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

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.

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HOW TO REPORT AND MONITOR THE PERFORMANCE OF WAITING LIST MANAGEMENT

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462302000442 ◽

2002 ◽

Vol 18 (3) ◽

pp. 611-618

Author(s):

Markus Torkki ◽

Miika Linna ◽

Seppo Seitsalo ◽

Pekka Paavolainen

Keyword(s):

Hallux Valgus ◽

Waiting Time ◽

Varicose Vein ◽

Elective Surgery ◽

Waiting Times ◽

Waiting List ◽

Mean Waiting Time ◽

Number Of Patients ◽

Potential Problems ◽

Queue Discipline

Objectives: Potential problems concerning waiting list management are often monitored using mean waiting times based on empirical samples. However, the appropriateness of mean waiting time as an indicator of access can be questioned if a waiting list is not managed well, e.g., if the queue discipline is violated. This study was performed to find out about the queue discipline in waiting lists for elective surgery to reveal potential discrepancies in waiting list management. Methods: There were 1,774 waiting list patients for hallux valgus or varicose vein surgery or sterilization. The waiting time distributions of patients receiving surgery and of patients still waiting for an operation are presented in column charts. The charts are compared with two model charts. One model chart presents a high queue discipline (first in—first out) and another a poor queue discipline (random) queue. Results: There were significant differences in waiting list management across hospitals and patient categories. Examples of a poor queue discipline were found in queues for hallux valgus and varicose vein operations. Conclusions: A routine waiting list reporting should be used to guarantee the quality of waiting list management and to pinpoint potential problems in access. It is important to monitor not only the number of patients in the waiting list but also the queue discipline and the balance between demand and supply of surgical services. The purpose for this type of reporting is to ensure that the priority setting made at health policy level also works in practise.

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

Bulletin of The Royal College of Surgeons of England ◽

10.1308/147363511x579468 ◽

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.

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Waiting time information services: how well do different statistics forecast a patient's wait?

Australian Health Review ◽

10.1071/ah020075 ◽

2002 ◽

Vol 25 (6) ◽

pp. 75 ◽

Cited By ~ 6

Author(s):

David A. Cromwell ◽

David A. Griffths

Keyword(s):

Waiting Time ◽

Public Hospital ◽

Elective Surgery ◽

Waiting Times ◽

Information Services ◽

Waiting List ◽

Web Based ◽

Time Information ◽

Sydney Australia ◽

Patient Waiting

This study investigates how accurately the waiting times of patients about to join a waiting list are predicted by the types of statistics disseminated via web-based waiting time information services. Data were collected at a public hospital in Sydney, Australia, on elective surgery activity and waiting list behaviour from July 1995 to June 1998.The data covered 46 surgeons in 10 surgical specialties. The accuracy of the tested statistics varied greatly, being affected more by the characteristics and behaviour of a surgeon's waiting list than by how the statistics were derived. For those surgeons whose waiting times were often over six months, commonly used statistics can be very poor at forecasting patient waiting times.

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P-BN44 The impact of the COVID-19 pandemic on waiting lists for laparoscopic cholecystectomy and its effect on patient care and outcomes

British Journal of Surgery ◽

10.1093/bjs/znab430.042 ◽

2021 ◽

Vol 108 (Supplement_9) ◽

Author(s):

Geraint Herbert ◽

Charlotte Thomas

Keyword(s):

Laparoscopic Cholecystectomy ◽

Patient Care ◽

Positive Impact ◽

Elective Surgery ◽

Emergency Operation ◽

Waiting Lists ◽

Waiting List ◽

Subtotal Cholecystectomy ◽

Significant Difference ◽

The Impact

Abstract Background It has been widely reported that the COVID-19 pandemic has had a detrimental impact on waiting lists for elective surgery in the NHS. Delays in laparoscopic cholecystectomy (LC) are likely to prolong suffering for symptomatic patients and risk increasing complications for patients which may then require emergency care and intervention. In this study we aim to quantify the impact of the COVID-19 pandemic on elective waiting lists and to assess what implications this might have on patient care and outcomes. Methods Electronic health records were retrospectively interrogated for patients undergoing LC in both March 2019 (prior to the COVID-19 pandemic) and March 2021. The following data was captured: age, gender, elective vs emergency operation, laparoscopic vs open, total vs subtotal cholecystectomy, use of drains, length of stay/daycase rates, the number of emergency presentations prior to operation and the number of days between being listed for surgery and their operation. The results were analysed using SPSS Statistics (IBM, New York). Results 111 patients were included in the study (25 male and 86 female). Of these, 60 had their LC in 2019, and 51 in 2021. The age and gender distribution of the patients in both time periods were similar. The median number of days on the waiting list was significantly higher (P < 0.001) for patients in 2021 at 379.5 days, compared with 153 days in 2019. There was a significant increase in the number of emergency presentations prior to LC in 2021 (P = 0.025) with an average of 0.7 presentations per patient compared with 0.45 in 2019. Additionally, there was a significant increase in the number of emergency LC performed in 2021 (P = 0.002), with 15 performed compared with 4 in 2019, representing 29.4% and 6.7% of all LC respectively. There was no significant change in rates of conversion to open, drains or subtotal cholecystectomy. There was no significant difference in daycase rates for elective patients in either period (55% vs 58%). Conclusions Whilst there has been no change in the operative outcomes for patients undergoing LC, there has been a stark increase in the length of time patients are on a waiting list prior to undergoing elective LC. This has resulted in a significant increase in the number of emergency presentations and the number of emergency LC performed. This study demonstrates the wider impact of increasing waiting list times beyond the prolonged suffering of symptomatic patients. A significant reduction in waiting list times would be beneficial to both patients and healthcare providers, with the aim of reducing the number of emergency presentations. A reduction in these would have a positive impact on acute services and on the associated cost implications.

