A prospective cohort study of 200 acute care gallbladder surgeries: The same disease but a different approach

From the Division of Acute Care Surgery, Department of Surgery, University of Arizona, Tucson, Arizona.
The journal of trauma and acute care surgery 10/2012; 73(5). DOI: 10.1097/TA.0b013e318265fe82
Source: PubMed

ABSTRACT BACKGROUND: For patients who present to the emergency department (ED) with symptomatic cholelithiasis, surgery is indicated only if they are diagnosed of acute cholecystitis (AC). We hypothesized that, because preoperative signs and diagnostic tests are not sensitive enough to diagnose AC, coupled with the potential health care burden of non-AC gallbladder, surgery may be offered sooner. METHODS: We prospectively evaluated 200 patients who presented to ED with clinical suspicion of gallbladder disease, including a right upper quadrant/epigastric abdominal pain and cholelithiasis, and who underwent laparoscopic cholecystectomy. We correlated the preoperative clinical findings, including ultrasonography results, with the surgeon's intraoperative assessment (OR-GB) and with the pathology report (PA-GB). A multiple logistic regression model was performed. RESULTS: Of the gallbladders, 116 were declared AC by OR-GB but only 54 by PA-GB, (r = 0.31, p < 0.001). The median time to surgery was 17 hours; 75% of the patients underwent surgery within 24 hours. The sensitivity of ultrasonography for AC according to PA-GB was 38%, and 16% when combined all preoperative findings. Both figures dropped to 27% and 11% when correlated to OR-GB. Our regression identified persistent abdominal pain, positive ultrasonography result, and a body mass index of greater than 40 to be significant predictors of AC according to PA-GB; however, only the persistent abdominal pain remained significant according to OR-GB. CONCLUSION: The study confirmed the lack of sensitivity of signs and diagnostic tools to diagnose AC. Because of the acute care surgery model, we believe that the approach to the patients who present to the ED with suspected gallbladder disease is to offer them surgery as soon as feasible, with or without AC. This approach will avoid an unnecessary delay as well as quickly relieve patient's pain and suffering; the health care system will benefit from a cost-effective reduction in number of outpatient referrals and repeated ED visits. LEVEL OF EVIDENCE: Diagnostic study, level II.

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Available from: Bellal Joseph, Sep 03, 2015
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    ABSTRACT: The acute care surgery (ACS) model has been shown to improve work flow efficiency and to reduce hospital stay. We hypothesized that, in patients with gallbladder (GB) disease who were admitted through our emergency department (ED) and then underwent surgery, the ACS model shortened the time to surgery, decreased the length of hospital stay, and reduced hospital costs. We retrospectively queried our GB surgery practice records for 2008 (before the establishment of the ACS model at our institution in 2009). We then performed time and cost comparison with our prospectively maintained GB surgery practice database for 2010. We excluded any inpatient GB surgeries and any GB surgeries that were performed for choledocholithiasis and acute pancreatitis. Our study was composed of 94 patients from the pre-ACS period (2008) and 234 patients from the ACS period (2010). Patients' baseline characteristics were similar between the two periods, except for a higher percentage of females in the ACS period (77% vs. 66%, p = 0.04). Approximately one third of patients from both periods had acute cholecystitis. In the ACS period, the mean time to surgery, that is, from ED arrival to operating room arrival, was shorter (20.8 [13.8] hours vs. 25.7 [16.2] hours, p = 0.007); more patients underwent surgery within 24 hours after ED arrival (75% vs. 59%, p = 0.004); and more patients underwent surgery between 12:00 midnight and 7:00 AM (25% vs. 6.4%, p < 0.001). As a result, hospital length of stay was 1.4 days shorter in the ACS period, with cost saving per patient of approximately $1,000. We found that implementation of ACS model led to benefits for patients who came to our ED with GB disease, including shorter time to surgery, shorter hospital stay, and decreased hospital costs. The ACS model benefits the health care system. Therapeutic study, level IV.
    03/2014; 76(3):710-714. DOI:10.1097/TA.0000000000000117
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    ABSTRACT: Introduction The current literature regarding hemorrhagic complications in patients on long-term antiplatelet therapy undergoing emergent laparoscopic cholecystectomy is limited. The aim of our study was to describe hemorrhagic complications in patients on pre-hospital aspirin (ASP) therapy undergoing emergent cholecystectomy. Methods We performed a one-year retrospective analysis of our prospectively maintained acute care surgery database. The two groups (ASP group vs. No-ASP group) were matched in a 1:1ratio for age, gender, previous abdominal surgeries, and co-morbidities. Primary outcome measures were: intra-operative hemorrhage, post-operative anemia, need for blood transfusion, conversion to open cholecystectomy. Intraoperative hemorrhage was defined as intraoperative blood loss of > 100 ml; post-op anemia was defined by > 2 g/dL drop in hemoglobin. Results A total of 112 [ASP: 56, No-ASP: 56] patients were included in the analysis. The mean age was 65.9±10 years, 50% were male. There was no difference in age (p=0.9), gender (p=0.9), and co-morbidities (p=0.7) between the two groups. There was no difference in intra-operative blood loss>100ml (p=0.5), post-operative anemia (p=0.8), blood transfusion requirement (p=0.9), and conversion to open surgery (p=0.7) between patients on ASA therapy and patients not on ASA therapy. Conclusion Emergent laparoscopic cholecystectomy is a safe procedure in patients on long term aspirin therapy. Pre-hospital use of aspirin therapy as an independent factor should not be used to delay emergent cholecystectomy. Level of Evidence Level III, Therapeutic Study, Retrospective Comparative Study.
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    ABSTRACT: Background Laparoscopic cholecystectomies may be performed at night in high-volume acute care hospitals. We hypothesized that non-elective nighttime laparoscopic cholecystectomies are associated with increased post-operative complications. Study Design We conducted a single-center retrospective review of consecutive laparoscopic cholecystectomy patients between October 2010 and May 2011 at a safety-net hospital in Houston, Texas. Data were collected regarding demographics, operative time, time of incision, length of stay, 30-day postoperative complications (bile leak/biloma, common bile duct injury, retained stone, superficial surgical site infection, organ space abscess, bleeding) and death. Statistical analyses were performed using STATA 12. Results Over 8 months, 356 patients had non-elective laparoscopic cholecystectomies. A majority were female (289, 81.1%) and Hispanic (299, 84%). There were 108 (30%) nighttime surgeries. There were 29 complications in 18 patients – there were fewer daytime than nighttime patients who had at least one complication (4.0 vs. 7.4%, p=0.18). On multivariate analysis, age (OR 1.06 per year, 95% CI 1.02 to 1.10, p=0.002), case duration (OR 1.02 per minute, 95% CI 1.01 – 1.02, p=0.001), and nighttime surgery (OR 3.33, 95% CI 1.14 – 9.74, p=0.001) were associated with an increased risk of 30-day surgical complications. Length of stay was significantly longer for daytime than nighttime patients (median 3 vs. 2 days, p<0.001). Conclusions Age, case duration, and nighttime laparoscopic cholecystectomy were predictive of increased 30-day surgical complications at a high-volume safety-net hospital. The small but increased risk of complications with nighttime laparoscopic cholecystectomy must be balanced against improved efficiency at a high-volume, resource-poor hospital.
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