ORIGINAL ARTICLE ANZJSurg.com
Are we meeting the British Society of Gastroenterology guidelines for cholecystectomy post-gallstone pancreatitis? Lee R. Creedon,* Chris Neophytou,* Paul C. Leeder† and Altaf K. Awan* *Department of Hepatobiliary Surgery, Royal Derby Hospital, Derby, UK and †Department of Upper Gastrointestinal Surgery, Royal Derby Hospital, Derby, UK
Key words cholecystectomy, gallstones, general surgery, laparoscopic, morbidity, pancreatitis. Correspondence Mr Lee R. Creedon, Department of Hepatobiliary Surgery, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK. Email: [email protected] L. R. Creedon MRCS; C. Neophytou MBBS; P. C. Leeder FRCS; A. K. Awan FRCS. Accepted for publication 24 July 2014. doi: 10.1111/ans.12827
Abstract Background: The aim of this study was to audit the current management of patients suffering with gallstone pancreatitis (GSP) at a university teaching hospital for compliance with the British Society of Gastroenterology (BSG) guidelines regarding cholecystectomy post-GSP. Methods: Data were collected on all patients identified via the hospital coding department that presented with GSP between January 2011 and November 2013. Patients with alcoholic pancreatitis were excluded. The primary outcome was the length of time in days from diagnosis of GSP to cholecystectomy. Secondary outcomes included readmission with gallstone-related disease prior to definitive management and admitting speciality. Results: One hundred and fifty-eight patients were identified with a presentation of GSP during the study period. Thirty-nine patients were treated conservatively. One hundred and six patients underwent laparoscopic cholecystectomy a median (interquartile range) interval of 33.5 days (64 days) post-admission. Patients with a severe attack as classified by the Glasgow severity score (n = 16) waited a median of 79.5 days (71.5) for cholecystectomy. Only 32% (n = 34) of patients with mild disease underwent cholecystectomy during the index admission or within 2 weeks. When grouped by admitting speciality, patients admitted initially under hepatobiliary surgery waited significantly fewer days for definitive treatment compared with other specialities (P < 0.0001). Twenty-one patients (19.8%) re-presented with gallstone-related pathology prior to undergoing cholecystectomy. Conclusions: Only 32.1% were treated as per BSG guidelines. About 19.8% (n = 21) of the patients suffered further morbidity as a result of a delayed operation and there is a clear difference between admitting speciality and the median time to operation.
Introduction Gallstones are the most common cause of acute pancreatitis within the United Kingdom and represent a cohort of patients that can benefit from reduced risk of further attacks through surgical or endoscopic intervention. The outcome of an attack of an acute pancreatitis can result in substantial morbidity such as necrotizing pancreatitis or pancreatic pseudocyst, while mortality is quoted between 2% and 8%.1 Historical management of patients admitted with acute gallstone pancreatitis (GSP) has been non-operative for uncomplicated cases, with patients returning for interval cholecystectomy several weeks or months after admission. Increasing evidence towards acute laparoscopic cholecystectomy (LC) during the index admission or within 2 weeks of presentation is © 2014 Royal Australasian College of Surgeons
changing this view point,2–4 with no evidence of increased complications or conversion to open when compared with elective cholecystectomy. This is also the case for treatment of other gallstone-related disease such as acute cholecystitis or biliary colic.5,6 In 2005, the British Society of Gastroenterology (BSG) revised their current guidelines on the management of acute pancreatitis and made specific recommendations regarding LC post-GSP.7 The management of patients suffering with acute pancreatitis was audited by our department in 2010, where it was revealed that not a single patient was treated within the recommended guidelines. Recommendations from the 2010 audit were focused around education of the involved departments to encourage early specialist referral and increase the opportunity of acute LC. ANZ J Surg •• (2014) ••–••
2
Creedon et al.
