scholarly journals P-EGS07 Two years of Acute Biliary Admissions at a tertiary care centre over the Covid-19 pandemic: a closed loop audit with implementation of an acute referral system

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Andrew Refalo ◽  
Annabelle White ◽  
Hedda Widlund ◽  
Husam Ebied
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Acute Cholecystitis ◽  
Patient Outcomes ◽  
Waiting Times ◽  
Tertiary Care ◽  
Referral System ◽  
Biliary Colic ◽  
Gallstone Pancreatitis ◽  
Tertiary Care Centre ◽  
Readmission Rates

Abstract Background AUGIS recommends patients diagnosed with acute cholecystitis and gallstone pancreatitis to receive a laparoscopy cholecystectomy on the index admission, ideally within 72 hours of presentation. Early laparoscopic cholecystectomy is associated with better patient outcomes and reduced readmission rates. During the Covid-19 pandemic emergency surgery, if possible was avoided. These patients are referred for an elective cholecystectomy, however waiting times can be lengthy with readmissions common prior to surgery.  Methods We performed a closed loop audit on acute biliary admissions to a central London tertiary care centre. We assessed waiting times to laparoscopic cholecystectomy for patients fit for surgery as well as readmissions prior to surgery. The data was collated over a one-year period (01/03/2019 to 29/02/2020), analysed and presented to the senior biliary surgery team. A dedicated e-referral system for patients who did not receive a laparoscopic cholecystectomy on index admission was implemented. Post intervention admissions were re-audited over a second year (01/03/2020- 30/01/2021) and re-analysed to assess the effect of the intervention.   Results A total of 111 patients with acute cholecystitis, 52 with gallstone pancreatitis, 34 with biliary colic, 36 with choledocholithiasis and 10 with ascending cholangitis, were included. Prior to implementation of our referral system average waiting time to laparoscopic cholecystectomy was 98.2 weeks, reduced to 47.7 weeks post referral system implementation. Reduction in waiting times resulted in readmission rates reduced by: 23.3% in Choledocholithiasis; 17.4% in Biliary Colic;   16.7% in Ascending Cholangitis; 12.8% in Acute Cholecystitis and 8.3% in Gallstone pancreatitis.  Conclusions Admissions with acute biliary colic compose a substantial workload. The COVID-19 pandemic has resulted in a preference for elective versus emergency laparoscopic cholecystectomy. However, delay in surgery results in a readmission burden on emergency surgery departments and worse patient outcomes hence laparoscopic cholecystectomy should be performed as soon as possible following initial admission. This audit demonstrates that a dedicated biliary referral system reduced waiting time which translates to a reduction in admission rates. The importance of this referral system is magnified in the recovery phase of the pandemic where we continue to recover waiting times.

scholarly journals Laparoscopic cholecystectomy during COVID-19 pandemic- Retrospective analysis of tertiary care centre

2021 ◽  
Vol 2 (2) ◽  
pp. 82-86
Author(s):  
Uttam Laudari ◽  
Rosi Pradhan ◽  
Dibesh Shrestha ◽  
Bibek Timilsina ◽  
Suhail Sapkota ◽  
...  
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Retrospective Analysis ◽  
Infection Prevention ◽  
Open Cholecystectomy ◽  
Gallbladder Disease ◽  
Tertiary Care ◽  
Infection Prevention And Control ◽  
Biliary Colic ◽  
Tertiary Care Centre ◽  
Duration Of Hospitalization

INTRODUCTION: Laparoscopic cholecystectomy is the most commonly performed general surgical procedure. During the COVID-19 pandemic, general recommendation worldwide is to postpone elective surgeries as far as possible to decrease the resource utilization and also aerosol-related transmission among hospital staff and patients. We conducted this study to see the burden of gallbladder disease, their management and outcomes of all patients who presented to our centre during first wave of COVID-19 pandemic. METHODS: We conducted a retrospective analysis of all patients who underwent laparoscopic cholecystectomy at the Hospital for Advanced Medicine and Surgery (HAMS) after the commencement of strict lockdown in the first wave of the COVID-19 pandemic. Ethical approval for the study was taken from Nepal Health Research Council. All the surgeries were performed as per HAMS interim policy for infection prevention and control during the COVID-19 pandemic. Data were extracted from the discharge sheet and outcomes in terms of duration of hospitalization, morbidity, mortality, and COVID -19 infection among patient and operating team staff after surgery were assessed. RESULTS: Out of 110 cases operated for gallbladder disease, 90 patients were included in the study with complete data. The most common presentations were dyspepsia (28) and biliary colic (22). Patients were managed with laparoscopic cholecystectomy (79), percutaneous cholecystostomy (4), laparoscopic subtotal cholecystectomy (5), open cholecystectomy (1). The median duration of hospitalization 22 hours. There was no COVID-19 transmission among staff and patients. CONCLUSIONS: Laparoscopic cholecystectomies are feasible during COVID-19 pandemic and safely performed following infection prevention guidelines. It can be still be performed in day case basis to decrease the bed occupancy and avoiding crowd in hospitals.  

