TY - JOUR
AU - Coombs, N J
AB - Abstract Background The British Society of Gastroenterology recommends that all patients with gallstone pancreatitis should undergo cholecystectomy within 2 weeks. This study assessed whether these guidelines are feasible and cost-effective. Methods Admissions for gallstone pancreatitis between January 2006 and January 2008 were reviewed. Readmissions for subsequent pancreatitis or biliary pathology were noted together with additional investigations, severity scores, hospital stay and time to cholecystectomy. The costs of readmission and theoretical costs of developing a dedicated operating list were provided by independent accountants. Results During the 2 years, 153 patients were admitted. Twenty-one patients (13·7 per cent) had further attacks requiring 40 readmissions. There were no deaths. Additional hospital costs related to readmissions were £172 170, including bed occupancy (£67 860), investigations (£12 510) and 153 cholecystectomies on an existing theatre list (£91 800). The estimated cost of staffing a half-day theatre list every fortnight, performing 153 cholecystectomies, was £170 391. Conclusion Instigating a dedicated theatre for cholecystectomy after biliary pancreatitis has many potential benefits. The costs of readmissions and ad hoc operating are balanced by those of a dedicated theatre list in the long term. Implementation of the guidelines would save approximately £900 annually and be cost neutral. Introduction Acute gallstone pancreatitis is associated with considerable morbidity (15–50 per cent) and a mortality rate ranging from less than 1 per cent in mild disease1 up to 30 per cent in severe necrotizing pancreatitis2,3. The reported incidence in the UK varies between regions4, ranging from 150 to 420 patients per million population3,5. Historically, local protocols dictated the management of pancreatitis but these often lacked consensus and evidence-based opinion. In 1998, the British Society of Gastroenterology published guidelines for the management of pancreatitis6 and these were revised in 2005 by the UK Working Party on Acute Pancreatitis5. These current guidelines form the basis of evidence-based protocols to which all units in the UK should adhere. One key recommendation is that ‘…all patients with biliary pancreatitis should undergo definitive management of gall stones during the same hospital admission, unless a clear plan has been made for definitive treatment within the next two weeks…’5. This means a cholecystectomy, either open or laparoscopic, with intraoperative bile duct evaluation. Cholecystectomy should be delayed only in patients with severe acute pancreatitis who have signs of lung injury or systemic disturbance, in whom surgery should be planned when such signs have resolved5. However, there is evidence that these guidelines are not adhered to routinely in some units. A prospective audit of the management of gallstone pancreatitis found that only 44·7 per cent of patients had definitive surgery after 8 months and consequently there was an 18·4 per cent unplanned readmission rate7. In another study the median time to surgery was 67·5 days and 21 per cent of patients were readmitted to hospital while awaiting surgery8. If surgery was completed within 4 weeks, the readmission rate reduced to 6 per cent8. Readmission to hospital places additional pressures on finite National Health Service (NHS) resources. Surgery at the time of initial presentation of gallstone pancreatitis may ease the financial burden of readmitting a patient to hospital. The aim of this retrospective study was to assess compliance with the published recommendations of the British Society of Gastroenterology in a district general hospital, and to carry out an economic study to demonstrate whether the implementation of systems to achieve the 2-week target for definitive surgery after an attack of biliary pancreatitis would be financially viable. Methods The notes of all patients admitted between January 2006 and January 2008 with a diagnosis of pancreatitis were reviewed retrospectively. The Medway™ electronic system (System C Healthcare, Maidstone, UK) was used to verify and record pathology and radiology data. Gallstone pancreatitis was diagnosed on the basis of an appropriate clinical history with an increase in serum amylase (more than 360 units/l; normal range 30–122 units/l) and ultrasonographic evidence of gallstones. Deranged liver function tests (LFTs) were reported if there was an increase in plasma levels of alkaline phosphatase (more than 170 units/l) or aspartate aminotransferase (over 35 units/l), with increased plasma bilirubin levels (above 17 µmol/l). Isolated raised bilirubin measurements were ignored. Alanine aminotransferase, although sensitive for the diagnosis of gallstone aetiology9, is not routinely measured in this