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Ravi Vohra

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Evidence? Level 1 evidence support early or acute laparoscopic cholecytectomyin: Biliary colic (1 RCT, n=75) Cholecystitis (6 RCTs, n=488) Gallstone pancreatitis ... – PowerPoint PPT presentation

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Title: 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
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