K. O. Memeh1, S. Jhajj1, K. Tran1, R. A. Berger1,2, T. S. Riall1, A. Aldridge1,2 1University Of Arizona,Surgery,Tucson, AZ, USA 2Flagstaff Medical Center,Surgery,Flagstaff, AZ, USA
Introduction:
About 3-8% of acute calculous cholecystitis (ACC) present with common bile duct stone (CBDS). The 2010 American Society of Gastrointestinal Endoscopy (ASGE) and the 2016 World Society of Emergency Surgery (WSES) guideline on the management of gallstone with significant risk(high risk[HR] and intermediate risk[IR]) of CBDS recommend pre-operative imaging and ERCP for patient with IR and HR for CBDS respectively. Our group adopted a different approach; primary laparoscopic cholecystectomy (LC) with intraoperative cholangiogram (IOC) for all patients HR and IR for CBDS, and then proceed with intra-operative ERCP (IOERCP) for patients with positive IOC, with the intention of reducing length of stay (LOS) and hospital cost (HoC) without negatively impacting outcome.We believe that this approach is Safe, Fast and cost Effective ( ‘SaFE’) and we thus review the outcome of the ‘SaFE’ approach and compares it with the traditional (ASGE/WSES guided) approach.
Methods:
We retrospectively reviewed the medical record of consecutive patients, 18 years and older presenting with ACC with significant risk for CBDS who underwent LC + IOC +/- IOERCP between Jan 2015 and Feb 2017 in our institution. Patients with cholangitis and pre-operative imaging suggestive of CBD mass (other than stone) were excluded. Patients were stratified into ASGE Intermediate risk (ASGE-IR) and ASGE High risk (ASGE-HR) for CBDS based on the published ASGE criteria. We reviewed pre-operative liver function test, total bilirubin and imaging.Complications( cystic duct leak, post ERCP pancreatitis) and hospital charges (HoC) were evaluated. The student t-test was utilized to analyse difference in LOS when compared to similar patients managed prior to the implementation of the SaFE approach.
Results:
A total of 568 patients presented with ACC and suspicion for CBDS, hence had LC + IOC. IOERCP was performed for positive IOC in 87(15%) patients. Of the 87 patients, 34(39%) was ASGE-HR for CBDS.Medain pre-op T bil was 4.1 and 0.8 for ASGE HR and IR respectively.2 IR patients had negative IOERCP. Average LOS was 1.8 days for both HR and IR patient groups. There was no cystic duct leak and no conversion to open cholecystectomy in any of the 87 patients. Two (1 patient per group) had mild post ERCP pancreatitis. Mean HoC was $10,099 per patient.Prior to implementing the SaFE approach( i.e using the ASGE/WSES guideline),similar cohort of patients had an average LOS of 3.4 days( p < 0.000) , and mean HoC of $14,320 a diffence of $2,941 with estimated cost saving of $255,867 in the 2 year period.
Conclusion:
Our findings suggest that ACC patients who are ASGE-HR, WSES- HR, and ASGE-IR for CBDS could be managed similarly using the ‘SaFE’ approach with significant reduction in both LOS and HoC without any increase in procedure-related morbidity.