Patterns of prevalence and contemporary clinical management strategies in complicated acute biliary calculous disease: an ESTES ‘snapshot audit’ of practice

Abstract

Background Acute complications of biliary calculi are common, morbid, and complex to manage. Variability exists in the techniques utilized to treat these conditions at an individual surgeon and unit level. Aim To identify, through an international prospective nonrandomized cohort study, the epidemiology and areas of practice variability in management of acute complicated calculous biliary disease (ACCBD) and to correlate them against reported outcomes. Methods A preplanned analysis of the European Society of Trauma and Emergency Surgery (ESTES) 2018 Complicated Biliary Calculous Disease audit was performed. Patients undergoing emergency hospital admission with ACCBD between 1 October 2018 and 31 October 2018 were included. All eligible patients with acute complicated biliary calculous disease were recorded contemporaneously using a standardized predetermined protocol and a secure online database and followed-up through to 60 days from their admission. Endpoints A two-stage data collection strategy collecting patient demographics, details of operative, endoscopic and radiologic intervention, and outcome metrics. Outcome measures included mortality, surgical morbidity, ICU stay, timing of operative intervention, and length of hospital stay. Results Three hundred thirty-eight patients were included, with a mean age of 65 years and 54% were female. Diagnosis at admission were: cholecystitis (45.6%), biliary pancreatitis (21%), choledocholithiasis with and without cholangitis (13.9% and 18%). Index admission cholecystectomy was performed in just 50% of cases, and 28% had an ERCP performed. Morbidity and mortality were low. Conclusion This first ESTES snapshot audit, a purely descriptive collaborative study, gives rich ‘real world’ insights into local variability in surgical practice as compared to international guidelines, and how this may impact upon outcomes. These granular data will serve to improve overall patient care as well as being hypothesis generating and inform areas needing future prospective study.

Patients over 65 years with Acute Complicated Calculous Biliary Disease are Treated Differently—Results and Insights from the ESTES Snapshot Audit

“…Patients younger than 65 were more likely to undergo index admission cholecystectomy than those C 65 years (64.7% vs. 37.8%, p = 0.001). Cholecystectomy alone was performed in 99.3% of cases [18]. 2).…”

“…In particular, elderly patients appear to accrue excess morbidity and mortality following gallbladder surgery [16]. Acknowledging acute complicated calculous biliary disease (ACCBD) as a common set of clinical problems presented to general surgeons, the Cohort Studies Group of the European Society for Trauma and Emergency Surgery (ESTES) set out to capture real-world data on the epidemiology, and contemporary management of these patients [17,18]. Traditional medical school teaching identifies the 6Fs (fair, fat, fertile, female, forty, and family history) as phenotypic predictors of symptomatic gallstone disease [19].…”

Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study

“…Instead, a prospective non-randomized observational study of strictly controlled patient cohorts using time-bound patient accrual and multicenter assessment may be better suited to answer current care questions. Such studies are known as snapshot audits, and this exploration parses data from the SnapAppy cohort study to answer questions regarding mesoappendix and appendix management as a preplanned evaluation of the specifics of appendicitis management using laparoscopic techniques [ 6 – 8 ].…”

Differential Management Strategies and Outcomes in Patients over 65 years with Acute Calculous Biliary Disease—Results and Insights from the ESTES Complicated Biliary Calculous Disease Snapshot Audit

“…An ageadjusted Charlson co-morbidity index [14][15][16] has been recently validated, while limitations in the discriminating power of the prognostic p-POSSUM score have been recognised in the older patient [17]. management of these patients [18,19]. While traditional medical school teaching identi es the 6Fs (fair, fat, fertile, female, forty and family history) as predictors of the population most likely to present with symptomatic gallstone disease [20], it was notable that the cohort presenting to European emergency departments were older, with a median age of 67 years.…”