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Emergency surgery (DRAFT)

10.1093/med/9780198749813.003.0007 ◽

2018 ◽

Author(s):

Jonathan Wild ◽

Emma Nofal ◽

Imeshi Wijetunga ◽

Antonia Durham Hall

Keyword(s):

General Surgery ◽

Hospital Admissions ◽

Surgical Intervention ◽

Elective Surgery ◽

Trauma Surgery ◽

Emergency Operation ◽

Emergency General Surgery ◽

Symptom Palliation ◽

The Impact ◽

Theatre List

Emergency general surgery comprises patients with surgical problems requiring surgical intervention or post-operative surgical patients who require further surgical intervention or symptom palliation at any time of the day or night. Beyond the cases discussed below, this will include also emergency presentations from all of the sub-specialty chapters covered so far. Over 600,000 emergency hospital admissions are made to general surgery. Of these patients, they comprise the sickest patient cohort relative to the majority of elective patients, which results from sepsis, shock, or organ dysfunction from the underlying causative pathology, as well as the impact of any pre-existant comorbid states. This often has a significant impact on patient outcome, with high rates of morbidity and mortality relative to elective surgery. With this in mind, a lot of work has been channelled into improving outcomes for these patients. Furthermore, emergency and trauma surgery is beginning to establish itself as a subspecialty in itself. This chapter starts by making applied discussion of the assessment and initial investigation of acute abdominal pain, a complaint that comprises half of the annual 600,000 emergency general surgical admissions. It covers the pertinent features of diagnosis, investigation, and management of a range of common or serious emergency surgical and trauma cases that will be encountered on the acute surgical take. Kidney transplantation is not in itself an emergency operation when you consider the degree of pre-operative preparation of recipient donors, but is included in this chapter as it is commonly encountered by junior trainees on the emergency theatre list when donors are found at short notice.

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Upper gastrointestinal and hepatopancreatobiliary surgery

Oxford Handbook for Medical School ◽

10.1093/med/9780199681907.003.0042 ◽

2019 ◽

pp. 779-796

Keyword(s):

Gastric Cancer ◽

Gallstone Disease ◽

Intensive Therapy ◽

Gastrointestinal Surgery ◽

Biliary Colic ◽

Whipple’S Procedure ◽

Hepatopancreatobiliary Surgery ◽

Oesophageal Dysmotility ◽

Pancreatic Operations ◽

Upper Gastrointestinal

This chapter reviews upper gastrointestinal surgery (UGI) for diseases of the oesophagus, stomach, gall bladder and biliary system, and the duodenum as well as an overlap with hepatopancreatobiliary (HPB) surgery. It highlights ‘places to be’ to see UGI conditions including the emergency department, radiology, ward, theatre, and intensive therapy unit, and radiology and endoscopy procedures to see. Common UGI conditions are discussed including oesophageal dysmotility and cancer, hiatus hernia, gastro-oesophageal reflux disease, and gastric cancer. There is a helpful section detailing bariatric surgery with appropriate information for a medical student. It also discusses HPB conditions such as gallstone disease, biliary colic, and acute pancreatitis. It also reviews pancreatic operations such as Whipple’s procedure. This chapter includes good pictorial guidance and is written for both those looking to apply for medicine, and those in medical school.

