Meta-analysis of the cost-effectiveness of early versus delayed cholecystectomy for acute cholecystitis

Management and patient outcomes following admission with acute cholecystitis in Ireland: A national registry-based study

INTRODUCTION

Acute cholecystitis is a common general surgical emergency, accounting for 3-10 % of all patients attending with acute abdominal pain. International guidelines suggest that emergency cholecystectomy is the treatment of choice for uncomplicated acute cholecystitis where feasible. There is a paucity of published data on the uptake of emergency cholecystectomy in Ireland.

AIM

The aim of this study was to evaluate the management of acute cholecystitis in Ireland and to establish the rate of emergency cholecystectomy performed.

METHODS

All patients with acute cholecystitis presenting to public hospitals in Ireland between January 2017 and July 2023 were identified using the National Quality Assurance and Improvement System (NQAIS). Data were collected on patient demographics, co-morbidities, length of stay, operative intervention, endoscopic intervention, critical care admissions, in-patient mortality, and readmissions. Propensity score matched analysis and logistic regression were performed to account for selection bias in comparing patients managed with cholecystectomy and those managed conservatively.

RESULTS

20,886 admission episodes were identified involving 17,958 patients. 3585 (20 %) patients underwent emergency cholecystectomy in total. 3436 (96 %) of these were performed laparoscopically, with 140 (4 %) requiring conversion to an open procedure, and common bile duct injuries occurring in 4 (0.1 %) of patients. In comparison to patients treated conservatively, patients who underwent cholecystectomy were younger (median 50 v 60 years, p < 0.001) and more likely to be female (64 % v 55 % p < 0.001). Following propensity score matched analysis, those who had an emergency cholecystectomy had reduced length of stay (LOS) (median 5 days (IQR 3-8) v 6 days (interquartile range (IQR) 3-10), p < 0.001) and fewer readmissions to hospital (282 (8 %) v 492 (14 %), p < 0.001). On logistic regression, age >65 (OR 1.526), CCI >3 (OR 2.281) and non-operative management (OR 1.136) were significant risk factors for adverse outcome.

CONCLUSION

Uptake of emergency cholecystectomy in Ireland remains low, and is carried out on a younger, fitter cohort of patients. In those patients, however, it is associated with improved outcomes for cholecystitis compared to conservative management, including shorter LOS and reduced readmission rates for matched cohorts.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

[Clinical and economic aspects of laparoscopic surgery for acute cholecystitis in delayed presentation]

OBJECTIVE

To study the clinical and economic features of laparoscopic surgery for acute cholecystitis in delayed presentation.

MATERIAL AND METHODS

A prospective non-randomized study (2020-2021) included 101 patients (73.2% (n=74) men and 26.8% (n=27) women, mean age 58±14.9 years) with acute cholecystitis who underwent laparoscopic cholecystectomy. Cost-effectiveness analysis of laparoscopic cholecystectomy at various periods after clinical manifestation was performed.

RESULTS

Surgical treatment within 72 hours was performed in 15% (n=16) of cases (group 1), within 4-10 days - in 57.5% (n=58) (group 2), after 10 days - in 26.7% (n=27) of patients (group 3). Overall incidence of postoperative complications was 2.9%, postoperative mortality - 1.9% (two patients died from widespread peritonitis). Surgery time was 70 [65-83], 85 [69-110] and 115 [80-125] min (H=15.55, p<0.001), hospital-stay - 6 [5-7], 9 [7-10] and 11 [7-14] days, respectively (H=21.86, p<0.001). Cost of direct (medical and non-medical) treatment amounted to 29484 [27 509-33 885], 41265 [34 306-48 301] and 50591 [37 069-62 483] rubles, respectively (H=29.71, p<0.001)).

CONCLUSION

Delayed hospitalization and surgical treatment of acute cholecystitis after 72 hours are accompanied by higher treatment costs by 29% in the period up to 10 days and by 58% after 10 days. These results require further validation and adjustment in large samples.

Cost analysis of index versus delayed cholecystectomy for acute cholecystitis in a New Zealand Provincial Centre

BACKGROUND

Evidence suggests index cholecystectomy (IC) in patients with acute cholecystitis is safe, has decreased hospital stay and is cheaper than delayed cholecystectomy (DC). Costs of cholecystectomy have not previously been investigated in New Zealand. The aim of this study was to compare cost of IC with DC for patients with acute cholecystitis.

