Ravi VohraWest Midlands Research Collaborative

Clinical Variation in Practice of Laparoscopic Cholecystectomy and Surgical Outcomes: a multi-centre, prospective,

population-based cohort study

Why?

• Management varies widely between surgeons and hospitals– Acute vs. Elective

• Cholecystectomy is common

• 66,000 cholecystectomies were performed during the 2011-12 financial year in England alone

• Trainees are involved in

Evidence?

• Level 1 evidence support early or acute laparoscopic cholecytectomy in:

– Biliary colic (1 RCT, n=75)

– Cholecystitis (6 RCTs, n=488)

– Gallstone pancreatitis (1RCT, n=303)

(Meta-analysis)

Retrospective data

Harrison et al. BMJ, 2012;344:e3330

Sinha et al. Surg Endosc, 2013;27(1):162-75.

Nottingham CCG

AUGIS/RCS 2013

Aim

• Hypothesis: Within the UK different practices are being adopted resulting in important differences in surgical outcomes

• To investigate surgical outcomes following acute, ‘delayed’ and elective cholecystectomies

• Multi-centre, contemporary, prospective, cohort study

• Audit standard: All-cause 30-day readmission rate should be less than 10% following cholecystectomy (primary outcome measure)

Methods

• Two-month period (March- April 2014) with 30 day follow up

• All patients undergoing cholecystectomy– Acute (first acute admission with biliary disease through A&E or GP

and cholecystectomy performed during that index admission)

– Elective (planned elective admission for cholecystectomy who have been referred from their GP and added to the routine surgical waiting list from the outpatient department only

– Delayed (all other planned cholecystectomies).

Post-operative data• In-hospital complications• In-hospital re-interventions and re-

imaging• Date of discharge 30-day data• All-cause A&E attendance• All-cause 30-day readmission• Date of re-admission• Complications• Re-interventions and re-imaging• Date of discharge following readmission• 30-day mortality

Preoperative• Age; Gender, BMI, ASA• Current Admission Date• Operation Date• Timing of Surgery• Pre-operative indication• Number of previous surgical admissions• Investigations

Intra-operative data• Seniority of surgeons• Speciality of surgeon• Perioperative antibiotics• Method of operation• Degree of difficulty• Complications• Intraoperative cholangiography• CBD exploration performed• Abdominal drain left at the end

28 Data points

One week, 5 centres• 34 Choles• All laparoscopic• Range 0 - 15 procedures• LoHS 1 day (0-5 days)

Pilot

Acute Delayed Elective02468

101214161820

Lap

Conclusion

Population-based cohort study

Determine variation and impact on surgical outcomes in a non-trial cohort

‘The Power of Many’

West Midlands ~1500

England ~ 10,000

UK ~ 12,000

Ewen.griffiths@uhb.nhs.uk

Ravinder.vohra@uhb.nhs.uk

www.choles-study.org