Abstract
<i>Aim</i>: Early Laparoscopic Cholecystectomy (ELC) for acute cholecystitis is widely accepted as the standard of care. The capacity to deliver this has been strongly linked to the establishment of Acute Surgical Units (ASU). This study aimed to determine the relative effects of surgeon preference on ELC rates. <i>Method</i>: A retrospective audit of patients with acute cholecystitis was carried out over 6 months in 3 hospitals in 2018. One hospital had an ASU and 2 hospitals had no ASU. The timing of cholecystectomy, intraoperative cholangiogram rates and length of hospital stay were collected. <i>Results</i>: 175 patients were included; 92 admitted to the ASU hospital and 83 admitted to non-ASU hospitals. When adjusted for severity, the ELC rate was 62% and 31% (P<0.0001) in the ASU hospital and non-ASU hospitals respectively in patients with mild (Tokyo Grade I) disease. There was no difference between intraoperative cholangiogram rates between hospitals. The initial length of stay was on average 2.4 days shorter in the early ELC patients (MD=-2.4, 95% CI 1.3 to 3.4). The 2 Non-ASU hospitals varied significantly in ELC rates (19% and 48% P=0.0158), the hospital with the higher ELC rates shared senior surgical staff with the ASU hospital. <i>Conclusion</i>: Hospitals with an ASU are better able to provide timely surgery to patients presenting with acute cholecystitis and this is associated with a reduction of time in hospital for these patients, but surgeon preference may be more important in determining ELC rates than the ASU model of care.
Highlights
Laparoscopic cholecystectomy has become the mainstay of treatment for acute cholecystitis
175 unique presentations of acute cholecystitis were recorded at the study hospitals in the six-month study period
Ninety-two patients presented to Hospital A (ASU), fifty-two patients presented to Hospital B (Non-Acute Surgical Units (ASU)), and thirty-one presented to Hospital C (Non-ASU), for a total of ninety-two in the ASU group and eighty-three in the nonASU group
Summary
Laparoscopic cholecystectomy has become the mainstay of treatment for acute cholecystitis. The timing of surgery can be divided into ‘early’ and ‘delayed’. The most common definition is commencement of laparoscopic cholecystectomy within 72 hours of the patient’s admission to hospital [1,2,3], and this is the definition of ELC used in this study. There are no current Australian-specific guidelines for the management of acute cholecystitis, the international stance favours ELC for patients presenting with acute cholecystitis in most cases. The 2014 National Institute for Health and Care Excellence guidelines recommend surgery as early as possible after admission and the Tokyo Guidelines 2018 (TG18) recommend surgery be carried out as early as possible regardless of time of onset, ideally within 72 hours of presentation [2, 4]
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