METHODS

A retrospective analysis of adults admitted to Northland hospitals with acute cholecystitis between 1 January 2015 and 31 December 2019 who underwent subsequent cholecystectomy, was performed. Actual patient-level costs were utilized for cost comparison between IC and DC. Factors associated with increased costs were assessed using multivariate analysis.

RESULTS

Two hundred and eleven patients were included in the study; 72 (34%) underwent IC and 139 (65%) DC. There was no significant difference in total cost for IC ($12 767) versus DC ($12 029) (p = 0.192); this persisted on multivariate analysis. Patients having IC had more severe cholecystitis, and 90-day representation rate following DC was 35%. Costs were increased by severity of cholecystitis, age, American Society of Anesthesiology score (ASA) and travel distance.

CONCLUSION

This study showed there is no significant difference in cost between IC and DC for patients with acute cholecystitis in Northland, New Zealand. Severity, increasing age, ASA and travel distance were drivers of costs. To recognize the cost benefits of IC, it is likely that increased rates of IC are needed.

Effects of Individualized Nursing Based on Zero-Defect Theory on Perioperative Patients Undergoing Laparoscopic Cholecystectomy

Objective

This study is aimed at analyzing the effects of individualized nursing based on the zero-defect theory on perioperative patients undergoing laparoscopic cholecystectomy.

Methods

174 patients who underwent laparoscopic cholecystectomy from 1st November 2019 to 30th November 2020 were enrolled as the research subjects and randomly divided into control and observation groups. The patients in the control group received conventional perioperative nursing care, and the patients in the observation group were treated with individualized nursing based on the zero-defect theory.

Results

The heart rate, diastolic blood pressure, and systolic blood pressure level of patients in two groups after nursing decreased significantly, and the reduction in the observation group was more significant than that in the control group. The depression and anxiety scores of the two groups after nursing were decreased, and the decrease in the observation group was significantly greater than that in the control group. The time to first postoperative exhaust, return to normal intake, out-of-bed activity, and hospital stay in the observation group was less than that in the control group. The incidence of postoperative complications in the observation group was substantially lower than that in the control group. The satisfaction degree of nursing care in the observation group was significantly higher than that in the control group.

Conclusion

Individualized nursing care based on zero-defect theory can effectively reduce the perioperative psychological stress response of patients with laparoscopic cholecystectomy. It helps to improve the negative emotions of depression and anxiety, promotes the recovery of disease, reduces postoperative complications, and improves nursing satisfaction, which is worthy of clinical promotion.

Incremental net benefit of cholecystectomy compared with alternative treatments in people with gallstones or cholecystitis: a systematic review and meta-analysis of cost–utility studies

Introduction

Cholecystectomy is a standard treatment in the management of symptomatic gallstone disease. Current literature has contradicting views on the cost-effectiveness of different cholecystectomy treatments. We have conducted a systematic reappraisal of literature concerning the cost-effectiveness of cholecystectomy in management of gallstone disease.

Methods

We systematically searched for economic evaluation studies from PubMed, Embase and Scopus for eligible studies from inception up to July 2020. We pooled the incremental net benefit (INB) with a 95% CI using a random-effects model. We assessed the heterogeneity using the Cochrane-Q test, I2 statistic. We have used the modified economic evaluation bias (ECOBIAS) checklist for quality assessment of the selected studies. We assessed the possibility of publication bias using a funnel plot and Egger’s test.

Results

We have selected 28 studies for systematic review from a search that retrieved 8710 studies. Among them, seven studies were eligible for meta-analysis, all from high-income countries (HIC). Studies mainly reported comparisons between surgical treatments, but non-surgical gallstone disease management studies were limited. The early laparoscopic cholecystectomy (ELC) was significantly more cost-effective compared with the delayed laparoscopic cholecystectomy (DLC) with an INB of US$1221 (US$187 to US$2255) but with high heterogeneity (I2=73.32%). The subgroup and sensitivity analysis also supported that ELC is the most cost-effective option for managing gallstone disease or cholecystitis.

Conclusion

ELC is more cost-effective than DLC in the treatment of gallstone disease or cholecystitis in HICs. There was insufficient literature on comparison with other treatment options, such as conservative management and limited evidence from other economies.