institution. A diagnosis of severe pancreatitis was defined by an Acute Physiology And Chronic Health Evaluation (APACHE) II score of at least 8 within 24 h of admission. Patients with alcohol-related pancreatitis or with pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) were excluded. Also excluded from the analysis were patients considered unsuitable for definitive laparoscopic surgery owing to severe pre-existing respiratory disease. All information on the patient's admission was recorded together with details of unplanned readmissions to hospital with recurrent pancreatitis or biliary pathology, time to definitive surgery, APACHE II scores and derangements in LFTs. Patients with deranged LFTs had preoperative magnetic resonance cholangiopancreatography (MRCP). If there were ductal calculi, preoperative ERCP with sphincterotomy was performed. Laparoscopic cholecystectomy was carried out in the standard manner using a four-port technique. Intraoperative imaging was not employed routinely. Conversion to open cholecystectomy via Kocher's right upper quadrant incision was reserved for patients in whom it was considered unsafe to proceed with laparoscopic surgery. As laparoscopic common bile duct exploration was not available, any residual ductal stones were removed by postoperative ERCP and sphincterotomy. Economic information regarding the costs associated with unplanned readmissions was sought from two independent directorate accountants with a special interest in surgery, from separate trusts (Great Western Hospitals NHS Foundation Trust and North Bristol NHS Trust). For each patient readmitted, the total costs of each biochemical or haematological test, radiological procedure and bed occupancy were calculated, together with the cost of a planned day-case laparoscopic cholecystectomy on an existing operating list. Although these costs seem low compared with private institution tariffs, they accurately reflect ongoing costs of each test for the hospital trust. The numbers of emergency operating lists that would provide sufficient capacity for all patients with gallstone pancreatitis were calculated. This information was used to estimate the costs involved in setting up a theoretical dedicated laparoscopic cholecystectomy list to achieve the target of 2 weeks to surgery. Statistical analysis Fisher's exact two-tailed test was used to compare LFT derangement (deranged versus not deranged) and APACHE II severity (score less than 8 versus at least 8) against patient readmissions. Admissions were recorded as single admissions or multiple admissions for the purpose of statistical analysis. Results Between 1 January 2006 and 1 January 2008, 165 patients were admitted with gallstone pancreatitis. These emergency admissions were drawn from a population of 340 000. The annual incidence of gallstone pancreatitis as a first presentation in North Wiltshire was 48·5 per 100 000 population. The notes and follow-up details were not available for nine patients (5·5 per cent) and three (1·8 per cent) were excluded from further analysis as they were unfit for surgery, leaving 153 (75 men) for detailed analysis. Forty (26·1 per cent) of the 153 patients had severe biliary pancreatitis (APACHE II score 8 or more) on first presentation. A total of 132 (86·3 per cent) had no further admissions while awaiting definitive surgery, whereas 21 (13·7 per cent) developed recurrent pancreatitis or biliary pathology and required a total of 40 (range 1–5) readmissions to hospital. Eleven of these 21 patients had severe pancreatitis on initial admission to hospital. There was no significant difference in age between patients who had a single attack of gallstone pancreatitis and those with recurrent admissions (mean 55·4 versus 53·0 years; P = 0·537) (Table 1). There were no deaths in the study period. Readmitted patients were more likely to have deranged LFTs at primary admission (eight of 21 versus five of 132; P < 0·001) and were more likely to be classified as having severe pancreatitis on initial presentation when assessed by APACHE II score (11 of 21 versus 29 of 132; P = 0·006). Derangement of LFTs had a positive predictive value of 62 per cent for later readmission with pancreatitis. Table 1 Comparison of characteristics in patients with a single attack of biliary pancreatitis and those requiring readmission . Single admission . Readmitted patients . . Initial admission . Readmission . No. of patients 132 21 21 Age (years)* 53·0 (25–74) 55·4 (27–79) 55·4 (27–79) No. of admissions 132 21 40 Bed occupancy (days)* 7·5 (1–19) 7·5 (1–19) 5·9 (1–32) Median time to surgery (days) 168 136 Median APACHE II score 6 9 — APACHE II score ≥ 8·0 29 (22·0) 11 (52)† — Deranged LFTs 5 (3·8) 8 (38)‡ 3 (14) . Single admission . Readmitted patients . . Initial admission . Readmission . No. of patients 132 21 21 Age (years)* 