Factors Affecting Early Cholecystectomy for Acute Cholecystitis in Older People-A Population-Based Study.

OBJECTIVES: Acute cholecystitis is one of the most common surgical presentations in Australia and increases with age. Guidelines recommend early laparoscopic cholecystectomy (within 7 days), as it results in shorter length of stay, reduced costs and readmission rates. Despite this, there is a perception that early cholecystectomy may result in higher morbidity and conversion to open surgery in older patients. Our objective is to report the proportion of early versus delayed cholecystectomy in older patients in New South Wales (NSW), Australia, and to compare health outcomes and factors influencing variation. DESIGN: This is a retrospective population-based cohort study of all cholecystectomies for primary acute cholecystitis in NSW residents aged >50, between 2009 and 2019. The primary outcome was the proportion of early versus delayed cholecystectomy. We used multilevel multivariable logistic regression analyses adjusted for age, sex, comorbidities, insurance status, socio-economic status and hospital characteristics. RESULTS: A high rate (85%) of the 47,478 cholecystectomies in older patients were performed within 7 days of admission. Delayed surgery was associated with increasing age and comorbidity, male sex, Medicare-only insurance and surgery in low- or medium-volume centres. Early surgery was associated with shorter overall length of stay, fewer readmissions, less conversion to open surgery and lower bile duct injury rates. CONCLUSION: A high proportion of adults with cholecystitis are undergoing early cholecystectomy in NSW. Our results support the efficacy of early cholecystectomy in older patients and identify potentially modifiable factors relevant to health care professionals and policymakers.

Managing Adhesive Small Bowel Obstruction with Water-Soluble Contrast Should Be Protocolized: A Retrospective Analysis.

Aim Current literature emphasizes the effectiveness of computed tomography (CT) and water-soluble contrast agent, Gastrografin, in the investigation of adhesive small bowel obstruction (ASBO). As there is no management protocol for ASBO at our institution, the aim of this study was to determine the effect of imaging methods-CT, Gastrografin challenge (GC), or plain-film X-ray-on patient outcomes in a clinical setting. Methods All 163 emergency presentations of ASBO during the study period between December 2010 and September 2012 were collected retrospectively. Cases were divided into three groups: CT with oral contrast, GC, or plain-film X-ray only. The primary outcome was time to theater. Results Patients investigated with X-ray only were significantly less likely to require surgery (6% in plain-film X-ray vs. 35% and 20% in CT and GC, respectively; p = 0.003). In cases requiring surgery, GC was associated with a 24-hour longer time to imaging than CT ( p < 0.001). The time to theater was 71:25 hours for GC versus 46:39 for CT ( p = 0.039). There was no significant difference in bowel resection or complication rates. Conclusion Patients undergoing water-soluble contrast studies were subjected to unnecessary delays in their clinical course. These delays are costly and avoidable. The development and implementation of an evidence-based protocol for the management of small bowel obstruction is strongly recommended. The lack of a protocol likely caused significant delays in Gastrografin administration, reducing its known benefits for clinical decision-making and length of stay.