Improving Peri-operative Morbidity and Informed Patient Consent in Laparoscopic Cholecystectomy

Abstract

The overarching aim was ‘to improve the peri-operative morbidity and informed consent in patients undergoing laparoscopic cholecystectomy (LC)’. This was divided into three aspects: 1) the timing of LC, 2) specific diagnosis of gallstone disease (GD) and 3) the severity of GD. Firstly, across a large patient cohort (n=2768) a comprehensive set of outcomes are reported for emergency and elective LC and are compared to determine the relative risk of emergency LC. The first section provides robust variable balancing and demonstrates the significant morbidity of emergency LC compared to elective LC.

The next section investigates the risk of readmission, its predisposing factors and its associated morbidity. Most importantly, the morbidity of acute cholecystitis (AC), particularly ≥2 admissions of AC, are demonstrated. Following this, the optimal timings of LC to minimise readmissions and overall morbidity are recommended. In outpatients awaiting LC, a four-month target to elective LC is recommended to reduce the risk of readmissions and the associated morbidity. In patients admitted as an emergency, an expedited elective LC performed within 6-12 weeks is proposed as the gold-standard.

Following this, the ‘GALLRISK’ model aggregates risk factors to predict adverse peri-operative outcomes. The model can help prioritise patients for elective LC, indicate an appropriate operative unit (secondary vs. tertiary care) or list-type (pooled vs. consultant-specific) and can help inform patient consent. The model is reported as a research tool at https://gallrisk.com.

The thesis also aims to improve peri-operative morbidity and informed patient consent in AC subgroups. The present data demonstrates the heightened peri-operative risk of an emergency LC for AC but specifically in patients with 1 admission of AC. On the other hand, the advantages of emergency LC for AC are clear, namely the elimination of readmission-risk, the lower cost and shorter total length of stay. Patients with ≥2 admissions of AC may also benefit from emergency LC to reduce the rate of bile duct injury (BDI) and fistulation. Interestingly, no significant differences were observed between the timings of emergency (e.g. <72 vs. >72 hours) or elective LC (e.g. <6 vs. >6 weeks).

Overall, an expedited elective LC (within 6-12 weeks) is the gold standard operative strategy for AC admissions but ultimately, the operative strategy should be influenced by the expected elective LC waiting times. If opting for an expedited elective LC, timely LC must be achieved to reduce readmissions, and the date of surgery should be guaranteed prior to discharge. If patients cannot realistically be prioritised within 6-12 weeks, conservative management would not be advised, and emergency LC may be the superior approach.

Emergency LC for biliary colic (BC), gallstone pancreatitis and choledocholithiasis was found to be a safe approach. In such cases, emergency LC prevented further biliary readmission and in BC the overall morbidity was reduced.

By providing both proactive and timely elective LC for outpatients (within four months) and emergency LC for BC, gallstone pancreatitis and choledocholithiasis, overall waiting times for LC would be reduced. This would in turn reduce the number of admissions, readmissions and the overall morbidity of patients awaiting LC. With lower overall morbidity of LC, less resources would be required which would permit more resources to be allocated towards timely LC. This would further reduce waiting times and continue the cycle towards a reduction in overall morbidity.

The third aim was to improve peri-operative morbidity and informed patient consent in severe GD. Until the latter publications, the risk associated with subtotal cholecystectomy (STC) had not been quantified and as such informed patient consent could not be achieved in high-risk patients. Patients at high-risk of STC have been identified and the model has been published at https://subtotalrisk.com. Furthermore, through the development of the laparoscopic lumen-guided cholecystectomy (LLC), surgeons are presented with an alternative technique which may help improve rates of cystic duct control and reduce rates of post-operative complication and intervention rates. The use of a textbook outcome in LC is reported as a tool to report GD severity, improve patient consent, a metric for quality improvement and to help healthcare units manage their resource allocation.

Following this, an algorithm for the management of GD is proposed which incorporates key aspects presented in the thesis. The hypothetical improvements in outcomes that would be achieved by implementing the algorithm are reported. Furthermore, the impact of adopting the algorithm compared to current practice is reported. Significant improvements in morbidity rates, re-intervention rates, textbook outcome rates, cost and length of stay are reported. For example, around £1,303,998 could be saved per year per 1,000,000 population by following the algorithm. Furthermore, the rate of complications and salvage procedures could be reduced by approximately 30.5% and 59.5%, respectively, by following the algorithm.

Further steps were taken to improve informed consent by reporting individualised outcomes according to the timing of LC and GD diagnosis. Textbook outcomes, general risks, and operation-specific complication rates can be used to form patient-specific consent forms.

It is hoped that the analyses and conclusions presented in this thesis will help improve the perioperative morbidity of LC and to improve informed patient consent by acting as a standard of care. Furthermore, the implementation of the recommendations of the thesis should be evaluated through quality improvement methodology driven towards achieving improved outcomes.

Date of Award	2025
Original language	English
Awarding Institution	University of Dundee
Supervisor	Pradeep Patil (Supervisor), John Scollay (Supervisor), Benjie Tang (Supervisor) & Ghulam Nabi (Supervisor)