Early Laparoscopic Cholecystectomy Service Provision is Feasible and Safe in the Current UK National Health Service

This prospective study was carried out at UHNS, Stoke-on-Trent, UK, a hospital serving a population of 550,000. Ten consultant general surgeons (five upper gastrointestinal, one breast/colorectal and four colorectal) take part in the on-call rota for general surgery. In addition, three vascular/general consultant surgeons also participate in the on-call rota for general surgery. Before September 2007, each consultant surgeon was on call for 24 h, often also having elective responsibilities at the same time. The SoW rota (Table 1) was introduced in September 2007. Each consultant gastrointestinal/general surgeon is ‘SoW’ every tenth week and is on call for six out of seven days during the daytime from Friday 8am until Thursday 8am. The SoW has responsibilities for the emergency theatres during this week, but a different colleague is allocated to each morning emergency session to enable the SoW to carry out a full ward-round of all emergency admissions. The vascular consultant surgeon does 24 h only from 8am on Thursday till 8am on Friday including emergency theatre list on Thursday from 1pm till 6pm every third week. Each of the ten consultants has a separate night on-call rota, which also covers weekends. Any patient requiring emergency surgery overnight (i.e. those with life- or limb-threatening conditions) are handed back to the SoW consultant the following morning.

Demographic data, admission and discharge dates, complications, conversions to an open operation and deaths were collected for all patients who underwent early laparoscopic cholecystectomies between 1 January 2007 and 31 May 2008 (excluding the month of September 2007). The month of September was excluded as the SoW rota was being introduced in that month and may not have represented true work carried out in the hospital. For ease of comparison, patients were divided into Group A representing before introduction of SoW (1 January 2007 to 30 August 2007) and Group B representing after introduction of SoW (1 October 2007 to 31 May 2008). The total numbers of operations performed in the emergency theatre list in the two groups were also calculated.

Early laparoscopic cholecystectomy for acute gallstone disease is recommended on the basis of randomized clinical trials (RCTs)7–10 and several meta-analyses,1,2,11. A further potential benefit of early laparoscopic cholecystectomy is the avoidance of failed conservative treatment, which often leads to multiple interim re-admissions. In Taunton,5 28.5% of patients were re-admitted as emergencies with gallstone-related complications, whilst on a waiting list for surgery after having had an admission with acute cholecystitis. The authors concluded that all patients admitted as an emergency with symptomatic gallstones should be offered early cholecystectomy. This has also been recommended by the NHS Institute for Innovation and Improvement.12

Despite increasing evidence of the benefits and safety of early LC in acute gallstone disease, it is not widely practised in England. Hospital Episode Statistics (HES) data shows that only 15% of patients underwent cholecystectomy during the first emergency admission with acute gallbladder disease between April 2003 and March 2004.13 Although this may be due to a lack of emergency theatre time, there may also have been a shortage of experienced laparoscopic biliary surgeons in the past. There is also a perceived view among some theatre staff and anaesthetists that LC should be regarded as a routine procedure. With increased awareness, education and training, the percentage of patients undergoing cholecystectomy during the first emergency admission with acute gallbladder disease can be increased. On the other hand, there are potential issues of availability of operating time in the emergency theatres as more urgent life- and limb-threatening operations taking priority over early cholecystectomy leading to repeated cancellations.

The Royal College of Surgeons of England6 supports the separation of emergency and elective work-loads to maintain and improve standards in surgical care. There are a number of models proposed for separating emergency and elective surgical care. There is no universal solution and local circumstances will dictate the best method of service delivery. In UHNS, the SoW system assures faster access to senior surgical opinion for the assessment and treatment of surgical emergencies. Shift pattern working of junior doctors because of the European Working Time Directive (EWTD) has the potential for interrupting continuity of care, delaying the treatment of the patient and introducing errors of communication. The SoW model also provides better continuity of care for patients through a consultant-led emergency team.

We acknowledge that even with increased numbers of early LCs, there are still patients who are unable to have early surgery. Patients with resolving acute cholecystitis take a lower clinical priority on the emergency list and may incur long periods of delay. All patients are fully informed of this before booking for surgery. Anyone not willing to wait were discharged after conservative management and readmitted for delayed-interval cholecystectomy.

It has been suggested in an earlier study14 that a 12-h urgent theatre facility can be seen as analogous to the ‘trauma’ theatre where semi-emergency urgent cases, such as patients with acute cholecystitis and biliary pancreatitis can be dealt with. The introduction of a specialist team specialising in the management of acute gallbladder disease in Portsmouth15,16 lead to an increase in the early cholecystectomy rate at index admission. However, in our study, only separating emergency from elective surgical care with introduction of SOW made a significant difference in the number of early LC performed safely.

This study has demonstrated an increase in the efficiency of the emergency theatre following implementation of the SoW model in our hospital. It is possible to carry out early LC in an increased proportion of patients on their index admission without extra morbidity. We recommend the introduction of a suitable emergency surgical consultant on-call model separating emergency and elective surgical care depending on local circumstances. This can lead to significant cost savings and reduce re-admissions with recurrent morbidity.