Index Admission Laparoscopic Cholecystectomy, Our Experience after the Inception of Acute Care Surgery Programme

Abstract

Background: Gallstones are very common and frequently present as acute cholecystitis in up to 20 % of patients with symptomatic disease, with wide variation in severity. Laparoscopic Cholecystectomy (LC) has become the gold standard for treatment of symptomatic disease. Although multiple studies have confirmed its safety, LC at index admission is still not widely practiced in Ireland. We present our experience of a cohort of patients who underwent index admission laparoscopic cholecystectomy at Cork University Hospital since the start of the acute care surgery program in May 2017.Aim: To determine the feasibility and safety of laparoscopic cholecystectomy at index admission.Methods: All adult patients who presented to an acute surgical assessment unit (ASAU) with symptomatic gall stone disease and underwent early laparoscopic cholecystectomy at index admission were included. The duration of this prospective cohort study was 27 months (May 2017 to July 2019). Patient demographics, indication for surgery, post-operative complications and conversion rates were recorded. In addition, timing of imaging, imaging findings and length of hospital stay were also noted.Results: A total of 233 patients underwent laparoscopic Cholecystectomy at index admission for various indications. Median age was 50 years with range between 16 - 88. Male to female ratio was 1: 1.78. 142 (61%) patients had acute cholecystitis, while the other indications were CBD obstruction (15.5%), biliary colic (11%) and acute biliary pancreatitis (10.5%). 93 (40%) patients had pre-op MRCP while 41 (17.6%) underwent pre-op ERCP. All except 3 patients undergoing ERCP had pre-procedure MRCP. 2 patients had intra-operative cholangiograms. Overall morbidity was 4.7%. In terms of complications, 3 (1.3%) patients had bile leak and only 1 (0.85%) had re-operation. There was 1 common bile duct injury and only 1 conversion to open surgery. There was no mortality in this case series. The average length of hospital stay was 5.6 days. (Range 2 to 14 days).Conclusions: Index admission laparoscopic cholecystectomy for acute cholecystitis, choledocholithiasis, biliary colic and acute biliary pancreatitis, has been a safe and feasible treatment option in our hospital. A safe practice can be ensured by adherence to this care pathway and a multidisciplinary, consultant-led service. Index cholecystectomy service can be provided safely to reduce disease-related morbidity and multiple re-admissions in patients awaiting interval surgery.