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398 Outcome of Laparoscopic Cholecystectomy in Patients Over 80 Years Old

British Journal of Surgery ◽

10.1093/bjs/znab259.046 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

D Gumaa ◽

A Hunt ◽

D Karunaratne ◽

S Shresta ◽

B Al-Robaie

Keyword(s):

Laparoscopic Cholecystectomy ◽

Gallstone Disease ◽

District General Hospital ◽

The Elderly ◽

Biliary Colic ◽

Old Patients ◽

Medical Background ◽

Admission Data ◽

Emergency Group ◽

Elective Group

Abstract Background Gallstone disease is a common cause of morbidity in old patients. Conservative treatment is usually the first line of treatment due to concerns about the risk of surgery. In our study we are trying to assess the outcome of laparoscopic cholecystectomy in patients over 80 years old. Method Retrospective cohort study done in a large district general hospital where good number of laparoscopic cholecystectomy is done every year. Main outcome is Mortality, return to theatre and post op ITU admission. Data collected from patients records. Results 74 patients in total were operated on. 14 operations were done as emergency (during the same inpatient admission). Indication for surgery varied between cholecystitis, pancreatitis and biliary colic. But the main indication in the emergency group was acute cholecystitis. 55 % of the patients had significant medical background with ASA 3. 30 days mortality was 0 in both emergency and elective groups. 2 patients required ITU admission post op, mainly for premorbid status, and both were in the emergency group. There was only one return to theatre in the emergency group for washout. 90% of the elective group patients were done as day case with no post op complications. Conclusions Laparoscopic cholecystectomy is safe operation to be done in the elderly population. ITU admission is mainly because of the patient’s co-morbidities so patients should be selected carefully and have proper pre op assessment.

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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

British Journal of Surgery ◽

10.1093/bjs/znab430.067 ◽

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.

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156 Could a Cohort of Patients be Listed Directly from Video Clinic to Surgery with Assessment on Day of Surgery? The Implementation of Video Clinic in Surgical Patients During the COVID-19 Lockdown

British Journal of Surgery ◽

10.1093/bjs/znab259.441 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

A Gendia ◽

M Al-Ardah ◽

R Jones ◽

S Korambayil ◽

J Clark ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Waiting Time ◽

Healthcare Services ◽

Vital Role ◽

Biliary Colic ◽

Face To Face ◽

Global Pandemic ◽

Retrospective Audit ◽

General Surgeons ◽

Hospital Visits

Abstract Aim To report the feasibly and the safety of utilizing video Clinic during the 2020 pandemic in scheduling a cohort of patients to laparoscopic cholecystectomy (LC) without the need of face-to-face assessment. Method A retrospective audit from May to October 2020 was conducted on patients with symptomatic biliary colic disease and selected low risk demographics who were vetted and scheduled for laparoscopic cholecystectomy through video clinic under one of the general surgeons (AC) in a large district hospital. All patients were given the option to have their face-to-face assessment on the day of surgery and if there would be any concerning signs, they would be postponed or investigated if required. Results 33 patients agreed on the proposed option and were scheduled to LC based on virtual assessment, mean age of 42(±13) years old and 26(79%) were females. 16 (49%) patients had their surgery with average waiting time of 2.1(±1) months and mean BMI of 29.9(±7). 17 (51%) patients are pending future surgery dates. there was no cancellation based on surgery day assessment and or unexpected events intraoperatively. Conclusions As virtual clinics played a major role in providing healthcare services during the global pandemic, scheduling patients to surgery without face-to-face assessment was applicable and safe in selected demographics. This could have the potential of reducing waiting time, travelling costs and hospital visits. Moreover, communications with patients regarding the proposed same day assessment played a vital role in reaching a mutual agreement.

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Prompt laparoscopic cholecystectomy would reduce morbidity and save hospital resources

Annals of The Royal College of Surgeons of England ◽

10.1308/003588414x13814021680111 ◽

2014 ◽

Vol 96 (4) ◽

pp. 294-296 ◽

Cited By ~ 1

Author(s):

BWP Rossi ◽

E Bassett ◽

M Martin ◽

S Andrews ◽

S Wajed

Keyword(s):

Laparoscopic Cholecystectomy ◽

Elective Surgery ◽

Waiting Times ◽

Emergency Admission ◽

Waiting List ◽

Document Management ◽

Document Management System ◽

Patient Morbidity ◽

Hospital Resources

Introduction Limited resources and organisational problems often result in significant waiting times for patients presenting with an indication for cholecystectomy. This study investigated the potential false economy of such practice. Methods Retrospective analysis of all patients on a waiting list for cholecystectomy between July 2007 and October 2010 was performed. The hospital computer document management system and patients’ notes were used to collect data. Results A total of 1,021 patients were included in the study; 701 were listed from clinic and 320 were listed following an emergency admission. The median time on a waiting list before surgery was 96 days (range: 5–381 days). Eighty-seven patients (8.5%) had an emergency admission with a gallstone related problem while on a waiting list. This resulted in 488 cumulative inpatient days. There was a significant correlation between increased time spent on the waiting list and increased chance of an emergency admission (p=0.01). Patients added to the waiting list from emergency admissions were more likely to be admitted with complications than those listed from clinic (15.3% vs 5.4%, p<0.01). There was no association between age (p=0.53) or sex (p=0.23) and likelihood of emergency admission while on a waiting list. Conclusions Prompt elective surgery and same-admission emergency laparoscopic cholecystectomy can reduce waiting list patient morbidity and is likely to save resources in the long term.

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