Optimising the outcomes of index admission laparoscopic cholecystectomy and bile duct exploration for biliary emergencies: a service model

Abstract

Aims The 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. Methods A 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. Results Over 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%. Conclusion Index 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.

Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients

“…Although the current study had a high workload of biliary emergencies and subsequently a high percentage of difficult cholecystectomies, the morbidity rates for the whole study [ 6 ] were lower than many published studies [ 10 – 16 ]. Laparoscopic CBDEs were also performed in the emergency cohort with a low reintervention rate compared to other studies on CBDE [ 11 – 18 ] as shown in Table 5 .…”

“…The objective assessment of operative complexity facilitates audit, research, assessment of training and comparison between studies. The referral pathways and operative techniques have been described in detail in previous studies [5][6][7][8].…”

Specialist-led urgent cholecystectomy for acute gallstone disease

“…Our centre reported its initial experience of urgent cholecystectomy in 2004; at this time, the implementation of a specialist upper GI surgery service led to a reduction in laparoscopic conversion rates from 32 to 12% [ 12 ]. Other centres have reported reducing conversion rates as experience grows and specialisation increases [ 7 , 13 ]. In the CholeS study, the overall open surgery rate was 4.3%, although for emergency cholecystectomy it was 7.4%; these figures are typical of published studies [ 14 ].…”

The incidence, operative difficulty and outcomes of staged versus index admission laparoscopic cholecystectomy and bile duct exploration for all comers: a review of 5750 patients

“…The referral pathways, operative techniques and postoperative management have been described in the previous studies [7,8]. Emergency admissions with suspected biliary pathology undergo abdominal ultrasound and a plain X-ray of the chest.…”