A survey of the timing and approach to the surgical management of cholelithiasis in patients with acute biliary pancreatitis and acute cholecystitis in the UK

Abstract

[306][307][308][309][310][311][312] Audit weeks. This would take the form of a cholecystectomy (and bile duct clearance if necessary) in fit patients and an endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy in the unfit. Indeed the risk of recurrence of acute biliary pancreatitis in the presence of cholelithiasis could be as high as 60% within 6 months. 3Endoscopic sphincterotomy significantly reduces the risk of recurrent acute biliary pancreatitis in unfit patients to 2-5% at 2 years. [4][5][6] In the management of acute cholecystitis, the conventionally adopted approach of conservative treatment and interval cholecystectomy has its distinct disadvantages. Whilst the majority of patients respond to such treatment approach, up to one-fifth of patients fail to do so and require an urgent cholecystectomy. [7][8][9] Moreover, up to one-quarter of patients who have recovered from acute cholecystitis relapse while awaiting an interval cholecystectomy. 7 In a randomised controlled trial of early versus delayed open cholecystectomy for acute cholecystitis some 25 years ago, Lahtinen and colleagues 7 found early surgery to be safe and associated with significantly shorter operating time, and had avoided the complications of failed medical treatment. A number of recent randomised clinical trials have addressed the timing and surgical approach to cholecystectomy in patients with acute cholecystitis, 9-13 and demonstrated that laparoscopic cholecystectomy performed during the index admission with acute cholecystitis was associated with a shorter hospital stay, 9,11-13 quicker recovery, 9 and a reduction in the overall treatment cost when compared with open cholecystectomy during the index admission with acute cholecystitis 12 or interval laparoscopic cholecystectomy. 9,11,13 Moreover, early laparoscopic cholecystectomy was safe, and earlier reports of increased risk of bile duct injuries 14 were not substantiated by more recent experiences. 9,11,13,15 The aims of this study, therefore, were to survey the currently adopted practice of the UK surgeons in the surgical management of acute biliary pancreatitis and acute cholecystitis, to evaluate the impact of various subspecialty interests on the practice adopted, and to suggest pathways towards a better implementation of the guidelines and other evidence-based management approaches. Materials and MethodsThe names and addresses of the practising members of the Association of the Surgeons of Great Britain and Ireland were obtained from the Association's office, and a postal questionnaire was sent to its 1086 current members. The survey included a general questionnaire, as well as a questionnaire that addressed the current practice adopted by each surgeon in relation to the timing and approach to the surgical management of acute biliary pancreatitis and acute cholecystitis (see Appendix). The reply to the questionnaire was anonymous. Statistical analysisThe replies were compiled on a computer database for analysis. Data were analysed using SPS...

Urgent Cholecystectomy for Acute Cholecystitis in a District General Hospital – Is it Feasible?

“…Only 15-20% of surgeons have adopted the policy of urgent cholecystectomy during the index admission. 29,30 The perceived risk of higher complications (particularly bile duct injury and conversion rates) may be responsible for the unpopularity of early laparoscopic cholecystectomy. Other possible contributory factors could be the delays caused by availability of emergency operating lists and the radiology investigations, which essentially means that the surgeons miss the 'window of opportunity' for surgical intervention.…”

Outcomes of early cholecystectomy (within 7 days of admission) for acute cholecystitis according to diagnosis and severity grading by Tokyo 2013 Guideline

“…Recently, early laparoscopic cholecystectomy is suggested as the first line treatment in acute cholecystitis (11). Unfortunately, the rate of early cholecystectomy in patients with acute cholecystitis still remains low (15-40%) (14)(15)(16). In our hospital, the most preferred clinical application is interval cholecystectomy, except our group.…”

“…Although several guidelines suggest ELC in acute cholecystitis (10)(11)(12)(13), the rate of early cholecystectomy still remains low i.e. 15-40% (14)(15)(16).…”

Single center retrospective analysis of early vs. delayed treatment in acute calcolous cholecystitis: application of a clinical pathway and an economic analysis

“…In 2007, the first international guidelines for the treatment of ACC were published, called Tokyo Guidelines (TG), [13] in order to uniform the management of this common pathology among the world surgical community. However, data available at this time still show that up to 80% of the patients with ACC have not received definitive surgical treatment during the first hospital admission [14][15][16][17][18] although early treatment has been proved to be better. On the basis of this debate, we performed a retrospective analysis of the patients admitted to our institution with non-complicated ACC during the last six years, and we also had the opportunity to match two different modalities, DLC vs ELC, for the treatment of ACC.…”