EP.TH.649Identifying Factors Associated with Readmissions after acute biliary admission. Can it help prioritising patients in COVID recovery plans?

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Annabelle White ◽  
Andrew Refalo ◽  
Hedda. Widlund ◽  
William Knight ◽  
Husam Ebied
Keyword(s):  
Acute Cholecystitis ◽  
Health Care Services ◽  
Biliary Colic ◽  
Gallstone Pancreatitis ◽  
Biliary Disease ◽  
Readmission Rates ◽  
Patient Demographics ◽  
Care Services ◽  
Increased Risk ◽  
Biliary Pathology

Abstract Aim We conducted a retrospective analysis of readmissions after Acute admission with biliary pathology managed conservatively under the Surgical Team in a teaching London Hospital from 01/03/2019-29/02/2020 Methods We obtained records of patients admitted with Acute Cholecystitis, Biliary Colic, Cholelithiasis, Choledocholithiasis and Gallstone Pancreatitis from the Audit Department between 01/03/2019-29/02/2020, and analysed these regarding patient demographics, comorbidities, duration of index admission, method of diagnosis and management and identified patients’ readmissions Differences in readmission rates based on before mentioned characteristics were studied. Results 157 patients presented between 01/03/2019-29/02/2020, 76 acute cholecystitis, 22 Biliary Colic, 24 Gallstone Pancreatitis, 6 Ascending Cholangitis and 29 Choledocholithiasis The highest representation rate was for patients with choledocholithiasis (41.3%) followed by Acute Cholecystitis (31.5%), 3 patients required cholecystostomies. Baseline characteristics and differences in these characteristics based on occurrence of readmission were studied. 45-60 age group, increasing comorbidity, and biliary obstruction were all associated with increased risk of readmission. Conclusion Readmissions is a substantial burden on the health care services and patient’s safety and QoL We propose adherence to the NICE/BSG Guidelines for management of Acute Biliary Disease, to alleviate this pressure which is already sometimes challenging due to the logistics and resources and would be more challenging with the COVID situation and limited emergency and elective theatre availability so the group at high risk of readmission should be prioritised in the recovery plans.

scholarly journals P73 Trends in ultrasound guided musculoskeletal injections at one tertiary care centre over 6 years

Rheumatology ◽  
2020 ◽  
Vol 59 (Supplement_2) ◽  
Author(s):  
Kunal Lall ◽  
Vivian Ejindu ◽  
Patrick D. W Kiely
Keyword(s):  
Soft Tissue ◽  
Time Pressure ◽  
Waiting Times ◽  
Tertiary Care ◽  
Fold Increase ◽  
Ultrasound Guided ◽  
Tertiary Care Centre ◽  
The Impact ◽  
Effective Service

Abstract Background Ultrasound (US) has brought many benefits into rheumatologic practice, delivery of targeted injections into joints, bursae and other structures. Whilst many joints may be accurately injected in clinic, guided by clinical landmarks, US permits injections into anatomically less accessible sites. We have assessed trends in the number and type of requests for US guided joint or soft tissue injections from the rheumatology department over the last 6 years, and the impact on waiting times. Methods Details of all requests for US guided joint or soft tissue injections were obtained from the St George’s PACS system from 1 January 2013 - 31 December 2018. Review of patient records was conducted to determine whether the referral was routine or urgent, the waiting time between referral and appointment, the joint or structure to be injected, and whether an injection into the requested site was actually performed. Results Table 1 shows the total number of out-patient attendances in rheumatology per year from 2013 - 2018, the number of referrals for US-guided injection, the proportion requested urgently and waiting times for routine and urgent cases. Over 6 years requests for US guided injections have risen 2.3-fold, from <1% to nearly 2% of all out-patient attendances. Of 1834 requests, no injections were given in 420 instances (23%), due to patient preference or lack of indication at time of US. In 2018 of all joint or tendon/bursa injections initiated in rheumatology, 260 (38%) were given in routine clinic time without delay, and 420 (62%) were requested by US with a delay of over 2 months. Conclusion Over 6 years a 33% increase in out-patient clinic workload has been accompanied by a disproportionate 2.3-fold increase in requests for US guided injections, representing >50% of injections initiated by the service. One explanation may be time pressure in clinic. This trend has not been matched by increased radiology capacity, with urgent requests now waiting >6 weeks. This has implications for quality of care, staffing and effective service delivery. The trend to fewer injections in clinic will continue if clinicians become increasingly reliant on radiology colleagues. Disclosures K. Lall None. V. Ejindu None. P.D.W. Kiely None.