PROSPERO registration number

CRD42020194052.

Preoperative risk factors for technical difficulty in emergent laparoscopic cholecystectomy for acute cholecystitis

AIM

We have routinely performed emergent laparoscopic cholecystectomy (LC) as soon as we diagnosed acute cholecystitis (AC), if patients could tolerate surgery. This study was conducted to identify the preoperative risk factors that predict the technical difficulty of emergent LC for AC.

METHODS

A retrospective review of patients with AC who underwent emergent LC between 2012 and 2019 was conducted. Technical difficulty was defined as the presence of the following conditions: open conversion, operative time ≥120 min, or blood loss ≥500 ml.

RESULTS

In all, 327 patients were included and divided into difficult LC (DLC, n = 61) and nondifficult LC (non-DLC, n = 266). Multivariate logistic analysis revealed that symptom duration ≥72 h was the only independent risk factor for DLC. Comparison of late LC (beyond 72 h, LLC) and early LC (within 72 h, ELC) showed a lower rate of creation of the critical view of safety and a longer hospital stay, as well as a longer operative time, a larger amount of bleeding, and a higher open conversion rate in LLC. However, the postoperative complication rates were equivalent.

CONCLUSION

LC for AC with symptom duration ≥72 h tends to be technically difficult. However, it is acceptable regarding operative outcomes.

The imaging diagnosis of cholecystitis in the adult ED: a comparative multi-reader, multivariable analysis of CT and US image features

PURPOSE

The purposes of this study are (1) to utilize multivariable logistic regression in order to evaluate which image feature combination is most predictive in the diagnosis of cholecystitis for computed tomography (CT) and ultrasound (US) in adult ED patients and (2) to use these results to compare the accuracy of CT and US.

METHODS

For RUQ pain patients undergoing US and CT at the same visit, multiple image features were evaluated independently by 2 radiologists blinded to additional data. Inter-reader variability was measured with the Kappa statistic. Sonographic Murphy's sign (SMS) information was obtained from original reports. Multivariable logistic regression was utilized to develop optimal predictive models for each modality. For US, models with/without SMS were compared to establish its relative value.

RESULTS

446 patients met inclusion criteria. For CT, the combination of cholelithiasis, short-axis gallbladder diameter > 3 cm, pericholecystic fluid or inflammation, and mural thickening > 3 mm provided the optimal model for both readers. For US, the optimal model included cholelithiasis, short-axis diameter > 3 cm, mural heterogeneity/striation, and sludge/debris for both readers. Kappa = 0.79-0.96 for included image features. For both readers, CT and US models had equivalent diagnostic performances; the SMS did not contribute significantly to US models.

CONCLUSION

For a diagnosis of cholecystitis in the ED, (1) the optimal image feature combination for CT is cholelithiasis, short-axis diameter > 3 cm, pericholecystic fluid or inflammation, mural thickening > 3 mm; and cholelithiasis, short-axis diameter > 3 cm, mural heterogeneity/striation, sludge/debris for US; (2) CT and US have equivalent diagnostic performance; (3) inter-reader reliability is substantial to excellent for utilized image features; (4) the SMS does not affect US model accuracy.

Laparoscopic cholecystectomy for acute cholecystitis: onset of symptoms and severity grade as a tool for choosing the optimal timing

BACKGROUND

Acute cholecystitis is an acute inflammation of the gallbladder. It represents one-third of all surgical emergency hospital admissions and has significant socioeconomic impact. Laparoscopic cholecystectomy, regardless of age, is the gold standard for this disease, but the optimal timing of surgical intervention is an open issue since Tokyo guidelines 2007.

METHODS

We recruited from March 2015 to June 2018, in a retrospective study, 144 patients with acute cholecystitis and treated with laparoscopic cholecystectomy. The patients were divided into two groups: group A (n=66), operated within 72 hours and group B (n=78), between 72 hours and 1 week after the onset of symptoms. After, the two groups were further stratified by the grade of severity of acute cholecystitis in according to Tokyo guidelines: in group A, 39 patients were grade I and 27 grade II; in group B, 48 patients were grade I and 30 grade II.