Table 1 Interval between index admission and laparoscopic cholecystectomy between different specialities Specialty
Hepatobiliary surgery Upper gastrointestinal surgery Colorectal surgery Vascular surgery
Number of patients
Median time to operation (days)
Interquartile range (days)
Laparoscopic cholecystectomy within guidelines
Severe gallstone pancreatitis
22 28 41 15
6 (P < 0.0001) 41.5 47 32
9.75 75.75 57 169.5
17 (77%) 7 (25%) 8 (20%) 4 (27%)
3 5 6 2
Aims The aims of this study were to determine the current management of GSP within a university teaching hospital, to compare this practice with the recommended BSG guidelines and to identify any improvement of the results of the same study undertaken between January and December 2010, completing this audit cycle. The primary outcome measure was length of time between initial presentation and cholecystectomy. Secondary outcomes were readmission with gallstone-related disease while awaiting cholecystectomy, admitting speciality, conversion to open cholecystectomy and death from gallstone-related disease.
Audit standards A revision of the 2003 BSG guidelines for the treatment of acute pancreatitis was made in 2005.7 Our audit standard was based around their guidelines: • All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission, unless a clear plan has been made for definitive treatment within the next 2 weeks.
Methods A retrospective clinical study of all patients that presented with GSP between January 2011 and November 2013 was undertaken. The hospital data analysis service was accessed to identify all patients coded as presenting with acute pancreatitis related to gallstones: 206 patients. Each patient admission was analysed to exclude incorrectly coded admissions (no evidence of acute pancreatitis) and those patients with alcohol-induced pancreatitis which left 158 patients to be included in the study. Alcohol-induced pancreatitis was diagnosed if no evidence of gallstones was identified upon ultrasonography and there was a history of either chronic or acute alcohol abuse. Demographics, laboratory results, Glasgow severity score8 on admission, length of stay and timing of intervention (i.e. cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP)) if any, was noted. Admitting speciality was recorded as well as gallstone-related readmissions prior to definitive treatment or patient death. A Kruskal–Wallis test was used to identify any significant difference between the waiting times of the different admitting specialities.
Results Patient demographics A total of 158 patients were admitted between January 2011 and November 2013, inclusive that were correctly diagnosed as suffering
with GSP. The majority of patients were female (n = 96), with 62 males. The mean age in years was 55.4 with a range of 19–87 years.
Patient management Thirty-nine patients were treated conservatively because of anaesthetic risks and 12 patients underwent ERCP, three during the index admission. The remaining 106 patients underwent LC at varying intervals post-index admission. The median waiting time was 33.5 days with an interquartile range (IQR) of 64.75 days. The majority of patients that underwent LC (84.9%) presented with a mild severity score (Glasgow score of 150) waited a median time of 79.5 days (IQR 71.5) for cholecystectomy. Only one patient with a severe attack of acute pancreatitis underwent LC within 14 days of the index admission. Interestingly, the median length of stay was found to be lower in the cohort of patients with severe acute pancreatitis than those with a mild attack (8 days versus 13.7 days). All operations were completed laparoscopically with complication rates equivalent to that of our elective LC population.
Admitting speciality The data were further divided into admitting speciality in order to determine if this made any difference to the time it took to undergo cholecystectomy. There was a significant difference between patients admitted initially under hepatobiliary (HPB) surgery and the other specialities (P < 0.0001) (Table 1). It was also identified that a higher proportion of those admitted under HPB underwent LC during the index admission or within the recommended 2-week period post-admission (Table 1). There was no significant difference between the frequencies of patients diagnosed with severe GSP between the admitting specialities as noted in Table 1. Inpatient stay between the specialities was found to be surprisingly similar throughout and therefore is highly unlikely to affect the length of time to operation (Table 2).