scholarly journals Acute Laparoscopic Cholecystectomy: Delays in Acute Surgery and Cost Analysis of Aproposed New Service

2011 ◽  
Vol 93 (7) ◽  
pp. 261-265
Author(s):  
AJ Cockbain ◽  
AL Young ◽  
E McGinnes ◽  
GJ Toogood
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Acute Cholecystitis ◽  
Meta Analysis ◽  
Gallstone Disease ◽  
Cochrane Review ◽  
Length Of Hospital Stay ◽  
Biliary Colic ◽  
Complication Rates ◽  
Acute Surgery ◽  
Symptomatic Gallstone Disease

Acute laparoscopic cholecystectomy (ALC) is widely considered the most appropriate management for patients presenting with acute cholecystitis as supported by a recent meta-analysis and Cochrane review. Although the benefit of ALC is less clear in patients with biliary colic, few would disagree that earlier cholecystectomy is preferable for most patients with symptomatic gallstone disease. ALC has similar complication rates to elective laparoscopic cholecystectomy (ELC) and a reduced total length of hospital stay. Recurrent symptoms from untreated gallstone disease are common, with the risk of developing more severe complications such as acute cholecystitis, acute pancreatitis or cholangitis while waiting for an operation. It has been reported that patients awaiting ELC after an acute admission have significantly more general practitioner (GP) attendances than those who receive ALC, that they have an average of one emergency department attendance for symptom recurrence and that one in six requires hospital admission due to the severity of recurrent symptoms.

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

2020 ◽  
Author(s):  
Muhammad Aakif ◽  
Zeeshan Razzaq ◽  
James Byrne ◽  
Hamid Mustafa ◽  
Mudassar Majeed ◽  
...  
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Acute Cholecystitis ◽  
Length Of Hospital Stay ◽  
Index Admission ◽  
Acute Care Surgery ◽  
Biliary Colic ◽  
Biliary Pancreatitis ◽  
Acute Biliary Pancreatitis ◽  
Symptomatic Disease ◽  
Care Surgery

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.

scholarly journals Gallbladder perforation: management in a tertiary care centre

2018 ◽  
Vol 5 (10) ◽  
pp. 3346
Author(s):  
Prashant Tubachi ◽  
K. Sphurti Kamath ◽  
Mallikarjun Desai ◽  
Harsha Kodliwadmath
Keyword(s):  
Surgical Treatment ◽  
Acute Cholecystitis ◽  
Computerized Tomography ◽  
Open Cholecystectomy ◽  
Tertiary Care ◽  
Diagnostic Procedures ◽  
Gallbladder Perforation ◽  
Type I ◽  
Tertiary Care Centre ◽  
Intravenous Antibiotics

Background: Retrospective study in the management of perforated gallbladder and clinical outcome in a tertiary care centre.Methods: Total of 583 patients underwent laparoscopic or open cholecystectomy between 2015 to 2017. Out of these eleven patients had perforated gallbladder (1.9%). Niemeier’ classification used for gallbladder perforation. Both Ultrasonography and Abdominal computerized tomography was used in this study. The parameters like age, gender, method of management, diagnostic procedures, time between date of admission to time of surgery, surgical treatment, duration of hospital stay and post-operative morbidity were evaluated.Results: Out of the eleven cases, eight patients were male and three were female. Nine patients were above the age of fifty years. According to Niemer classification, seven patients had type I perforation, three patients had type II perforation and one had type one perforation. Out of the eleven cases, eight were clinically diagnosed to be acute cholecystitis and three were clinically diagnosed to have peritonitis. The cases diagnosed to have peritonitis- underwent immediate intervention. The remaining eight cases were initially managed conservatively with intravenous antibiotics, imaging and workup was done, following which intervention was done.Conclusions: Early diagnosis and emergency surgical treatment of gallbladder perforation with peritonitis is of crucial importance. If the patient is stable then intervention after optimising has better outcome. Abdominal computerized tomography for acute cholecystitis patients may contribute to the preoperative diagnosis of gallbladder perforation. 

scholarly journals P-EGS14 From Gallstone Disease to Cholecystectomy: An audit looking at the waiting times for cholecystectomy in a small District General Hospital

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Jacob Mewse ◽  
Virginia Ledda ◽  
Ellie Connor ◽  
Peter Frank Mason
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Waiting Time ◽  
Negative Impact ◽  
Elective Surgery ◽  
Waiting Times ◽  
Gallstone Disease ◽  
Gastrointestinal Surgery ◽  
Emergency Operation ◽  
Biliary Colic ◽  
Emergency General Surgery

