Variability in Management of Acute Calculous Cholecystitis: An Institutional Survey

Philippe Paci, MD, Pepa Kaneva, MSc, Julio F. Fiore Jr, PhD, Melina C. Vassiliou, MD, MEd, Liane S. Feldman, MD. Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Centre, McGill University

INTRODUCTION: Although literature and expert consensus support early cholecystectomy as definitive management in acute calculous cholecystitis (ACC), variations in management practices persist.  The purpose of this study was to identify practice variations within a single institution including decision for operative management or percutaneous cholecystostomy and management of concomitant biliary obstruction, and to compare these practices with guideline recommendations.

METHODS AND PROCEDURES: A web-based survey was sent to faculty members and senior residents (≥PGY3) of a Canadian university-affiliated general surgery division at four academic hospitals.  The faculty represent surgeons with various subspecialty interests who also take general surgery/acute care surgery call.  The 18-item survey was divided into 3 sections: demographics, management based on 8 clinical scenarios, and perceived logistic barriers. Clinical scenarios varied in severity of ACC classified by the 2013 Tokyo Guidelines, patient age and comorbidities, and risk of concurrent choledocholithiasis.  Questions were developed after identifying best practices using a structured literature search.

RESULTS: From 74 potential respondents, 34 faculty members and 24 senior residents responded to the survey (78% response rate).  Of these, 85% performed at least 1 emergency cholecystectomy in the past year.   For mild ACC, 91% of respondents agreed with early cholecystectomy as optimal management.  However, for mild ACC in a comorbid patient (ASA3), this decreased to 65%, with the remainder opting for a “cool down” period (22%) or cholecystostomy tube (13%).  For mild ACC in an elderly healthy patient, only 62% opted for early cholecystectomy, with 27% favoring nonoperative management and 11% placing a cholecystostomy tube. There was a range of preferences when the presentation included an intermediate risk of choledocholithiasis, where guidelines recommend either intraoperative cholangiogram (IOC) or preoperative EUS or MRCP: 32% opted for ERCP, 20% for preoperative MRCP or EUS and only 27% chose to perform an IOC. Regarding perceived barriers, 44% of staff cited lack of OR time as being responsible for delaying early cholecystectomy. Barriers to IOC were increased OR time (cited by 29% of staff) and lack of training (cited by 37% of residents).

CONCLUSION: Variations in opinions about best management of ACC were identified within a Canadian university-affiliated general surgery division.  While management was consistent with guidelines for straightforward cases in healthy patients, increasing variability was seen as case complexity and patient comorbidity increased. This information will be used to design a knowledge translation project targeting gaps in management with best practice guidelines and identified barriers. 

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