Hospital readmissions A total of 21 (19.8%) patients were readmitted to the hospital with gallstone-related pathology prior to undergoing definitive management. Eight patients (7.6%) were readmitted with acute pancreatitis, eight patients (7.6%) with acute cholecystitis and five patients (4.7%) with biliary colic. There were no deaths in this group. © 2014 Royal Australasian College of Surgeons
Cholecystectomy post-pancreatitis
3
Table 2 Median inpatient stay of patients with gallstone pancreatitis between different specialities Specialty
Hepatobiliary surgery Upper gastrointestinal surgery Colorectal surgery Vascular surgery
Median length of stay (days) 6 7 6 7
Discussion This study identifies that despite the poor compliance with guidelines being highlighted during the 2010 audit, there is still plenty of room for improvement. The benefit of early cholecystectomy is well established as a safe and effective treatment for suitable patients presenting with GSP3 and should therefore be accepted as standard care. Despite this, it is clear that a number of factors may influence the timing of cholecystectomy. Within the majority of UK hospitals, emergency admissions are accepted by general surgical consultants from different general surgical specialties. It is not uncommon for vascular surgeons to remain part of the general surgical on-call rota within some UK hospitals because of the training pathway that has resulted in vascular surgeons being competent in managing general surgical admission (preCalman trainees). With the recent division of vascular surgery into a speciality within its own right, new training pathways will likely continue to enforce the division of general and vascular surgery and in the future reduce the number of vascular surgeons that receive the general surgical take. Our experience has shown that this influences waiting time for LC, with the likely explanation being a lack of experience of nonHPB surgeons in performing acute cholecystectomies. It is also likely that despite the internal audit, they are less aware of the guidance regarding timing of LC. This is further evidenced by the higher proportion of patients that underwent LC within the HPB cohort within 2 weeks of presentation. Non-HPB surgeons would likely treat uncomplicated acute pancreatitis conservatively, with planned specialist referral on discharge. It is, however, surprising that we also found the performance of the upper gastrointestinal surgeons to be comparable with that of both colorectal and vascular specialists. This may point towards problems with access to theatre space to perform urgent cholecystectomy. The vast majority of LCs are performed on elective waiting lists for patients with symptomatic gallstones. Resistance of both theatre and anaesthetic staff towards ‘semi-elective’ LCs being placed on emergency theatre lists is common and can result in operations being delayed or cancelled. Education of these departments is important in order for them to understand both the patient and financial benefits of acute LCs. With the guideline period being 2 weeks, it is feasible for patients to go home and return within this period to undergo LC. Therefore, in order to ease pressures on the emergency theatre and staff, a second theatre could potentially be opened that is dedicated to ‘urgent’ LCs. A study that assessed the feasibility of this with regard to the number of required theatre sessions and the financial impli© 2014 Royal Australasian College of Surgeons
cations concluded that a half-day session every other week would provide adequate theatre time and prove cost neutral.9 We feel that it is unacceptable for suitable patients to be discharged and suffer further morbidity as a result of gallstones with the potential risk of acute severe pancreatitis. Our study revealed that just short of 20% of patients were readmitted while awaiting interval cholecystectomy, with other studies confirming the increased risk of readmission for recurrent biliary events, especially recurrent biliary pancreatitis.10–12 Although none of the patients in our cohort died, a previous study identified that a number of patients that were awaiting cholecystectomy died upon readmission with gallstone-related disease.12 In our study, conversion from laparoscopic to an open procedure did not occur in any of the cases. A Cochrane review found no increased risk of conversion to open cholecystectomy for those undergoing early LC for GSP.2 Neither did they find any increased risk of complications for patients suffering from mild pancreatitis. This finding has been mirrored in patients undergoing acute LC for acute cholecystitis.13,14 Although we have identified deficiencies in the quality of care that patients have received, it must be acknowledged that the limitations of a retrospective audit preclude considerations of the clinical decision-making process at the time of admission of each patient. It is therefore accepted that there may well be a cohort of patients that were not suitable to be treated as per guidance which may have had an effect on the given results. However, this effect would most certainly be small, as the vast majority of patients were admitted with a mild attack of acute pancreatitis.
Conclusions The BSG guidelines regarding definitive management of gallstones post-GSP are not currently being adhered to within our institution. Acute LC for GSP in suitable patients should be performed either during the index admission or within 2 weeks of presentation. A dedicated referral pathway for non-HPB surgeons should be implemented upon admission of suitable patients to ensure early specialist input. It should be feasible and cost neutral to instigate a regular urgent operating theatre session to provide this service. A similar service could extend to include patients suffering with acute cholecystitis. Although it should be acknowledged that the results of this study are exclusive to our institution; no other studies have identified rates of concordance with the guidance provided by the BSG, rather the feasibility of adherence to the guidelines. We therefore feel that this study highlights the importance of not only adherence to specific guidelines but also the use of audit as a valuable tool in the examination of local quality outcomes as a whole.
References 1. Sekimoto M, Takada T, Kawarada Y et al. JPN Guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis. J. Hepatobiliary Pancreat. Surg. 2006; 13: 10–24. 2. Gurusamy KS, Nagendran M, Davidson BR. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst. Rev. 2013; (9): CD010326.
