The Cost of Ignoring Acute Cholecystectomy

Abstract

Ann R Coll Surg Engl 2009; 91: 39-42 39One-fifth of Western adults will develop gallstones, with women three times more commonly affected than men; approximately 20% will become symptomatic.1 The treatment of choice for symptomatic cholelithiasis remains cholecystectomy. The traditional open approach has now largely been replaced by laparoscopic cholecystectomy which was first introduced into the UK in 1990. Whilst waiting for elective cholecystectomy, approximately 70% of patients will suffer on-going biliary symptoms 2 and up to 50% will require admission.3 Repeated hospital admissions increase costs and utilise beds unnecessarily. Traditionally, patients admitted with biliary symptoms have been treated conservatively with intravenous fluids, analgesia and antibiotics in cholecystitis to allow the inflammation to settle followed by delayed cholecystectomy. 4 In the early years of laparoscopic cholecystectomy, surgery for acute cholecystitis was eschewed because of increased rates of bile duct injury; 5 however, as it has entered routine practice, it has become clear that there is no increase in complications associated with surgery in the acute setting.6 Acute laparoscopic cholecystectomy during the index hospital admission is associated with decreased overall hospital stay. 7,8 Seven of the nine general surgeons in our hospital performed elective laparoscopic cholecystectomy during the study period, but none performed acute laparoscopic cholecystectomy. Patients admitted with acute biliary symptoms were managed conservatively and cholecystectomy scheduled for a second admission. This study was designed to identify the number of patients admitted with acute biliary symptoms once the decision to perform cholecystectomy had been made; the cost of additional or repeated investigations during these admissions and the cost implications for the trust in terms of tariff income were estimated. Immediate cholecystectomy during the first admission is safe and effective, even when performed laparoscopically, but acute laparoscopic cholecystectomy has only recently become increasingly commonplace in the UK. This study was designed to quantify this problem in our hospital and its cost implications. PATIENTS AND METHODS The case notes of all patients undergoing laparoscopic cholecystectomy in our hospital between January 2004 and June 2005 were examined for details of hospital admissions with biliary symptoms or complications whilst waiting for elective cholecystectomy. Additional bed occupancy and radiological investigations were recorded and these costs to the trust calculated. We compared the potential tariff income to the hospital trust for the actual management of these patients and if a policy of acute laparoscopic cholecystectomy on first admission were in place. RESULTS In the 18-month study period, 259 patients (202 females) underwent laparoscopic cholecystectomy. Of these, 147 presented as out-patients and only 11% required hospital admission because of biliary symptoms whilst waiting for elective surgery. There ...

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

“…These include shorter LOS, 5,6 reduced repeat admissions and consequent substantial cost savings. [12][13][14] ELC is the optimum treatment for AC. …”

Low ninety-day re-admission rates after emergency and elective laparoscopic cholecystectomy in a district general hospital

“…16 However, it is important to establish whether these benefits are negated by higher re-admission episodes following emergency laparoscopic cholecystectomy, which would increase overall costs for both the hospital and patient.…”

Economic Implications of Providing Emergency Cholecystectomy for All Patients With Biliary Pathology

“…These findings are supported by previously published reports. 1,6,18,20 Despite the considerable savings afforded to the primary care trusts from costs related to direct clinical care; from a hospital provider perspective, the policy of offering ALC is at best cost-neutral. 6 This is assuming that all cases are managed using established emergency lists.…”

“…1,6,18,20 Despite the considerable savings afforded to the primary care trusts from costs related to direct clinical care; from a hospital provider perspective, the policy of offering ALC is at best cost-neutral. 6 This is assuming that all cases are managed using established emergency lists. One study has examined the cost of dedicated nonemergency operating time to ALC using a model of discharge followed by readmission for an early (within 2 wk) interval cholecystectomy, and found to be cost-neutral, 20 but this may not be applicable to in-patient ALC resource allocation.…”

“…[2][3][4][5] Further reports have discussed and reported favorably regarding the potential costsavings from ALC. 6,7 This manuscript reports the results of a pilot study within the University Hospitals of Leicester (UHL) to ALC for patients presenting with biliary pathology (acute cholecystitis, biliary colic, gallstone pancreatitis, and obstructive jaundice) to a tertiary referral Hepatobiliary Unit. The focus was to assess the safety and efficacy of ALC and assess its overall merits in terms of global cost-savings to primary care, as well as to critically appraise the income generated to the unit hospital in managing such patients aggressively.…”