53·0 (25–74) 55·4 (27–79) 55·4 (27–79) No. of admissions 132 21 40 Bed occupancy (days)* 7·5 (1–19) 7·5 (1–19) 5·9 (1–32) Median time to surgery (days) 168 136 Median APACHE II score 6 9 — APACHE II score ≥ 8·0 29 (22·0) 11 (52)† — Deranged LFTs 5 (3·8) 8 (38)‡ 3 (14) Values in parentheses are percentages unless indicated otherwise; * values are mean (range). APACHE, Acute Physiology And Chronic Health Evaluation; LFT, liver function test. † P = 0·006, ‡ P < 0·001 versus single admission (Fisher's exact test). Open in new tab Table 1 Comparison of characteristics in patients with a single attack of biliary pancreatitis and those requiring readmission . Single admission . Readmitted patients . . Initial admission . Readmission . No. of patients 132 21 21 Age (years)* 53·0 (25–74) 55·4 (27–79) 55·4 (27–79) No. of admissions 132 21 40 Bed occupancy (days)* 7·5 (1–19) 7·5 (1–19) 5·9 (1–32) Median time to surgery (days) 168 136 Median APACHE II score 6 9 — APACHE II score ≥ 8·0 29 (22·0) 11 (52)† — Deranged LFTs 5 (3·8) 8 (38)‡ 3 (14) . Single admission . Readmitted patients . . Initial admission . Readmission . No. of patients 132 21 21 Age (years)* 53·0 (25–74) 55·4 (27–79) 55·4 (27–79) No. of admissions 132 21 40 Bed occupancy (days)* 7·5 (1–19) 7·5 (1–19) 5·9 (1–32) Median time to surgery (days) 168 136 Median APACHE II score 6 9 — APACHE II score ≥ 8·0 29 (22·0) 11 (52)† — Deranged LFTs 5 (3·8) 8 (38)‡ 3 (14) Values in parentheses are percentages unless indicated otherwise; * values are mean (range). APACHE, Acute Physiology And Chronic Health Evaluation; LFT, liver function test. † P = 0·006, ‡ P < 0·001 versus single admission (Fisher's exact test). Open in new tab Patients readmitted with pancreatitis required 234 bed-nights to recover (mean 5·9 nights per readmission). All required additional radiological investigations including plain radiography and ultrasonography (Table 2). An additional 18 outpatient clinic appointments were used to reassess these patients. The median time to definitive surgery was 136 (range 13–560) days. All operations were carried out laparoscopically with no conversion to an open procedure. Eighteen patients had preoperative ERCP but none had postoperative ERCP. There were 15 preoperative MRCPs. The total cost of managing the 21 patients with recurrent biliary pancreatitis, and the cost of providing definitive surgery for all 153 patients on an existing operating list was £172 170 (Table 2). Table 2 Summary of additional investigations and cost estimates associated with patients readmitted with biliary pancreatitis . n . Item tariff (£) . Total cost (£) . 24-h stay on general surgical ward 234 290 67 860 24-h stay in intensive care or high-dependency unit 0 1631 or 710 0 Chest radiography 47 27 1269 Abdominal radiography 40 27 1080 Ultrasonography 43 65 2795 Computed tomography 8 148 1184 Magnetic resonance cholangiopancreatography 2 178 356 Clinic attendance  New 12 163 1956  Follow-up 6 80 480 Endoscopic retrograde cholangiopancreatography 2 525 1050 Biochemistry and haematology tests 234 10 2340 Consumables used during routine laparoscopic cholecystectomy 153 600 91 800 Total cost 172 170 . n . Item tariff (£) . Total cost (£) . 24-h stay on general surgical ward 234 290 67 860 24-h stay in intensive care or high-dependency unit 0 1631 or 710 0 Chest radiography 47 27 1269 Abdominal radiography 40 27 1080 Ultrasonography 43 65 2795 Computed tomography 8 148 1184 Magnetic resonance cholangiopancreatography 2 178 356 Clinic attendance  New 12 163 1956  Follow-up 6 80 480 Endoscopic retrograde cholangiopancreatography 2 525 1050 Biochemistry and haematology tests 234 10 2340 Consumables used during routine laparoscopic cholecystectomy 153 600 91 800 Total cost 172 170 Open in new tab Table 2 Summary of additional investigations and cost estimates associated with patients readmitted with biliary pancreatitis . n . Item tariff (£) . Total cost (£) . 24-h stay on general surgical ward 234 290 67 860 24-h stay in intensive care or high-dependency unit 0 1631 or 710 0 Chest radiography 47 27 1269 Abdominal radiography 40 27 1080 Ultrasonography 43 65 2795 Computed tomography 8 148 1184 Magnetic resonance cholangiopancreatography 2 178 356 Clinic attendance  New 12 163 1956  Follow-up 6 80 480 Endoscopic retrograde cholangiopancreatography 2 525 1050 Biochemistry and haematology tests 234 10 2340 Consumables used during routine laparoscopic cholecystectomy 153 600 91 800 Total cost 172 170 . n . Item tariff (£) . Total cost (£) . 