4
3. Bouwense SA, Besselink MG, van Brunschot S et al. Pancreatitis of biliary origin, optimal timing of cholecystectomy (PONCHO trial): study protocol for a randomized controlled trial. Trials 2012; 13: 225. 4. Saeb-Parsy K, Mills A, Rang C, Reed JB, Harris AM. Emergency laparoscopic cholecystectomy in an unselected cohort: a safe and viable option in a specialist centre. Int. J. Surg. 2010; 8: 489–93. 5. Gutt CN, Encke J, Köninger J et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann. Surg. 2013; 258: 385–93. 6. Chang TC, Lin MT, Wu MH, Wang MY, Lee PH. Evaluation of early versus delayed laparoscopic cholecystectomy in the treatment of acute cholecystitis. Hepatogastroenterology 2009; 56: 26–8. 7. UK guidelines for the management of acute pancreatitis. Gut 2005; 54 (Suppl. 3): iii1–9. 8. Imrie CW, Benjamin IS, Ferguson JC et al. A single-centre double-blind trial of Trasylol therapy in primary acute pancreatitis. Br. J. Surg. 1978; 65: 337–41. 9. Monkhouse SJ, Court EL, Dash I, Coombs NJ. Two-week target for laparoscopic cholecystectomy following gallstone pancreatitis is achievable and cost neutral. Br. J. Surg. 2009; 96: 751–5.
Creedon et al.
10. van Baal MC, Besselink MG, Bakker OJ et al. Timing of cholecystectomy after mild biliary pancreatitis: a systematic review. Ann. Surg. 2012; 255: 860–6. 11. Johnstone M, Marriott P, Royle TJ et al. The impact of timing of cholecystectomy following gallstone pancreatitis. Surgeon 2014; 12: 134– 40. 12. El-Dhuwaib Y, Deakin M, David GG, Durkin D, Corless DJ, Slavin JP. Definitive management of gallstone pancreatitis in England. Ann. R. Coll. Surg. Engl. 2012; 94: 402–6. 13. de Mestral C, Rotstein OD, Laupacis A et al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis. Ann. Surg. 2014; 259: 10–5. 14. Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst. Rev. 2013; (6): CD005440.
© 2014 Royal Australasian College of Surgeons
Are we meeting the British Society of Gastroenterology guidelines for cholecystectomy post-gallstone pancreatitis? Lee R. Creedon,* Chris Neophytou,* Paul C. Leeder† and Altaf K. Awan* *Department of Hepatobiliary Surgery, Royal Derby Hospital, Derby, UK and †Department of Upper Gastrointestinal Surgery, Royal Derby Hospital, Derby, UK
Key words cholecystectomy, gallstones, general surgery, laparoscopic, morbidity, pancreatitis. Correspondence Mr Lee R. Creedon, Department of Hepatobiliary Surgery, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK. Email: [email protected] L. R. Creedon MRCS; C. Neophytou MBBS; P. C. Leeder FRCS; A. K. Awan FRCS. Accepted for publication 24 July 2014. doi: 10.1111/ans.12827
Abstract Background: The aim of this study was to audit the current management of patients suffering with gallstone pancreatitis (GSP) at a university teaching hospital for compliance with the British Society of Gastroenterology (BSG) guidelines regarding cholecystectomy post-GSP. Methods: Data were collected on all patients identified via the hospital coding department that presented with GSP between January 2011 and November 2013. Patients with alcoholic pancreatitis were excluded. The primary outcome was the length of time in days from diagnosis of GSP to cholecystectomy. Secondary outcomes included readmission with gallstone-related disease prior to definitive management and admitting speciality. Results: One hundred and fifty-eight patients were identified with a presentation of GSP during the study period. Thirty-nine patients were treated conservatively. One hundred and six patients underwent laparoscopic cholecystectomy a median (interquartile range) interval of 33.5 days (64 days) post-admission. Patients with a severe attack as classified by the Glasgow severity score (n = 16) waited a median of 79.5 days (71.5) for cholecystectomy. Only 32% (n = 34) of patients with mild disease underwent cholecystectomy during the index admission or within 2 weeks. When grouped by admitting speciality, patients admitted initially under hepatobiliary surgery waited significantly fewer days for definitive treatment compared with other specialities (P < 0.0001). Twenty-one patients (19.8%) re-presented with gallstone-related pathology prior to undergoing cholecystectomy. Conclusions: Only 32.1% were treated as per BSG guidelines. About 19.8% (n = 21) of the patients suffered further morbidity as a result of a delayed operation and there is a clear difference between admitting speciality and the median time to operation.
