ELECTIVE CHOLECYSTECTOMY

Risk of complications from gallstones while awaiting elective cholecystectomy

Risk of complications from gallstones while awaiting elective cholecystectomy

Introduction

Risk of complications from gallstones while awaiting are a common tool for managing access to elective surgery. However, little evidence is available on the health impact of delaying surgery for various conditions. Other than mortality, adverse events experienced by patients while on a waiting list have not been systematically examined. Without these data, appropriate access time for surgery must be determined on the basis of expert opinion.

When treatment is delayed, the condition of a patient on a surgical waiting list may deteriorate and require urgent medical attention. In this case, emergency admission for the awaited procedure may be regarded as an adverse effect of waiting. Also, routine operating room activity may be seriously disrupted by unexpected nonelective admissions of patients on waiting lists.

In patients with biliary colic caused by cholelithiasis, extended treatment delays may increase the probability that the patient will be admitted for delayed cholecystectomy as an emergency case. Emergency admission may be associated with more frequent or more severe attacks of biliary colic or other biliary complications such as acute cholecystitis, obstructive jaundice, cholangitis or pancreatitis. However, little is known about the relationship between time spent on a waiting list and the risk of emergency admission in these patients.

We describe the distribution of times spent waiting for the operation and assess the relationship between waiting-list times and the risk of emergency admission.

Method

The Department of Surgery, Queen's University, is housed at 2 tertiary referral centres that provide services to more than 500 000 residents of southeastern Ontario.

Eight general surgeons perform cholecystectomy. There is no priority ranking system. Each surgeon's office operates its waiting list independently.

Surgeons on call made the decision to operate on patients who presented to the emergency department by evaluating (a) the clinical presentation for symptoms of increased pain or fever and signs of persisting or worsening abdominal tenderness, guarding or rebound or (b) the ultrasonographic finding of a thick-walled gallbladder with pericholecystic fluid or a positive finding of hepatobilary iminodiacetic acid on radionuclide scan or (c) both (a) and (b).

Data on the timing and type of surgery were retrieved from the electronic hospital information system. We identified all adult patients who underwent emergency or elective cholecystectomy from 1997 to 2000 after being seen in clinic for biliary colic. Information on the date of the consultation visit was obtained from patient records through the quality assurance program at the Department of Surgery. Patients who underwent emergency surgery without a prior clinic appointment were not included. All cholecystectomies were initially attempted as laparoscopic procedures. Conversion to the open procedure was required when the dissection was not technically feasible or safe. Forty-one patients were excluded from the analysis because they had immediate (within 3 days) access to planned surgery, leaving a study group of 761.

The primary outcome was emergency admission for cholecystectomy due to the worsening of symptoms while awaiting elective surgery. A waiting-list time was calculated for each patient based on the ...