24-h stay on general surgical ward 234 290 67 860 24-h stay in intensive care or high-dependency unit 0 1631 or 710 0 Chest radiography 47 27 1269 Abdominal radiography 40 27 1080 Ultrasonography 43 65 2795 Computed tomography 8 148 1184 Magnetic resonance cholangiopancreatography 2 178 356 Clinic attendance  New 12 163 1956  Follow-up 6 80 480 Endoscopic retrograde cholangiopancreatography 2 525 1050 Biochemistry and haematology tests 234 10 2340 Consumables used during routine laparoscopic cholecystectomy 153 600 91 800 Total cost 172 170 Open in new tab Over the 2-year period, there was a requirement for 153 laparoscopic cholecystectomies. This could be achieved by using a fortnightly half-day operating list providing three operations per list (25 lists per year each with three cases) (Table 3). The estimated cost of providing this service in 2008 was £170 391. The theoretical annual economic savings would be approximately £900, thus making it effectively cost neutral. Table 3 Theoretical costs for developing a specific laparoscopic service for gallstone pancreatitis . n . Cost (£) . No. of urgent laparoscopic operations required over 2 years 153 No. of operating lists required (3 procedures/list) 51 Cost per list 3341  4-h general anaesthetic list including anaesthetics and  recovery staff 1236  Surgeon 305  Consumables (3 operations) 1800 Theoretical costs for 51 lists and 153 operations 170 391 . n . Cost (£) . No. of urgent laparoscopic operations required over 2 years 153 No. of operating lists required (3 procedures/list) 51 Cost per list 3341  4-h general anaesthetic list including anaesthetics and  recovery staff 1236  Surgeon 305  Consumables (3 operations) 1800 Theoretical costs for 51 lists and 153 operations 170 391 Open in new tab Table 3 Theoretical costs for developing a specific laparoscopic service for gallstone pancreatitis . n . Cost (£) . No. of urgent laparoscopic operations required over 2 years 153 No. of operating lists required (3 procedures/list) 51 Cost per list 3341  4-h general anaesthetic list including anaesthetics and  recovery staff 1236  Surgeon 305  Consumables (3 operations) 1800 Theoretical costs for 51 lists and 153 operations 170 391 . n . Cost (£) . No. of urgent laparoscopic operations required over 2 years 153 No. of operating lists required (3 procedures/list) 51 Cost per list 3341  4-h general anaesthetic list including anaesthetics and  recovery staff 1236  Surgeon 305  Consumables (3 operations) 1800 Theoretical costs for 51 lists and 153 operations 170 391 Open in new tab Discussion This analysis has shown that the introduction of a fortnightly half-day operating list dedicated to laparoscopic cholecystectomy following pancreatitis would be cost neutral and could achieve national recommendations for management of pancreatitis. This should prevent most unplanned readmissions. In this retrospective study 13·7 per cent of patients diagnosed with gallstone pancreatitis were readmitted to hospital, similar to previous findings7,8. Only three patients were treated within 14 days of admission and so most cases failed to comply with published guidelines5,6. The aim of these guidelines was to reduce morbidity and mortality from recurrent pancreatitis. Timely definitive surgery9 with appropriate bile duct imaging and exploration reduces this risk to standard background rates10. Recurrent pancreatitis can be life threatening, with one study reporting a mortality rate of 17 per cent for severe disease11. There were no deaths in the readmission group in this study. Published compliance with the 2-week guideline is variable11. One prospective study showed that only 33 per cent of patients had definitive surgery within 4 weeks4, whereas others achieved 89·6 per cent compliance with the 2-week limit for definitive surgery12. In the present study the median time to surgery was 168 days in the single-admission group and 136 days in the readmitted group. This discrepancy could easily be addressed by an additional regular operating list. The APACHE II scoring system based on age, and physiological and chronic health variables was used to assess the severity of pancreatitis. This scoring system has been evaluated extensively13 and validated14,15 as a tool for predicting hospital mortality and disease severity. The median APACHE II score on initial admission was 9 in those who were readmitted compared with 6 in those who had a single admission. A higher proportion of patients who were readmitted had more severe disease on first admission. This is useful in identifying those patients on first admission who are at higher risk of readmission. It is also of interest that eight of the 13 patients with deranged LFTs were in the readmission group. Deranged LFTs usually result from bile duct stones, the presence of which seems to increase the risk of recurrent pancreatitis. Deranged LFTs had a positive predictive value of 61·5 per cent in this series, suggesting that this group of patients should be prioritized for urgent laparoscopic surgery and either preoperative or intraoperative evaluation of the bile ducts. This study has several strengths. All patient data were identified from a