Introduction Gallstones are the most common cause of acute pancreatitis within the United Kingdom and represent a cohort of patients that can benefit from reduced risk of further attacks through surgical or endoscopic intervention. The outcome of an attack of an acute pancreatitis can result in substantial morbidity such as necrotizing pancreatitis or pancreatic pseudocyst, while mortality is quoted between 2% and 8%.1 Historical management of patients admitted with acute gallstone pancreatitis (GSP) has been non-operative for uncomplicated cases, with patients returning for interval cholecystectomy several weeks or months after admission. Increasing evidence towards acute laparoscopic cholecystectomy (LC) during the index admission or within 2 weeks of presentation is © 2014 Royal Australasian College of Surgeons
changing this view point,2–4 with no evidence of increased complications or conversion to open when compared with elective cholecystectomy. This is also the case for treatment of other gallstone-related disease such as acute cholecystitis or biliary colic.5,6 In 2005, the British Society of Gastroenterology (BSG) revised their current guidelines on the management of acute pancreatitis and made specific recommendations regarding LC post-GSP.7 The management of patients suffering with acute pancreatitis was audited by our department in 2010, where it was revealed that not a single patient was treated within the recommended guidelines. Recommendations from the 2010 audit were focused around education of the involved departments to encourage early specialist referral and increase the opportunity of acute LC. ANZ J Surg •• (2014) ••–••
2
Creedon et al.
Table 1 Interval between index admission and laparoscopic cholecystectomy between different specialities Specialty
Hepatobiliary surgery Upper gastrointestinal surgery Colorectal surgery Vascular surgery
Number of patients
Median time to operation (days)
Interquartile range (days)
Laparoscopic cholecystectomy within guidelines
Severe gallstone pancreatitis
22 28 41 15
6 (P < 0.0001) 41.5 47 32
9.75 75.75 57 169.5
17 (77%) 7 (25%) 8 (20%) 4 (27%)
3 5 6 2
Aims The aims of this study were to determine the current management of GSP within a university teaching hospital, to compare this practice with the recommended BSG guidelines and to identify any improvement of the results of the same study undertaken between January and December 2010, completing this audit cycle. The primary outcome measure was length of time between initial presentation and cholecystectomy. Secondary outcomes were readmission with gallstone-related disease while awaiting cholecystectomy, admitting speciality, conversion to open cholecystectomy and death from gallstone-related disease.
Audit standards A revision of the 2003 BSG guidelines for the treatment of acute pancreatitis was made in 2005.7 Our audit standard was based around their guidelines: • All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission, unless a clear plan has been made for definitive treatment within the next 2 weeks.
Methods A retrospective clinical study of all patients that presented with GSP between January 2011 and November 2013 was undertaken. The hospital data analysis service was accessed to identify all patients coded as presenting with acute pancreatitis related to gallstones: 206 patients. Each patient admission was analysed to exclude incorrectly coded admissions (no evidence of acute pancreatitis) and those patients with alcohol-induced pancreatitis which left 158 patients to be included in the study. Alcohol-induced pancreatitis was diagnosed if no evidence of gallstones was identified upon ultrasonography and there was a history of either chronic or acute alcohol abuse. Demographics, laboratory results, Glasgow severity score8 on admission, length of stay and timing of intervention (i.e. cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP)) if any, was noted. Admitting speciality was recorded as well as gallstone-related readmissions prior to definitive treatment or patient death. A Kruskal–Wallis test was used to identify any significant difference between the waiting times of the different admitting specialities.
Results Patient demographics A total of 158 patients were admitted between January 2011 and November 2013, inclusive that were correctly diagnosed as suffering
with GSP. The majority of patients were female (n = 96), with 62 males. The mean age in years was 55.4 with a range of 19–87 years.
