using SELDI-TOF MS have been inconsistent because different chip surfaces and interference with high-abundant proteins. This study examines the influence of these factors on the detection of discriminating diagnostic biomarkers.

METHODS

Serum from fourteen from patients with PC, disease controls (DC, n = 14) and healthy volunteers (HV, n = 14) were evaluated by SELDI using H50, IMAC, Q10 and CM10 chips. A further evaluation was undertaken after depletion of seven high-abundant proteins using spin cartridges.

RESULTS

More protein peaks were detected in whole serum than in depleted serum for IMAC, H50 and Q10 chips: 60 vs 39, 56 vs 48 and 69 vs 65, respectively, while the CM10 found less peaks in serum (27 vs 47 peaks). However, there were more differentially expressed peaks in the depleted serum samples for PC vs DC and PC vs HV samples using the H50, Q10 and CM10 ProteinChip arrays, whereas for IMAC arrays, more discriminating peaks were seen in non-depleted serum. The highly significant peaks observed on Q10, CM10 and H50 are consistent with the previous finding of ApoA-I (m/z 27,910-28000) and ApoA-II (m/z 8758 and 17,240). In addition, a number of new discriminating protein peaks were found on different ProteinChip arrays, notably peaks at m/z 4280 and 7763 on IMAC arrays.

CONCLUSION

This study confirms the diagnostic value of ApoA-I&II and identifies further potential diagnostic biomarkers for pancreatic cancer when multiple chip surfaces are used with depletion of the most highly-abundant proteins.

Outcomes of appendicectomy in an acute care surgery model

OBJECTIVE

To assess the outcomes of appendicectomy in an acute care surgery (ACS) model compared with a traditional on-call (Trad) model.

DESIGN

Retrospective historical control study comparing appendicectomy outcomes in the Trad period (April 2004 to March 2005) with outcomes in the ACS period (April 2006 to March 2007).

SETTING

The Prince of Wales Public Hospital, a metropolitan tertiary referral centre in Sydney.

PATIENTS

All adult patients undergoing appendicectomy during 1-year periods before and after the introduction of the ACS model.

INTERVENTION

The introduction of an ACS model for managing all emergency general surgical presentations.

MAIN OUTCOME MEASURE

Complication rate.

RESULTS

A total of 402 appendicectomies were performed, 176 during the Trad period and 226 during the ACS period. There was no perioperative mortality. The complication rate was lower in the ACS period than the Trad period (9.3% v 17.0%; P = 0.02). After the intervention, there was no significant change in the time from presentation to arrival in theatre or in length of stay, but the proportion of operations performed at night (24:00-08:00) was reduced from 26.1% to 15.0% (P = 0.006). The proportion of negative appendicectomies was reduced from 22.7% to 17.3%, but the change was not statistically significant (P = 0.08). There was no difference in perforation rate before and after the intervention (13.6% v 13.3%; P = 0.86).

CONCLUSION

The ACS model provides a safe surgical environment for patients and is associated with a reduced complication rate. Under the ACS model, there was an increase in the number of patients treated conservatively overnight, but this did not lead to an overall increase in perforation rate or length of stay.