RESULTS

The operative time was longer in group B patients versus group A. In group B, there was a greater difficulty in dissecting and detecting the Calot's triangle, more conversions to open, a greater mean length of hospital stay and more post-operative days. In patients with grade II, especially in the group B, were greater inflammation stage, conversions to open, difficulty in the dissection of the Calot's triangle, mean length of hospital stay and post-operative days. The operative timing within 72 hours in patients with grade I, have only advantage in the mean length of hospital stay, while in grade II, the advantages are also in the lesser difficulty in dissecting the Calot's triangle, fewer conversions and fewer post-operative days.

CONCLUSIONS

Early laparoscopic cholecystectomy for acute cholecystitis should be performed considering not only the onset of symptoms, but above all the grade of severity of AC in according with TG. Grade II, particularly, must be treated within 72 hours and by experienced surgeon.

Fast track pathway provides safe, value based care on busy acute care surgery service

BACKGROUND

Fast track (FT) pathways have been adopted across a multitude of elective surgeries but have been slow to be adopted into the acute care surgery realm. We hypothesized that an FT pathway for acute cholecystitis patients would decrease patient length of stay and resource utilization.

METHODS

All patients at two hospitals, one with an FT pathway and one with a traditional pathway, who underwent an urgent laparoscopic cholecystectomy for acute cholecystitis between May 1, 2019, and October 31, 2019, were queried using CPT codes. Exclusion criteria were conversion to open or partial cholecystectomy. Retrospective chart review was used to gather demographics, operative, hospital course, and outcomes. Time to operating room, hospital length of stay, and resource utilization were the primary outcomes.

RESULTS

There was a total of 479 urgent laparoscopic cholecystectomies performed, 430 (89.8%) were performed under the FT pathway. The median (interquartile range [IQR]) time to the operating room was not different: 14.1 hours (IQR, 8.3-29.0 hours) for FT and 18.5 hours (IQR, 11.9-25.9 hours) for traditional (p = 0.316). However, the median length of stay was shorter by 15.9 hours in the FT cohort (22.6 hours; IQR, 14.2-40.4 hours vs. 38.5 hours; IQR, 28.3-56.3 hours; p < 0.001). Under the FT pathway, 33.0% of patients were admitted to the hospital and 75.6% were discharged from the postanesthesia care unit, compared with 91.8% and 12.2% on the traditional pathway (both p < 0.001). There were 59.6% of the FT patients that received a phone call follow up, as opposed to 100% of the traditional patients having clinic follow up (p < 0.001). The emergency department bounce back rate, readmission rates, and complication rates were similar (p > 0.2 for all). On multivariate analysis, having a FT pathway was an independent predictor of discharge within 24 hours of surgical consultation (odds ratio, 7.65; 95% confidence interval< 2.90-20.15; p < 0.001).

CONCLUSION

Use of a FT program for patients with acute cholecystitis has a significant positive impact on resource utilization without compromise of clinical outcomes.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

An analysis of the incidence, causes and preventative approaches to gram-negative bloodstream infections of hepatopancreatobiliary origin

Background

Gram-negative bloodstream infection (GNBSI) is a threat to public health in terms of mortality and antibiotic resistance. The hepatopancreatobiliary (HPB) cohort accounts for 15%-20% of GNBSI, yet few strategies have been explored to reduce HPB GNBSI.

Aim

To identify clinical factors contributing to HPB GNBSI and strategies for its prevention.

Methods

We performed a retrospective analysis of 433 cases of HPB GNBSI presenting to four hospitals between April 2015 and May 2019. We extracted key data from hospital and primary care records including: the underlying source of GNBSI; previous documentation of biliary disease; and any previous surgical or non-surgical management.

Findings

Out of 433 cases of HPB GNBSI, 388 had clear evidence of HPB origin. The source of GNBSI was related to gallstone disease in 282 of the 388 cases (73%) and to HPB malignancy in 70 cases (18%). Of the gallstone-related cases, 117 had previously been diagnosed with symptomatic gallstones. Of the 117 with a previous presentation, 93 could have been prevented with a laparoscopic cholecystectomy at the first presentation of gallstones, while 18 could have been prevented if intraoperative biliary tract imaging had been performed during a prior cholecystectomy. Of the 70 malignant cases, five could have been prevented through earlier biliary stenting, use of metal stents instead of plastic stents or earlier pancreaticoduodenectomy.

Discussion

The incidence of HPB GNBSI could be reduced by up to 30% by the implementation of alternative management strategies in this cohort.

