Introduction
Methods
Protocol
Center eligibility
Patient eligibility
Data capture
Outcome measure
Statistical analysis
Ethical considerations
Results
Participating centers
Model of unscheduled surgical care
Who provides unscheduled surgical care? | |
General surgery on-call | 18 (72%) |
Acute care surgery | 7 (28%) |
Undertaken training in hepatobiliary surgery? | |
No | 17 (68%) |
Yes | 8 (32%) |
Patient demographics
Total 338 | |
---|---|
Age, mean (SD) | 64.5 (18.4) |
Sex, n (%) | |
Male | 156 (46.2%) |
Female | 182 (53.8%) |
BMI, mean (SD) | 28.5 (6.4) |
Smoking, n (%) | |
Smoker | 165 (48.8%) |
Nonsmoker | 55 (16.3%) |
Ex-smoker > 6 weeks | 118 (34.9%) |
American Society of Anesthesiology Status, n (%) | |
1 | 62 (18.6%) |
2 | 149 (44.7%) |
3 | 95 (28.5%) |
4 | 27 (8.1%) |
Age-adjusted Charlson co-morbidity index, mean (SD) | 3.36 (2.6) |
APACHE-II score, mean (SD) | 12.3 (7.59) |
Admitting diagnosis, n (%) | |
Cholecystitis | 154 (45.6%) |
Biliary pancreatitis | 71 (21.0%) |
Choledocholithiasis with cholangitis | 47 (13.9%) |
Choledocholithiasis without cholangitis | 61 (18.0%) |
Bilio-enteric fistula | 5 (1.5%) |
Diagnosis
Clinical features
Diagnostic radiologic investigations
Ultrasound
Computed tomography (CT)
Magnetic resonance cholangiopancreatography (MRCP)
Operative management
Surgical intervention | 169/338 (50%) |
During the index admission | 152 (89.9%) |
Cholecystectomy | 152 (100%) |
Laparoscopic | 127 (83.6%) |
Conversion to open | 13 (8.5%) |
Open | 12 (7.9%) |
Subtotal cholecystectomy | 5/152 (3.3%) |
Laparoscopic | 4 |
Conversion to open | 1 |
Interval elective re-admission | 17 (10.1%) |
Cholecystectomy | 17 (100%) |
Laparoscopic | 17 (100%) |
Did not receive operative treatment | 169/338 (50%) |
Bile Duct management | 104/338 (30.8%) |
Intraoperative ERCP | 11/104 (10.6%) |
ERCP as separate procedure | 87/104 (83.6%) |
Intraoperative CBD exploration (laparoscopic) | 4/104 (3.8%) |
Intraoperative CBD exploration (open) | 2/104 (1.9%) |
Interventional radiology | 26/338 (7.7%) |
Cholecystostomy | 23/26 (88.5%) |
Drainage of abscess or fluid collection | 1/26 (3.8%) |
Percutaneous transhepatic cholangiography (PTC) ± drain | 2/26 (7.7%) |
Postoperative complications
Model of unscheduled care | Postoperative complications | Interval | Total | |
---|---|---|---|---|
index admission | Interval | |||
General surgery on-call | Abscess | 3 (100%) | 0 | 3 (100%) |
Bile duct injury | 5 (83.3%) | 1 (16.7%) | 6 (100%) | |
A | 3 (75%) | 1 (25%) | 4 (100%) | |
D | 1 (100%) | 0 | 1 (100%) | |
E2 | 1 (100%) | 0 | 1 (100%) | |
Hemorrhage | 1 (100%) | 0 | 1 (100%) | |
Wound infection | 4 (100%) | 0 | 4 (100%) | |
Enterotomy | 1 (100%) | 0 | 1 (100%) | |
Total | 14 (93.3%) | 1 (6.7%) | 15 (100%) | |
Acute care surgery | Abscess | 3 (100%) | 0 | 3 (100%) |
100.0% | 0.0% | 100.0% | ||
Bile duct injury | 3 (100%) | 0 | 3 (100%) | |
A | 3 (100%) | 0 | 3 (100%) | |
Haemorrhage | 0 | 0 | 0 | |
Wound infection | 0 | 0 | 0 | |
Enterotomy | 0 | 0 | 0 | |
Total | 6 (100%) | 0 | 6 (100%) | |
Total | Abscess | 6 (100%) | 0 | 6 (100%) |
Bile duct injury | 8 (88.9%) | 1 (11.1%) | 9 (100%) | |
A | 6 (85.7%) | 1 (14.3%) | 7 (100%) | |
D | 1 (100%) | 0 | 1 (100%) | |
E2 | 1 (100%) | 0 | 1 (100%) | |
Hemorrhage | 1 (100%) | 0 | 1 (100%) | |
Wound infection | 4 (100%) | 0 | 4 (100%) | |
Enterotomy | 1 (100%) | 0 | 1 (100%) | |
Total | 19 (95%) | 1 (5%) | 20 (100%) |
Endoscopic management
Antimicrobial Prescription | 307/338 (90.8%) |
Piperacillin/tazobactam | 133 (39.3%) |
Amoxicillin/clavulanate | 65 (19.2%) |
Meropenem | 23 (6.8%) |
Metronidazole | 15 (4.4%) |
Cephalosporin | 14 (4.1%) |
Ciprofloxacin | 13 (3.8%) |
Gentamycin | 10 (3.0%) |
Ciprofloxacin and metronidazole | 11 (3.3%) |
Cephalosporin and metronidazole | 11 (3.3%) |
Amoxicillin/clavulanate and gentamycin | 6 (1.8%) |
Amoxicillin/clavulanate and metronidazole | 6 (1.8%) |
Did not receive antimicrobial treatment | 31/338 (9.2%) |
Blood and bile cultures | 154/338 (45.5%) |
Blood cultures | |
Yes | 47 (30.5%) |
No | 107 (69.5%) |
Bile cultures | |
Yes | 35 (22.7%) |
No | 119 (77.3%) |
Organism identified on culture | 40 blood, 52 bile |
E. coli | 11 blood, 20 bile |
Klebsiella spp. | 2 blood, 4 bile |
Staphylococcus spp. | 3 blood, 3 bile |
Streptococcus spp. | 0 blood, 4 bile |
Enterococcus spp. | 0 blood, 4 bile |
Pseudomonas spp. | 1 blood, 1 bile |
Other organisms | 2 blood, 6 bile |
Polymicrobial | 1 blood, 10 bile |
No growth | 61 blood, 69 bile |
Interventional radiologic management
Critical care, thromboprophylaxis, and stress ulcer prophylaxis
Microbiology and antimicrobial therapy
Histopathology
Histopathology findings | Total |
---|---|
Acute calculous cholecystitis | 73 |
Gangrenous cholecystitis | 39 |
Acute on chronic cholecystitis | 49 |
Gallbladder empyema | 5 |
Xanthogranulomatous cholecystitis | 2 |
Atypia of bile duct epithelium | 1 |
Total | 169 |