Ravi Vohra

1
Clinical Variation in Practice of Laparoscopic
Cholecystectomy and Surgical Outcomes a
multi-centre, prospective, population-based
cohort study

• Ravi Vohra
• West Midlands Research Collaborative

2
Why?

• Management varies widely between surgeons and
  hospitals
• Acute vs. Elective
• Cholecystectomy is common
• 66,000 cholecystectomies were performed during
  the 2011-12 financial year in England alone
• Trainees are involved in

3
Evidence?

• Level 1 evidence support early or acute
  laparoscopic cholecytectomy in
• Biliary colic (1 RCT, n75)
• Cholecystitis (6 RCTs, n488)
• Gallstone pancreatitis (1RCT, n303)
• (Meta-analysis)

4
Retrospective data
Harrison et al. BMJ, 2012344e3330
Sinha et al. Surg Endosc, 201327(1)162-75.
5
Nottingham CCG
AUGIS/RCS 2013
6
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)

7
Methods

• Two-month period (March- April 2014) with 30 day
  follow up
• All patients undergoing cholecystectomy
• Acute (first acute admission with biliary disease
  through AE 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).

8
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 re-imaging
• Date of discharge
•  
• 30-day data
• All-cause AE attendance
• All-cause 30-day readmission
• Date of re-admission
• Complications
• Re-interventions and re-imaging
• Date of discharge following readmission
• 30-day mortality

9
Pilot

• One week, 5 centres
• 34 Choles
• All laparoscopic
• Range 0 - 15 procedures
• LoHS 1 day (0-5 days)

10
Conclusion

• Population-based cohort study
• Determine variation and impact on surgical
  outcomes in a non-trial cohort
• The Power of Many
• West Midlands 1500
• England 10,000
• UK 12,000

• Ewen.griffiths_at_uhb.nhs.uk
• Ravinder.vohra_at_uhb.nhs.uk
• www.choles-study.org