Introduction The debate as to how to best manage patients presenting acutely with complications of gallstones continues—whether to consider early emergency surgery or not. Perceptions of increased risk and greatly increased cost still persist about the early approach. We report on our experience from a regional hepatobiliary centre.
Methods A retrospective clinical study was conducted of all patients admitted with acute biliary symptoms, and who underwent cholecystectomy between January 2008 and August 2011. Costing data were calculated for each patient on an individual basis, including all theatre consumables, drugs and calculated cost for length of stay. A decision tree analysis economic model was created, using input data derived from the clinical study as well as the individual patient level costs, and uncertainty in this model tested with probabilistic sensitivity analyses. Categorical data were analysed using the χ2 test.
Results Of the 1888 patients who had a cholecystectomy during this period, 89 had an emergency or early laparoscopic cholecysytectomy (eLC) and 310 patients presented acutely with biliary disease and then went on to have a delayed cholecystectomy (dLC). Overall median length of stay (LoS) for the eLC group was 6 days, and for the delayed group was 7 days (p=NS), including the primary admission for medical treatment. The emergency readmission rate for all patients on the waiting list was 13% with a median stay of 4.5 days. Post-operative readmission rates were equivalent for both eLC (8%) and dLC (9%)—p=NS. Mean operating time was longer in the eLC group than the dLC group—120 min vs 60 min (p<0.05). Post operative ERCP rates were 3% for the eLC group and 0% for the dLC group (p=NS), post operative fluid collections requiring intervention were 6% for the eLC group as opposed to 0% for the dLC group (p=NS). The baseline cost difference between the eLC and dLC groups was around £150 more expensive for the eLC group. After complications and readmission costs were calculated and inputted into the decision tree analysis, this difference decreased to a cost of £52—more expensive for the eLC pathway.
Conclusion Early cholecystectomy on the index admission appears to be safe, with overall hospital stay slightly shorter. The difference in costs between the early and delayed pathway was essentially cost equivalent. But with NHS tariff (around £3650 for eLC and £2900 for dLC), the difference in net monetary benefit was around £700 per patient in favour eLC pathway. In a hospital conducting around 200 cholecystectomies per year on patients for acute biliary disease in the NHS, this could translate to a cost saving of over £140 000 per year.
Competing interests None declared.
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.