The impact of service reconfiguration on the provision of laparoscopic cholecystectomy for patients admitted with acute gallstone related disorders.

Abstract

Background: IAP/APA guidelines recommend cholecystectomy during index admission for mild biliary pancreatitis while NICE guidelines recommend cholecystectomy within one week of diagnosis of acute cholecystitis. The present study evaluates the impact of a 7-day HPB emergency service on compliance with these guidelines. Methods: Patients admitted acutely with gallstone disease in two 12-month periods (2013, 2015) were included. A 7-day HPB emergency service with 3 theatre sessions per week dedicated for urgent cholecystectomies was introduced in 2014. Primary endpoint was compliance with NICE and IAP/APA guidelines. Secondary endpoints included time to cholecystectomy, readmission rate and conversion rate. Results: 742 patients (n=305 in 2013) were included. Compliance with NICE guidelines improved from 44% in 2013 to 73% in 2015 (p<0.001). Compliance with IAP/APA guidelines improved from 28% to 73% (p=0.002). Time to surgery was reduced (28 vs 5 days, p<0.001). Proportion of index admission cholecystectomies was increased (37% vs 71%, p<0.005). Improvements were noted in operative time (135 vs 106 minutes, p=0.002), readmission rates (39% vs 20%, p<0.001) and length of stay (8 vs 6 days, p<0.001). There was no difference in conversion rates (5.5% vs 2.8%, p=0.411). Conclusion: A dedicated seven-day emergency HPB service can significantly improve compliance with the NICE and IAP/APA guidelines. Early surgery and reduction in readmission rates and hospital stay have significant patient and health economic benefits.