Prospective validation of an initial cholecystectomy strategy for patients at intermediate-risk of common bile duct stone

Iranmanesh, Pouya; Tobler, Olivier; Sousa, Sandra de; Frossard, Jean Louis; Morel, Philippe; Toso, Christian

doi:10.1016/j.gie.2016.08.015

Cited by 5 publications

(6 citation statements)

References 17 publications

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“…Initial LC for patients at intermediate risk of CBD stones has been shown to reduce LOS and cost without compromising patient outcomes. 26,27 Integration of both of these facets of care into perioperative management protocols is therefore important. Modifiable risk factors for increased intraoperative time include the operative grade, meeting operative acuity, and the procedure type.…”

Section: Discussionmentioning

confidence: 99%

“…Despite improved performance over ad hoc, clinical decision making their use in practice is not routine. Initial LC for patients at intermediate risk of CBD stones has been shown to reduce LOS and cost without compromising patient outcomes 26,27 . Integration of both of these facets of care into perioperative management protocols is therefore important.…”

Section: Discussionmentioning

confidence: 99%

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Standardizing process in acute biliary disease

Tranter‐Entwistle,

Eglinton,

Connor

2023

World j. surg.

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IntroductionThe perioperative management of biliary disease (BD) is variable across institutions with suboptimal outcomes for patients and health care systems. This results in inefficient utilization of limited resources. The aim of the current study was to identify modifiable factors impacting patients' time to theater, intraoperative time, and time to discharge as the constituents of length of stay to guide creation of a perioperative management protocol to address this variability.MethodsData were prospectively captured at Christchurch Hospital for all adult patients presenting for cholecystectomy between May 2015 and May 2022. Pre, post, and intraoperative factors were assessed for their impact on time to theater, operative time, and postoperative hours to discharge.ResultsFour thousand five hundred seventy‐seven patients underwent cholecystectomy during the study period, of which 2807 (61%) were acute presentations and made up the cohort for analysis. Time to theater was significantly impacted by preoperative imaging type, while operative grade and the procedure type had the most clinically significant impact on operative time. Postoperatively time to discharge was significantly impacted by drain placement.ConclusionsStandardizing management of BD would likely result in significant savings for the health care system and improved outcomes for patients. The data seen here evidence the importance of appropriate imaging selection, intraoperative difficulty operative grade identification, and low suction drain selection. These data have been incorporated in a perioperative management protocol as standardization of care across the patient workflow in BD is a sensible approach for ensuring optimal use of scarce resources.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Standardizing process in acute biliary disease

Tranter‐Entwistle,

Eglinton,

Connor

2023

World j. surg.

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“…Given this variation a number of algorithms have sought to formalise decision making [5, 6, 20–22]. Though there is data to suggest clinical algorithms are superior to clinician gestalt there is significant variance in practice [12, 23]. Furthermore, low accuracy and difficult point of care deployment has impeded algorithm uptake [22].…”

Section: Introductionmentioning

confidence: 99%

“…Current guidelines recommended magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) for those at intermediate risk of choledocholithiasis, with an aim to minimise the cost and complications of negative ERCP [6,[8][9][10][11]. However, the clinical equipoise is such that some clinicians have suggested intermediate risk patients go directly for laparoscopic cholecystectomy, with promising results [12]. Reflecting, as illustrated by Tranter et al that 73% of CBD stones will pass regardless of intervention [13].…”

Section: Introductionmentioning

confidence: 99%

The Challenges of Implementing Artificial Intelligence into Surgical Practice

et al. 2020

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Background Artificial intelligence is touted as the future of medicine. Classical algorithms for the detection of common bile duct stones (CBD) have had poor clinical uptake due to low accuracy. This study explores the challenges of developing and implementing a machine‐learning model for the prediction of CBD stones in patients presenting with acute biliary disease (ABD). Methods All patients presenting acutely to Christchurch Hospital over a two‐year period with ABD were retrospectively identified. Clinical data points including lab test results, demographics and ethnicity were recorded. Several statistical techniques were utilised to develop a machine‐learning model. Issues with data collection, quality, interpretation and barriers to implementation were identified and highlighted. Results Issues with patient identification, coding accuracy, and implementation were encountered. In total, 1315 patients met inclusion criteria. Incorrect international classification of disease 10 (ICD‐10) coding was noted in 36% (137/382) of patients recorded as having CBD stones. Patients with CBD stones were significantly older and had higher aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin and gamma‐glutamyl transferase (GGT) levels (p < 0.001). The no information rate was 81% (1070/1315 patients). The optimum model developed was the gradient boosted model with a PPV of 67%, NPV of 87%, sensitivity of 37% and a specificity of 96% for common bile duct stones. Conclusion This paper highlights the utility of machine learning in predicting CBD stones. Accuracy is limited by current data and issues do exist around both the ethics and practicality of implementation. Regardless, machine learning represents a promising new paradigm for surgical practice.

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“…A subsequent prospective validation study by the same investigators reached similar conclusions. 11 However, use of IOC may be decreasing, which may be attributable at least in part to the increasing use of preoperative biliary imaging and ERCP. [12][13][14] In summary, implementation of high-value care in the management of suspected choledocholithiasis requires accurate stratification into high-, intermediate-, and low-probability categories.…”

mentioning

confidence: 99%