“Same-day procedures decreased length of stay by 2 days and led to an approximately $30,000 cost savings with no difference in conversion rates or complications between the two cohorts. The success rate of operative ERCP was 100%,” Dr. Jeffrey Wild, of Geisinger Health System in Northeastern Pennsylvania, reported at the annual meeting of the American Association for the Surgery of Trauma.
The Geisinger study validated the findings of two previous European studies (Endoscopy 2006;38:779-86; Am. Surg. 2013;79:1243-7). “These studies found decreased length of stay by 2 to 3 days, they found no difference in the incidence of retained stones, no difference in conversion rates to open cholecystectomy, and there was no difference in complications between the two groups,” Dr. Wild said.
The Geisinger investigators conducted the single-center, retrospective study of 240 patients from 2010 to 2014 comparing same-day and separate-day approaches for patients with choledocholithiasis and cholecystitis. In all, 65 patients had same-day procedures, with an average length of stay of 3 days vs. 5 days for patients who had ERCP and cholecystectomy on separate days, Dr. Wild said.
Like the European studies, the Geisinger experience found no statistical difference in conversion rates to open operation (12% for same-day vs. 14% for separate-day procedures) while the rate of discharge to a skilled nursing facility was half in the same-day cohort: 10% vs. 20% for separate-day patients, Dr. Wild said.
The goal of the Geisinger gallbladder pathway is to facilitate early operations in patients with cholecystitis. “Patients who present with cholecystitis should undergo cholecystectomy within 24 hours of presentation, if appropriate,” Dr. Wild said. “If there is evidence of biliary obstruction and the need for further work-up, our goal is to have gastroenterology work-up and management of the patient and have cholecystectomy done within the first 48 hours.”
The study noted some slight variations between the same-day and separate-day approaches, Dr. Wild said. The success rate of the endoscopist to cannulate the ampulla and perform ERCP was 95% in the same-day group and 100% in the separate-day cohort. ERCP was positive in identifying common bile duct stones or sludge in 97% of the same-day group vs. 91% in separate-day patients. More patients in the separate-day cohort required a second ERCP, usually 3 or 4 weeks after discharge and for removal of biliary stents, Dr. Wild said. Demographics in both groups were similar.
Operating room times varied between the two groups, and even within the same-day group depending on the setting for the ERCP, according to Dr. Wild. For patients in the separate-day group, average operative time was 1 hour, 42 minutes; same-day patients who had ERCP in the endoscopy suite and then transferred to the OR for cholecystectomy averaged 1 hour, 34 minutes; while the same-day cohort who had both ERCP and cholecystectomy done in the OR averaged 2 hours, 12 minutes.
Same-day care required coordination between different departments, Dr. Wild said. “Patients in the same-day group required coordination between the acute care surgical service, anesthesia, and gastroenterology to make sure both procedures could be performed under the same general anesthesia,” he said. The same-day group was almost evenly split between having ERCP in endoscopy before moving to the OR and having both done in the OR, Dr. Wild said.
“The findings of this study are, Number 1, intuitively obvious and easily predicted; and, Number 2, why didn’t I think of that myself?” said discussant Dr. Michael Chang of Wake Forest University Baptist Medical Center, Winston-Salem, N.C.
Dr. Chang also noted that the study provides an example of how to restructure care organizations. “Grouping practitioners by disease process, as opposed to what board they’re certified by or what department they live in, is thought to be a more patient-centered approach to provide cost-effective care,” he said.
Dr. Chang and others asked how the Geisinger surgeons overcame institutional barriers in creating their care model. “Most institutions are still dependent on the gastroenterologists, and lining up that procedure with another service can be difficult,” Dr. Donald Reed Jr. of Lutheran Medical Group in Fort Wayne, Ind., noted.
Dr. Wild acknowledged at first the pathway encountered some resistance. “But what really started this process was that the endoscopy suite was closed on weekends and all the ERCPs were performed in OR,” he said. “And then we were taking patients the following morning back to the OR to take out their gallbladder. Some of my senior partners questioned why aren’t we doing these at the same time.”