Does Ambulatory Care Clinic Follow-up Improve the Acute Cholecystectomy Service at a DGH?

Azhar Shabbir^1, , Neil Houghton¹ and Namal Rupasinghe²

¹Department General Surgery, Royal Bolton NHS Trust, Bolton, UK

²Department Vascular and General Surgery, Countess of Chester Hospital, UK

Cite this paper:
Azhar Shabbir, Neil Houghton and Namal Rupasinghe. Does Ambulatory Care Clinic Follow-up Improve the Acute Cholecystectomy Service at a DGH?. Global Journal of Surgery. 2016; 4(1):1-4. doi: 10.12691/js-4-1-1

Abstract

Introduction: Biliary disease is a common cause of admission to UK hospitals and NICE guidance recommends early cholecystectomy [1]. Evidence supporting early cholecystectomy is primarily from tertiary centres [2,3,4]. This study was undertaken in a District General Hospital to assess the acute cholecystectomy service. The primary aim was to assess the effects of ambulatory follow-up care clinics on reducing complications and readmissions. Methods: Data were collected for 2 groups: all patients having acute cholecystectomy on purpose built operation theatre lists during 6 month periods before, and after, the introduction of ambulatory follow-up clinics in 2013 and 2014. The methodology was kept identical to allow a fair comparison. The Nottingham CCG standards for Gallstone disease were used as gold standard. Results: There were 77 laparoscopic cholecystectomies performed during the initial pre-ACC period. There was a reduction in the length of inpatient stay in the 30 day follow up compared with the acute cholecystectomies performed in emergency theatre from an earlier audit, however the data showed 15% re-admission and 1% re-operation in newly developed service. An ambulatory care clinic(ACC) was set up and data was re collected. In the post-ACC period 87 patients underwent acute laparoscopic cholecystectomy. Median length of stay was unchanged at 1 day (range 0-48). A small increase in the number of day case discharges from 42.8% to 48.3% was observed (p = 0.531). A decrease in all grades of complications was observed including 30 day re-admission. This was reduced from 15.6% to 8% (P<0.05). The reoperation rates were low and there was no mortality in either group. All these outcome measures met, or bettered, the standards from Nottingham CCG. Conclusions: The study showed that by introducing early and easily accessible ambulatory follow up, a reduction in re-admission rates can be achieved following acute cholecystectomy. There was no mortality during the study period, and a high day case rate with the demonstration that a safe service can be delivered in a DGH as compared to a tertiary center. We recommend that acute cholecystectomies with a provision for ambulatory follow up should be offered as a safe and effective practice.

Keywords:
cholecystectomy cholecystitis emergency general surgery ambulatory care

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References:

[1]	National Institute for Health and Care Excellence (2014) Gallstone disease: diagnosis and initial management. NICE guidelines [CG188].
[2]	Y Yamashita et al. TG13: Updated Tokyo Guidelines for acute cholangitis and acute cholecystitis. J Hepatobiliary Pancreat Sci 2013 20: 89-96.
[3]	de Mestral C, Rotstein OD, Laupacis A, Hoch JS, Zagorski B, Alali AS et al. Comparative operative outcomes of early and delyed cholecystectomy for acute cholecystitis. Ann Surg 2014; 259:10-15.
[4]	Gutt CN, Encke J, Koninger J, Harnoss JC, Weigand K, Kipfmuller K et al. Acute cholecystitis early versus delayed cholecystectomy, A multicenter randomized trial. Ann Surg 2013; 258:385-393.
[5]	Gul R, Dar RA, Sheikh RA, Salroo NA, Matoo AR, Wani SH. Comparison of early and delayed laparoscopic cholecystectomy for acute cholecystitis: Experience from a single centre. N Am J Med Sci 2013; 5:414-418.
[6]	Pitt H. Patient Value is Superior with Early Surgery for Acute Cholecystitis. Ann Surg 2014: 259:1:16-17.
[7]	Riall TS, Zhang D, Townsend C, Kuo Y-F, Goodwin J. Failure to Perform Cholecystectomy for Acute Cholecystitis in Elderly Patients Is Associated with Increased Morbidity, Mortality, and Cost. J Am Coll Surg 2009: 12:031: 668-677.
[8]	Commissioning Guide: Emergency General Surgery. RCS (Eng) and ASGBI 2014. http://www.rcseng.ac.uk/healthcare-bodies/docs/emergency-general-surgery-commissioning-guide.
[9]	Management of Acute Gallstone Diseases. AUGIS 2015 http://www.augis.org/wp-content/uploads/2014/05/Acute-Gallstones-Pathway-Final-Sept-2015.pdf.
[10]	Gurusamy K, Samraj K, Gluud C, et al. Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 2010;97(2):141-50.