Abstract Background Gallstone-related disease accounts for a third of emergency general surgery admissions and referrals. The average waiting time for acute gallstone presentations to laparoscopic cholecystectomy is about 7 days in England. This audit aims to identify emergency admissions and compare local management to the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) guidelines standards with a focus on waiting times for laparoscopic cholecystectomy (LC). Where AUGIS standards were not met, number of re-admissions and complications were identified. A cost analysis was also completed looking at the overall costs of delayed treatment. Methods We identified all patients admitted as an emergency between September 2019 and September 2020 with gallstone-related pathology. Patients not referred to the surgical team, with negative Ultrasound Scans (USS) or known HPB malignancy were excluded. The patients were divided into a pre- COVID -19 and during COVID-19 category (respectively before and after March 2020), to identify whether the cancellation to non- urgent elective surgery (due to COVID-19) had caused further delays or complications. Each patient’s management was compared to AUGIS guidelines depending on their diagnosis at presentation (biliary colic, cholecystitis, cholangitis, gallstone-related pancreatitis), focusing on the timing between presentation and LC. Results A total of 99 patients were identified. Of the patients presenting with biliary colic (n = 9 pre-COVID, n = 5 during COVID), none underwent LC within 72 hours from presentation as recommended by AUGIS. Of the patients presenting with cholecystitis (n = 20 pre-COVID and n = 16 during COVID), none had LC within the recommended 72 hours. 5 patients in each COVID group had LC, with a significantly longer waiting time compared to the pre-COVID group. Re-admissions and complications were similar for the cholecystitis patients in both COVID groups. In the gallstone-related pancreatitis group, only 1 patient underwent LC within the recommended 2 weeks. Conclusions This audit showed that locally we are failing to meet AUGIS guidelines for LC within 72 hrs, 2 weeks or 6 weeks both pre and during COVID. This has caused re-admissions of patients with cholecystitis, pancreatitis and perforated gallbladders. Factors that cause delay are limited access to USS, limited staff and theatre availability. To improve outcomes, it is necessary to implement a hot gallbladder service with dedicated theatre slots. A change in the overall perception of LC is also needed: this is should be considered an emergency operation as its delay has a significant negative impact on patients’ outcomes.

scholarly journals A predictive grading scale for acute cholecystitis

2019 ◽  
Vol 4 (1) ◽  
pp. e000324
Author(s):  
Sammy Siada ◽  
David Jeffcoach ◽  
Rachel C Dirks ◽  
Mary M Wolfe ◽  
Amy M Kwok ◽  
...  
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Length Of Stay ◽  
Systemic Inflammatory Response Syndrome ◽  
Inflammatory Response ◽  
Acute Cholecystitis ◽  
Hospital Length ◽  
Systemic Inflammatory Response ◽  
Hospital Length Of Stay ◽  
Gallstone Pancreatitis ◽  
Grading Scale

BackgroundAcute cholecystitis presents in a spectrum of severity, where acute disease may be complicated by severe inflammation, gangrene, and perforation. The goal of this study is to outline an evidence-based grading scale that predicts patient outcomes after laparoscopic cholecystectomy (LC).MethodsA retrospective review of all patients with a preoperative diagnosis of acute cholecystitis who underwent LC from August 2011 until June 2015 at a tertiary-level hospital was performed. Patients who underwent elective cholecystectomy, incidental cholecystectomy, a planned open cholecystectomy, had gallstone pancreatitis or choledocholithiasis, and those admitted to a non-surgical service were excluded. Severity of disease was obtained from operative and pathology reports, and patients were classified according to the following grading scale:Grade I: symptomatic cholelithiasis.Grade II: acute/chronic cholecystitis.Grade III: gangrenous/necrotizing cholecystitis.Grade IV: gallbladder perforation or abscess.The groups were compared on age, gender, body mass index, severity of gallbladder disease, presence of preoperative systemic inflammatory response syndrome, hospital length of stay, length of operation, complications within 30 days, conversion to open rate, and cost of hospitalization.ResultsDuring the study period, 1252 patients who underwent laparoscopic cholecystectomy were analyzed; 677 met inclusion criteria. The most common grade was grade 2, which was present in 80% of patients, followed by grade 3, which was found in 16% of patients. Grade 4 cholecystitis occurred in 1.2% of patients and grade 1 occurred in 3.2% of patients. There were statistically significant increases in age, presence of preoperative systemic inflammatory response syndrome, hospital length of stay, conversion to open rate, cost of hospitalization, and length of operation with increased cholecystitis grade.ConclusionsThe proposed grading scale is an accurate predictor of duration of operation, conversion to open rate, hospital length of stay, and cost of hospitalization.Level of evidenceIIIStudy typePrognostic

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