combination of patient notes and the electronic computer system. All patients admitted with gallstone pancreatitis during the study period were identified positively, and there were only nine incomplete data sets. This gives an accurate reflection of gallstone pancreatitis and its sequelae in North Wiltshire as acute surgical services are provided only by this institution, the nearest other acute hospitals being over 40 km away. Therefore, any readmissions could be expected to return to the initial hospital. Every investigation requested (radiological, biochemical and haematological) and performed is recorded electronically, as well as all subsequent outpatient and inpatient visits to the hospital. The cost calculations are therefore an accurate representation of the additional costs to the hospital of patients readmitted with pancreatitis. The NHS hospital tariffs for ERCP and MRCP are considerably lower than those of private providers. Using the lower NHS costs in the analysis strengthens the economic argument for early cholecystectomy. This investigation has shown, at least theoretically, that it is economically viable to set up a new operating list to deal with laparoscopic cholecystectomies after biliary pancreatitis. These results may help other units develop a business case for a gallstone pancreatitis service. In the absence of a dedicated cholecystectomy list, a subgroup of patients (those with severe disease and deranged LFTs) has been highlighted who are most at risk of an unplanned readmission and who therefore should be prioritized for early operative intervention. Although some advocate early laparoscopic cholecystectomy at the time of initial presentation of gallstone pancreatitis16, this ‘gold standard’ remains difficult to achieve within some district general hospitals, owing to limited capacity on emergency theatre lists which are often shared with other specialties. The study has some limitations. It is a single ‘snap-shot’ in time and the operating list has yet to be implemented. There may be other, as yet unaccounted for, factors that affect the feasibility of setting up and managing a new operating list. However, the implementation of a dedicated cholecystectomy list should liberate existing theatre time, enabling other elective surgery procedures to be performed, potentially generating additional income for the hospital and allowing waiting list targets to be achieved. This strategy for implementing national guidelines and carrying out laparoscopic cholecystectomy within 2 weeks of an attack of gallstone pancreatitis now requires prospective testing and auditing, and formal cost-effectiveness evaluation after a trial period. Acknowledgements The authors acknowledge Mrs H. Wright, Financial Director of North Bristol NHS Trust, and Mr G. Shone, Head of Financial Planning, Great Western Hospitals NHS Foundation Trust, for their help and advice with the financial aspects of this project, and Miss N. Betambeau and Dr M. A. Smith for help with statistics. The authors declare no conflict of interest. References 1 Carroll JK , Herrick B, Gipson T, Lee SP. 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An audit of the management of patients with acute pancreatitis against national standards of practice . Br J Surg 2007 ; 94 : 844 – 848 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Knaus WA , Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome from intensive care in major medical centers . Ann Intern Med 1986 ; 104 : 410 – 418 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Seneff MG , Knaus WA. Predicting patient outcomes from intensive care: a guide to APACHE, MPM, SAPS, PRISM and other prognostic scoring systems . J Intensive Care Med 1990 ; 5 : 33 – 52 . Google Scholar Crossref Search ADS WorldCat 15 Wong DT , Knaus WA. Predicting outcome in critical care: the current status of the APACHE prognostic scoring system . Can J Anaesth 1991 ; 38 : 374 – 383 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Sinha R . Early laparoscopic cholecystectomy in acute biliary pancreatitis: the optimal choice? HPB (Oxford) 2008 ; 10 : 332 – 335 . Google Scholar Crossref Search ADS PubMed WorldCat Footnotes Presented to the Fourth Alpine Liver and Pancreatic Society Conference, Madonna di Campiglio, Italy, February 2009, and to a meeting of the Association of Laparoscopic Surgeons of Great Britain and Ireland, Colchester, UK, November 2008 Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Two-week target for laparoscopic cholecystectomy following gallstone pancreatitis is achievable and cost neutral
JF - British Journal of Surgery
DO - 10.1002/bjs.6644
DA - 2009-06-15
UR - https://www.deepdyve.com/lp/oxford-university-press/two-week-target-for-laparoscopic-cholecystectomy-following-gallstone-u3bYPnlgQ4
SP - 751
EP - 755
VL - 96
IS - 7
DP - DeepDyve
ER -