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Outcomes after index cholecystectomy: a UK longitudinal multi-centre cohort Study
Aditya Borakati1, S Frances Hughes2, Hemant M Kocher2
1Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK.
Insights
Emergency cholecystectomy (EmC) reduces time to surgery for biliary pathology but increases length of stay and does not decrease re-attendances. Prioritizing patients who benefit most from EmC may be advantageous given theatre capacity constraints.
Area of Science:
- Gastroenterology
- Surgical Outcomes
- Health Services Research
Background:
- International guidelines recommend emergency cholecystectomy (EmC) for acute biliary pathology.
- This recommendation is based on trials that may not reflect real-world clinical capacity constraints.
- Patient selection for EmC may be influenced by prior emergency visits or decisions for elective surgery.
Purpose of the Study:
- To evaluate the justification of EmC in the context of clinical practice.
- To assess outcomes of EmC versus elective cholecystectomy (ElC) considering patient history and healthcare system capacity.
- To analyze time to surgery, re-attendance rates, and length of stay.
Main Methods:
- Longitudinal retrospective study of 2,056 patients undergoing cholecystectomy between 2016 and 2021 across four centers.
- Patients with emergency presentations of biliary pathology prior to surgery were included.
- Multilevel regression modeling identified predictors for time to surgery, re-attendance, and length of stay (LoS).
Main Results:
- EmC (13.1% of cases) was associated with a significant reduction in time to surgery (-112.32 days).
- However, EmC led to a significant increase in post-operative and overall LoS (+3.34 days).
- EmC did not significantly reduce emergency re-attendance rates prior to surgery.
Conclusions:
- While EmC expedites surgery, it increases length of stay and fails to reduce emergency re-attendance.
- Limited emergency theatre capacity necessitates prioritizing patients who gain the most benefit from EmC.
- The findings suggest a need to re-evaluate EmC protocols in resource-constrained environments.
Purpose:
International guidelines for management of acute biliary pathology recommend emergency cholecystectomy (EmC), citing improved outcomes compared to elective cholecystectomy (ElC) based on trials which may not reflect the capacity constraints in clinical practice, nor selection based on multiple prior attendances with emergency biliary pathology or attendances following a decision for ElC. We therefore conducted a longitudinal retrospective study evaluating all attendances with biliary pathology prior to cholecystectomy with the aim of assessing whether EmC is justified in this context.
Methods:
Data was collected on patients undergoing cholecystectomy between 2016 and 2021 at four centres. Patients who had an emergency presentation with a biliary pathology prior to cholecystectomy up to 2010 were included. Patients were divided into EmC and ElC groups, EmC was defined as cholecystectomy occurring during an emergency admission with biliary pathology. Multilevel regression modelling was used to identify independent predictors for time to surgery from index presentation, number of re-attendances and length of stay (LoS).
Results:
2,056 patients were included: 1,786 (86.9%) had ElC and 270 (13.1%) EmC. EmC was independently associated with a reduction in time to surgery (-112.32 days [95% CI -140.22 to -84.42]). However, there was a significant increase in both post-operative and overall LoS (+ 3.34 days [95% CI 1.81-4.86]) across all admissions with EmC. EmC did not significantly reduce rates of emergency re-attendance prior to surgery overall.
Conclusion:
Although EmC reduces time to surgery, it does not reduce the number of emergency re-attendances and increases LoS. In the context of limited emergency theatre capacity, it may be beneficial to prioritise those who benefit most from EmC.
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