Transcript CholeS talk - West Midlands Research Collaborative

Clinical Variation in Practice of
Laparoscopic Cholecystectomy and
Surgical Outcomes: a multi-centre,
prospective, population-based
cohort study
Ravi Vohra
West Midlands Research Collaborative
Why?
• Management varies widely between surgeons and hospitals
– Acute vs. Elective
• Cholecystectomy is common
• 66,000 cholecystectomies were performed during the 201112 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).
28 Data points
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
Post-operative data
• In-hospital complications
• In-hospital re-interventions and reimaging
• 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
Pilot
One week, 5 centres
• 34 Choles
• All laparoscopic
• Range 0 - 15 procedures
• LoHS 1 day (0-5 days)
20
Lap
15
Converted
10
5
0
Acute
Delayed
Elective
Conclusion
Population-based cohort study
Determine variation and impact on
surgical outcomes in a non-trial
cohort
[email protected]
[email protected]
‘The Power of Many’
West Midlands ~1500
England ~ 10,000
UK ~ 12,000
www.choles-study.org