1. Ravi Vohra West Midlands Research Collaborative Clinical Variation in Practice of Laparoscopic Cholecystectomy and Surgical Outcomes: a multi-centre, prospective, population-based cohort study

2. Why? Management varies widely between surgeons and hospitals – Acute vs. Elective Cholecystectomy is common 66,000 cholecystectomies were performed during the 2011- 12 financial year in England alone Trainees are involved in

3. Evidence? Level 1 evidence support early or acute laparoscopic cholecytectomy in: – Biliary colic (1 RCT, n=75) – Cholecystitis (6 RCTs, n=488) – Gallstone pancreatitis (1RCT, n=303) (Meta-analysis)

4. Retrospective data Harrison et al. BMJ, 2012;344:e3330 Sinha et al. Surg Endosc, 2013;27(1):162-75.

5. Nottingham CCG AUGIS/RCS 2013

6. Aim Hypothesis: Within the UK different practices are being adopted resulting in important differences in surgical outcomes To investigate surgical outcomes following acute, ‘delayed’ and elective cholecystectomies Multi-centre, contemporary, prospective, cohort study Audit standard: All-cause 30-day readmission rate should be less than 10% following cholecystectomy (primary outcome measure)

7. Methods Two-month period (March- April 2014) with 30 day follow up All patients undergoing cholecystectomy – Acute (first acute admission with biliary disease through A&E or GP and cholecystectomy performed during that index admission) – Elective (planned elective admission for cholecystectomy who have been referred from their GP and added to the routine surgical waiting list from the outpatient department only – Delayed (all other planned cholecystectomies).

8. Post-operative data In-hospital complications In-hospital re-interventions and re- imaging Date of discharge 30-day data All-cause A&E attendance All-cause 30-day readmission Date of re-admission Complications Re-interventions and re-imaging Date of discharge following readmission 30-day mortality Preoperative Age; Gender, BMI, ASA Current Admission Date Operation Date Timing of Surgery Pre-operative indication Number of previous surgical admissions Investigations Intra-operative data Seniority of surgeons Speciality of surgeon Perioperative antibiotics Method of operation Degree of difficulty Complications Intraoperative cholangiography CBD exploration performed Abdominal drain left at the end 28 Data points

9. One week, 5 centres 34 Choles All laparoscopic Range 0 - 15 procedures LoHS 1 day (0-5 days) Pilot

10. Conclusion Population-based cohort study Determine variation and impact on surgical outcomes in a non-trial cohort ‘The Power of Many’ West Midlands ~1500 England ~ 10,000 UK ~ 12,000 Ewen.griffiths@uhb.nhs.uk Ravinder.vohra@uhb.nhs.uk www.choles-study.org