Patient management Thirty-nine patients were treated conservatively because of anaesthetic risks and 12 patients underwent ERCP, three during the index admission. The remaining 106 patients underwent LC at varying intervals post-index admission. The median waiting time was 33.5 days with an interquartile range (IQR) of 64.75 days. The majority of patients that underwent LC (84.9%) presented with a mild severity score (Glasgow score of 150) waited a median time of 79.5 days (IQR 71.5) for cholecystectomy. Only one patient with a severe attack of acute pancreatitis underwent LC within 14 days of the index admission. Interestingly, the median length of stay was found to be lower in the cohort of patients with severe acute pancreatitis than those with a mild attack (8 days versus 13.7 days). All operations were completed laparoscopically with complication rates equivalent to that of our elective LC population.
Admitting speciality The data were further divided into admitting speciality in order to determine if this made any difference to the time it took to undergo cholecystectomy. There was a significant difference between patients admitted initially under hepatobiliary (HPB) surgery and the other specialities (P < 0.0001) (Table 1). It was also identified that a higher proportion of those admitted under HPB underwent LC during the index admission or within the recommended 2-week period post-admission (Table 1). There was no significant difference between the frequencies of patients diagnosed with severe GSP between the admitting specialities as noted in Table 1. Inpatient stay between the specialities was found to be surprisingly similar throughout and therefore is highly unlikely to affect the length of time to operation (Table 2).
Hospital readmissions A total of 21 (19.8%) patients were readmitted to the hospital with gallstone-related pathology prior to undergoing definitive management. Eight patients (7.6%) were readmitted with acute pancreatitis, eight patients (7.6%) with acute cholecystitis and five patients (4.7%) with biliary colic. There were no deaths in this group. © 2014 Royal Australasian College of Surgeons
Cholecystectomy post-pancreatitis
3
Table 2 Median inpatient stay of patients with gallstone pancreatitis between different specialities Specialty
Hepatobiliary surgery Upper gastrointestinal surgery Colorectal surgery Vascular surgery
Median length of stay (days) 6 7 6 7
Discussion This study identifies that despite the poor compliance with guidelines being highlighted during the 2010 audit, there is still plenty of room for improvement. The benefit of early cholecystectomy is well established as a safe and effective treatment for suitable patients presenting with GSP3 and should therefore be accepted as standard care. Despite this, it is clear that a number of factors may influence the timing of cholecystectomy. Within the majority of UK hospitals, emergency admissions are accepted by general surgical consultants from different general surgical specialties. It is not uncommon for vascular surgeons to remain part of the general surgical on-call rota within some UK hospitals because of the training pathway that has resulted in vascular surgeons being competent in managing general surgical admission (preCalman trainees). With the recent division of vascular surgery into a speciality within its own right, new training pathways will likely continue to enforce the division of general and vascular surgery and in the future reduce the number of vascular surgeons that receive the general surgical take. Our experience has shown that this influences waiting time for LC, with the likely explanation being a lack of experience of nonHPB surgeons in performing acute cholecystectomies. It is also likely that despite the internal audit, they are less aware of the guidance regarding timing of LC. This is further evidenced by the higher proportion of patients that underwent LC within the HPB cohort within 2 weeks of presentation. Non-HPB surgeons would likely treat uncomplicated acute pancreatitis conservatively, with planned specialist referral on discharge. It is, however, surprising that we also found the performance of the upper gastrointestinal surgeons to be comparable with that of both colorectal and vascular specialists. This may point towards problems with access to theatre space to perform urgent cholecystectomy. The vast majority of LCs are performed on elective waiting lists for patients with symptomatic gallstones. Resistance of both theatre and anaesthetic staff towards ‘semi-elective’ LCs being placed on emergency theatre lists is common and can result in operations being delayed or cancelled. Education of these departments is important in order for them to understand both the patient and financial benefits of acute LCs. With the guideline period being 2 weeks, it is feasible for patients to go home and return within this period to undergo LC. Therefore, in order to ease pressures on the emergency theatre and staff, a second theatre could potentially be opened that is dedicated to ‘urgent’ LCs. A study that assessed the feasibility of this with regard to the number of required theatre sessions and the financial impli© 2014 Royal Australasian College of Surgeons
cations concluded that a half-day session every other week would provide adequate theatre time and prove cost neutral.9 We feel that it is unacceptable for suitable patients to be discharged and suffer further morbidity as a result of gallstones with the potential risk of acute severe pancreatitis. Our study revealed that just short of 20% of patients were readmitted while awaiting interval cholecystectomy, with other studies confirming the increased risk of readmission for recurrent biliary events, especially recurrent biliary pancreatitis.10–12 Although none of the patients in our cohort died, a previous study identified that a number of patients that were awaiting cholecystectomy died upon readmission with gallstone-related disease.12 In our study, conversion from laparoscopic to an open procedure did not occur in any of the cases. A Cochrane review found no increased risk of conversion to open cholecystectomy for those undergoing early LC for GSP.2 Neither did they find any increased risk of complications for patients suffering from mild pancreatitis. This finding has been mirrored in patients undergoing acute LC for acute cholecystitis.13,14 Although we have identified deficiencies in the quality of care that patients have received, it must be acknowledged that the limitations of a retrospective audit preclude considerations of the clinical decision-making process at the time of admission of each patient. It is therefore accepted that there may well be a cohort of patients that were not suitable to be treated as per guidance which may have had an effect on the given results. However, this effect would most certainly be small, as the vast majority of patients were admitted with a mild attack of acute pancreatitis.
