OC-130 Emergency cholecystectomy; an economic evaluation of practice at a regional hepatobiliary centre

Abstract

Introduction: The debate as to how to best manage patients presenting acutely with complications of gallstones continues - whether to consider early emergency surgery on the index admission or to discharge the patient, who is then to be placed on a waiting list. Perceptions of increased risk and greatly increased cost still persist about the early approach. Although in patients with acute severe pancreatitis the recommendation from a clinical viewpoint is to perform an early cholecystectomy, we analysed whether the same strategy can be applied in patients presenting with other complications of gallstones e.g. cholecystitis. We report on our experience from a regional hepatobiliary centre. Methods: A retrospective study was conducted of all patients admitted with acute biliary symptoms, and who underwent emergency cholecystectomy on the index admission, at University Hospital Aintree, Liverpool, by the hepatobiliary team, between January 2008 and August 2011. The comparison group used was that of all patients who had a delayed cholecystectomy, i.e. who were discharged after initial medical treatment for bilary disease and were then placed on the surgical waiting list during this period. Costing data were calculated for each patient on an individual basis, including all theatre consumables, drugs and calculated cost for length of stay on a surgical ward. A decision tree roll back analysis was conducted, using input data derived from the clinical study as well as the individual patient level costs, in order to calculate the overall costs for both the early and delayed cholecystectomy arm of the study. Statistical analysis was conducted using the Chi squared test. Results: Of the 1888 patients who had a laparoscopic cholecystectomy during this period, 89 patients 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 risk of emergency readmissions for all patients on the waiting list was 13% with a median stay of this emergency admission 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 minutes vs. 60 minutes (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 mean baseline cost per patient for eLC was composed of 265.95 for theatre consumables, 780 for operating theatre time, 26.89 for drugs and 1590 for the overall ward inpatient cost including staffing costs, leading to a total of 2663. The cost for dLC was calculated at 2513, leading to a baseline cost difference between the eLC and dLC of around 150 (180) more expensive for the eLC group. But after complications and readmission costs were calculated and inputted into the decision tree analysis, this difference decreased to a cost of 52 (62) - more expensive for the eLC pathway. Conclusion: Early cholecystectomy on the index admission appears to be safe, with an overall length of stay slightly shorter for the early cholecystectomy pathway rather than that of a delayed pathway. The difference in costs between the early and delayed cholecystectomy pathway was minimal per patient, with both patients pathways being essentially cost equivalent. But with NHS tariff (i.e. income derived by the institution) being around 3197 (3836) for a eLC and 1390 (1668) for a dLC, the difference in net monetary benefit per patient was around 1755 (2106) per patient, which would be the income gained per patient by changing to a policy of early versus delayed cholecystectomy for acute biliary disease. In a hospital conducting around 200 cholecystectomies per year on patients for acute biliary disease in the National Health Service, this could translate to a cost saving of over 350,000 per year, or 420,000.