Emergency Gallbladder Removal – Do more, and sooner

Acute pancreatitis is an extremely painful and sometimes deadly condition. The main causes are gallstones and excessive consumption of alcohol. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report, Acute Pancreatitis: Treat the Cause, published in July this year, investigated the process of care for patients aged 16 years and older with acute pancreatitis in the UK. Its findings came as no real surprise to me.

The report highlights the importance of doing the simple things right and doing them first time round. Many patient readmissions with acute pancreatitis could be avoided if the underlying cause is identified and treated during the first admission. Guidelines for the management of Acute Pancreatitis (AP) are widely available in the UK and have been used for many years but this report shows that in a significant number of units the guidelines are simply not being followed. Amazingly 21% of patients where the cause of pancreatitis was not confirmed had not had an ultrasound performed; 20% of patients with AP were inappropriately prescribed antibiotics and 31% were not having early warning scores recorded.

The reports finding that 21% of patients with gallstone related AP had had previous admissions with the same diagnosis confirms many previous studies showing readmission rates as high as 33%. Patients with gallstone related AP need to have their gallbladders removed on the same admission. This will not only prevent further potentially life-threatening attacks, pain and morbidity but has been repeatedly shown to be cost effective. Some patients will be unsuitable due to frailty (many of whom will benefit from prophylactic endoscopic sphincterotomy) or need to recover from the co-morbidities of their severe AP. The Surgical Workload Outcomes Research Database (SWORD) has shown variance from 0-40% in early (within 10 days of admission) cholecystectomy (removal of the gallbladder) rates in hospitals accepting patients with AP and efforts need to be focused at driving up this national average from the current 14% level to what appears to be the appropriate level (given the exceptions above) of around 40%.

The Royal College of Surgeons (RCS) has recently set up a quality improvement project called Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) to advance the emergency cholecystectomy rates in the UK for patients with acute biliary pain or cholecystitis, or gallstone pancreatitis. Initially working with 13 hospitals in England and Wales over an 18-month period, it aims to use quality improvement as a means to support clinical teams in driving service improvement, thereby reducing variation and improving the overall quality of care in acute gallstone disease. The hospitals participating in the collaborative are identifying challenges specific to their local infrastructure and developing strategies in response to these. This is an exciting new project that will be launching on Thursday 6th October and we hope will make vast improvements in the delivery of care for these patients.

Mr Ian Beckingham is a laparoscopic surgeon with specialist interests in upper gastrointestinal procedures. He is president of the Association of Upper Gastrointestinal Surgeons (AUGIS) and has authored Royal College of Surgeons Commissioning Guidance on Gallstone diseases and the AUGIS / ASGBI Emergency General Surgery boards’ Acute Gallstone Diseases pathways document.