Conclusions The BSG guidelines regarding definitive management of gallstones post-GSP are not currently being adhered to within our institution. Acute LC for GSP in suitable patients should be performed either during the index admission or within 2 weeks of presentation. A dedicated referral pathway for non-HPB surgeons should be implemented upon admission of suitable patients to ensure early specialist input. It should be feasible and cost neutral to instigate a regular urgent operating theatre session to provide this service. A similar service could extend to include patients suffering with acute cholecystitis. Although it should be acknowledged that the results of this study are exclusive to our institution; no other studies have identified rates of concordance with the guidance provided by the BSG, rather the feasibility of adherence to the guidelines. We therefore feel that this study highlights the importance of not only adherence to specific guidelines but also the use of audit as a valuable tool in the examination of local quality outcomes as a whole.
References 1. Sekimoto M, Takada T, Kawarada Y et al. JPN Guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis. J. Hepatobiliary Pancreat. Surg. 2006; 13: 10–24. 2. Gurusamy KS, Nagendran M, Davidson BR. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst. Rev. 2013; (9): CD010326.
4
3. Bouwense SA, Besselink MG, van Brunschot S et al. Pancreatitis of biliary origin, optimal timing of cholecystectomy (PONCHO trial): study protocol for a randomized controlled trial. Trials 2012; 13: 225. 4. Saeb-Parsy K, Mills A, Rang C, Reed JB, Harris AM. Emergency laparoscopic cholecystectomy in an unselected cohort: a safe and viable option in a specialist centre. Int. J. Surg. 2010; 8: 489–93. 5. Gutt CN, Encke J, Köninger J et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann. Surg. 2013; 258: 385–93. 6. Chang TC, Lin MT, Wu MH, Wang MY, Lee PH. Evaluation of early versus delayed laparoscopic cholecystectomy in the treatment of acute cholecystitis. Hepatogastroenterology 2009; 56: 26–8. 7. UK guidelines for the management of acute pancreatitis. Gut 2005; 54 (Suppl. 3): iii1–9. 8. Imrie CW, Benjamin IS, Ferguson JC et al. A single-centre double-blind trial of Trasylol therapy in primary acute pancreatitis. Br. J. Surg. 1978; 65: 337–41. 9. Monkhouse SJ, Court EL, Dash I, Coombs NJ. Two-week target for laparoscopic cholecystectomy following gallstone pancreatitis is achievable and cost neutral. Br. J. Surg. 2009; 96: 751–5.
Creedon et al.
10. van Baal MC, Besselink MG, Bakker OJ et al. Timing of cholecystectomy after mild biliary pancreatitis: a systematic review. Ann. Surg. 2012; 255: 860–6. 11. Johnstone M, Marriott P, Royle TJ et al. The impact of timing of cholecystectomy following gallstone pancreatitis. Surgeon 2014; 12: 134– 40. 12. El-Dhuwaib Y, Deakin M, David GG, Durkin D, Corless DJ, Slavin JP. Definitive management of gallstone pancreatitis in England. Ann. R. Coll. Surg. Engl. 2012; 94: 402–6. 13. de Mestral C, Rotstein OD, Laupacis A et al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis. Ann. Surg. 2014; 259: 10–5. 14. Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst. Rev. 2013; (6): CD005440.
© 2014 Royal Australasian College of Surgeons
