Abstract
AimsThe rate of acute laparoscopic cholecystectomy remains low due to operational constraints. The purpose of this study is to evaluate a service model of index admission cholecystectomy with referral protocols, refined logistics and targeted job planning.MethodsA prospectively maintained dataset was evaluated to determine the processes of care and outcomes of patients undergoing emergency biliary surgery. The lead author has maintained a 28 years prospective database capturing standard demographic data, intraoperative details including the difficulty of cholecystectomy as well as postoperative outcome parameters and follow up data.ResultsOver five thousand (5555) consecutive laparoscopic cholecystectomies were performed. Only patients undergoing emergency procedures (2399,43.2% of entire group) were analysed for this study. The median age was 52 years with 70% being female. The majority were admitted with biliary pain (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgeons. 80% underwent surgery within 5 days (40% within 24 h). Cholecystectomies were performed on scheduled lists (44%) or dedicated emergency lists (29%). Two thirds had suspected bile duct stones and 38.1% underwent bile duct exploration. The median operating time was 75 min, median hospital stay 7 days, conversion rate 0.8%, morbidity 8.9% and mortality rate 0.2%.ConclusionIndex admission cholecystectomy for biliary emergencies can have low rates of morbidity and mortality. Timely referral and flexible theatre lists facilitate the service, optimising clinical results, number of biliary episodes, hospital stay and presentation to resolution intervals. Cost benefits and reduced interval readmissions need to be weighed against the length of hospital stay per episode.
Highlights
A biliary service supported by a clear hospital-wide referral protocol, flexible job planning and operating lists is able to deliver safe early/index admission cholecystectomy for patients presenting acutely with a variety of gallstone complications in keeping with guidelines. [2, 8, 9, 11, 21]
The current study demonstrates greater numbers of laparoscopic cholecystectomy (LC) performed as emergencies (43.2% v 16.3%) with much lower use of cross-sectional imaging—Magnetic resonance chlaongio-pancreatography (MRCP) and CT use was over threefold lower than national data (28.9% vs 8.4%) and (20.1% vs 6.9%) respectively [23]
Index admission LC for biliary emergencies is feasible for most patients in a dedicated biliary unit
Summary
This is a cohort study of consecutive patients undergoing surgery for gallstone emergencies performed or directly supervised by a single surgeon between February 1992 and July 2019. The surgeon’s prospectively maintained laparoscopic cholecystectomy (LC) database was interrogated for patient demographics, admission presentation, previous biliary admissions, radiological findings and intervals from admission to referral and from referral to surgery. Additional studied parameters: American Society of Anaesthesiologists (ASA) classification, grade of operating surgeon, operative difficulty grade, operative time, conversion to open, perioperative complications, readmissions, number of episodes (total episodes including previous and current episode and any readmissions), number of weeks from presentation to resolution and mortality. The operative difficulty grade was based on the modified five grade Nassar Scale [15]. IRB approval was not required as the management protocols were consistent with the recommendations of national and international societies.
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