Surgical ultrasonography at the bedside: a comparison of surgical trainees with trained sonographers for symptomatic cholelithiasis – a first Australian experience

Abstract

Background: Symptomatic cholelithiasis accounts for a significant burden of emergency general surgical presentations in Australia and the Western population. Access to hepatobiliary ultrasonography to facilitate diagnosis can lead to delays in timely treatment. Surgical ultrasonography at the bedside (SUB) can mitigate this barrier to patient care. This study assessed the diagnostic accuracy of SUB by trainees versus formal ultrasonographer or computed tomography examination for suspected symptomatic cholelithiasis. Methods: A prospective non-inferiority study of emergency patient admissions with abdominal pain in two tertiary referral hospitals during July 2017 to October 2018 was performed. Results of SUB were compared with accredited radiographer ultrasonography or computed tomography and histopathological assessment. Positive findings at SUB for symptomatic cholelithiasis included: cholelithiasis, gallbladder wall thickness 3 mm, pericholecystic fluid or sonographic Murphy's sign. Results: One hundred patients with epigastric or right upper quadrant pain underwent SUB. Mean patient age was 49 years (range 20-90 years), with 61 females and 39 males. Sensitivity and specificity for diagnosis of symptomatic cholelithiasis was 94.9% and 100% for SUB and 98.7% and 100% for accredited radiographers. Diagnostic accuracy was 96% for SUB and 99% for radiographer ultrasonography. Positive predictive value and negative predictive value were 100% and 84.6% for SUB and 100% and 96% for radiographers. The inter-rater reliability for features compatible with the diagnosis of symptomatic cholelithiasis was good with a kappa of 0.758 (95% confidence interval 0.587-0.929, P < 0.001). Conclusion: This first Australian experience demonstrates that general surgical trainees can accurately diagnose cholecystitis with SUB and this assessment is not inferior and has substantial agreement with accredited radiographer ultrasonography.

Bedside ultrasonography for acute gallstone disease: a diagnostic accuracy study of surgical registrars and emergency medicine physicians

“…This compares favourably with the 2017-2018 Australian study of surgical trainees, which recorded a kappa of 0.62 (95% CI 0.46-0.77) for the finding of gallstones. 7 These results are similar to other previously published studies. Two studies of bedside ultrasound performed by emergency medicine physicians have reported sensitivities of 88% and 87% and specificities of 90% and 88% for the finding of gallstones.…”

“…We were unable to replicate the results 2017-2018 Australian study of surgical trainees, which recorded a sensitivity and specificity of 94.9% and 100%, respectively. 7 However, other published studies of bedside ultrasound for acute cholecystitis have generally reported much lower sensitivities and specificities. For example, studies of bedside ultrasound performed by surgeons in Sweden, Japan and Iran have reported sensitivities of 60%, 84.2% and 89.6% and specificities of 98.6%, 92.1% and 96.6%, respectively, for the imaging diagnosis of acute cholecystitis.…”

“…In a 2018 Australian study, trainees in Sydney were trained with a single instruction session and subsequently demonstrated a sensitivity and specificity for the diagnosis of 'symptomatic cholelithiasis' of 94.9% and 100%, respectively. 7 This study reports the results of a diagnostic accuracy study of bedside ultrasound performed by both surgical registrars and emergency medicine physicians during a trial introduction to clinical practice as part of a multidisciplinary quality improvement project. This represents the first experience in New Zealand of a programme to train and evaluate surgical registrars in the routine use of bedside ultrasound.…”

Bedside ultrasonography by surgeons: a new diagnostic adjunct for cholecystitis and gallstone disease

“…Acceptable rates of diagnostic accuracy for bedside ultrasound performed by surgeons, in comparison to formal departmental ultrasound scans, have been demonstrated . Some published studies have reported sensitivities and specificities of well over 90% for the detection of gallstones alone . Ultimately, it is a realistic prospect for bedside ultrasound performed by surgical staff to become a standard diagnostic tool for the confirmation of acute cholecystitis or acute gallstone disease, followed directly by surgical treatment in the form of cholecystectomy.…”

“…In this issue of ANZ Journal of Surgery , Gaszynski et al report encouraging diagnostic results for bedside gallbladder ultrasound scans performed by surgical trainees at Campbelltown and Liverpool Hospitals in Sydney in the first documented experience in Australia and New Zealand. This is a prospective study of diagnostic accuracy for bedside ultrasound of the gallbladder performed by surgical trainees following a single short instruction session compared to formal departmental biliary ultrasound performed by an accredited ultrasonographer.…”