Evaluating the advantages of treating acute cholecystitis by following the Tokyo Guidelines 2018 (TG18): a study emphasizing clinical outcomes and medical expenditures

BACKGROUND

Acute cholecystitis (AC) is a common surgical emergency. The Tokyo Guidelines 2018 (TG18) provides a reliable algorithm for the treatment of AC patients to achieve optimal outcomes. However, the economic benefits have not been validated. We hypothesize that good outcomes and cost savings can both be achieved if patients are treated according to the TG18.

METHOD

This retrospective study included 275 patients who underwent cholecystectomy in a 15-month span. Patients were divided into three groups (group 1: mild AC; group 2: moderate AC with American Society of Anesthesiologists (ASA) physical status class ≤ 2 and Charlson Comorbidity Index (CCI) score ≤ 5; and group 3: moderate AC with ASA class ≥ 3, CCI score ≥ 6, or severe AC). Each group was further divided into two subgroups according to management (followed or deviated from the TG18). Patient demographics, clinical outcomes, and hospital costs were compared.

RESULTS

For group 1 patients, 77 (81%) were treated according to the TG18 and had a significantly higher successful laparoscopic cholecystectomy (LC) rate (100%), lower hospital cost ($1896 vs $2388), and shorter hospital stay (2.9 vs 8 days) than those whose treatment deviated from the TG18. For group 2 patients, 50 (67%) were treated according to the TG18 and had a significantly lower hospital cost ($1926 vs $2856), shorter hospital stay (3.9 vs 9.9 days), and lower complication rate (0% vs 12.5%). For group 3 patients, 62 (58%) were treated according to the TG18 and had a significantly lower intensive care unit (ICU) admission rate (9.7% vs 25%), but a longer hospital stay (12.6 vs 7.8 days). However, their hospital costs were similar. Early LC in group 3 patients did not have economic benefits over gallbladder drainage and delayed LC.

CONCLUSION

The TG18 are the state-of-the-art guidelines for the treatment of AC, achieving both satisfactory outcomes and cost-effectiveness.

Early versus delayed cholecystectomy for cholecystitis at high risk of operative difficulties: A propensity score-matching analysis

BACKGROUND

Numerous studies have demonstrated the superiority of early (EC) over delayed (DC) cholecystectomy for acute cholecystitis (AC). However, none have assessed the effect of operative difficulty when reporting on treatment outcomes.

METHODS

Outcomes of patients who underwent EC or DC between 2010 and 2019 were compared taking into account the operative difficulty evaluated by the Difficult Laparoscopic Cholecystectomy score (DiLC). For each patient, the DiLC score was retrospectively calculated and corresponded to the foreseeable operative difficulty measured on admission for AC. A propensity score was used to account for confounders. Primary endpoints were the length of stay (LOS) and the occurrence of a serious operative/post-operative event (SOE).

RESULTS

DC in patients with DiLC≥10 reduced the risk of SOE without increasing the LOS. Conversely, DC in patients with DiLC<10 increased the LOS without improving outcomes. Multivariate analysis found EC in patients with DiLC≥10 as the main independent predictor of SOE.

CONCLUSIONS

Provided prospective validation, DC for AC in patients with DiLC≥10 seems safer than EC and is not hospital-stay consuming.

Does the Surgeon's Caseload Affect the Outcome in Laparoscopic Cholecystectomy for Acute Cholecystitis?

BACKGROUND

This study investigated how annual caseloads and the surgeon's previous experience influence the outcome in laparoscopic cholecystectomy (LCC) for acute cholecystitis.

METHODS

A total of 892 patients treated in Helsinki University Hospital in 2013-2016 were retrospectively analyzed. Surgeons were compared regarding volume-over 5 LCCs for acute cholecystitis a year versus 5 or fewer LCCs a year, and experience-attendings versus residents.

RESULTS

High-volume surgeons (n=14) operated faster than low-volume surgeons (n=62) (91 vs. 108 min, P<0.001). Examining only procedures with an attending present, high-volume attendings (n=7) converted less (14.9% vs. 32.0%, P<0.001) and operated faster (95 vs. 110 min, P<0.001) compared with low-volume attendings (n=41). The results of residents did not significantly differ from the results of attendings.

CONCLUSIONS

Attending surgeons, performing >5 LCCs for acute cholecystitis a year, have shorter operative times and lower conversion rates.