Management of acute cholecystitis in UK hospitals: time for a change

Abstract

Early cholecystectomy for patients with acute cholecystitis is safe, cost effective, and leads to less time off work compared with delayed surgery. This study was designed to assess current practice in the management of acute cholecystitis in the UK. A postal questionnaire was sent to 440 consultant general surgeons to ascertain their current management of patients with acute cholecystitis. Replies were received from 308 consultants who were involved in treating patients with acute cholecystitis of whom 18 transferred these patients on to another team for further management the day after admission. Thirty two consultants (11%) routinely treated patients by early cholecystectomy, with limiting factors stated to be the availability of surgical staff, theatre space, and radiological investigations. The remaining consultants (n = 258) routinely manage their patients conservatively with intravenous antibiotics and allow the inflammation to resolve before undertaking cholecystectomy at a later date. Indications for undertaking early cholecystectomy during the first admission by this latter group included the presence of spreading peritonitis due to bile leak, empyema, and unexpected space on theatre list. The commonest method for both elective and early cholecystectomy is laparoscopic, but the percentage of consultants using an open method rises from 8% in the elective situation to 47% for urgent early cholecystectomy. Despite evidence which strongly advocates early cholecystectomy, this practice is routinely carried out by only 11% of consultants in the UK at present. O pinions among surgeons regarding the optimum management of acute cholecystitis remain divided. Some advocate early cholecystectomy during the initial admission, whereas others prefer to treat patients conservatively in the first instance with intravenous fluids and antibiotics and undertake delayed elective cholecystectomy. Two randomised controlled trials of early versus delayed laparoscopic cholecystectomy in the management of acute cholecystitis have both shown early laparoscopic cholecystectomy to be safe and associated with lower rates of conversion and reduced total hospital stay compared with delayed surgery.1 2 In addition, the hazards of conservative management of acute cholecystitis in the UK, especially with regard to patient readmissions, have recently been highlighted.3 4 The aim of this study therefore was to assess current practice in the management of acute cholecystitis by general surgeons in the UK. METHODSA postal questionnaire was sent to 440 consultant general surgeons. They were asked to provide details of their on-call commitments, subspecialist interests, and the management of patients under their care with acute cholecystitis. In particular they were asked whether they routinely opted for early cholecystectomy during the first admission or preferred initial conservative management and delayed interval cholecystectomy. Surgeons opting for early cholecystectomy were asked which factors limited this practice, with those opting fo...

Admission CRP Level as an Indicator for the Need of Percutaneous Cholecystostomy in Acute Cholecystitis

“…Patients with moderate cholecystitis (defined by severe local inflammation), or patients with increased operative risk due to significant comorbidities (even with mild local disease), are treated by I.V antibiotics (further referred as conservative treatment). Moreover, technical and organizational difficulties hamper the implementation of early cholecystectomy even in surgically fit patients [6][7][8][9]. Thus, many patients are not operated at the same admission, but are treated conservatively.…”

Impact of a dedicated emergency surgical unit on early laparoscopic cholecystectomy for acute cholecystitis

“…[5][6][7] The consensus on the optimal timing is still lacking, however, with 'early' being defined as ranging from 24 hours to 7 days from diagnosis or onset of symptoms. 7 Despite positive evidence, the rate of ELC remains low worldwide, [8][9][10] mainly on account of financial constraints, logistical difficulties and shortage of expertise. 6,8,11 Practice of early cholecystectomy in the UK is particularly poor by international standards [8][9][10] and possibly reflects the general provision of emergency surgical care.…”

Outcomes of early cholecystectomy (within 7 days of admission) for acute cholecystitis according to diagnosis and severity grading by Tokyo 2013 Guideline

“…Recently, early laparoscopic cholecystectomy is suggested as the first line treatment in acute cholecystitis (11). Unfortunately, the rate of early cholecystectomy in patients with acute cholecystitis still remains low (15-40%) (14)(15)(16). In our hospital, the most preferred clinical application is interval cholecystectomy, except our group.…”

“…Although several guidelines suggest ELC in acute cholecystitis (10)(11)(12)(13), the rate of early cholecystectomy still remains low i.e. 15-40% (14)(15)(16).…”