Standardization of surgeon-controlled variables - Impact on outcome in patients with acute cholecystitis

Objective To examine the effect of standardization of surgeon-controlled Variables on patient outcome after cholecystectomy for two cohorts of patients with acu te cholecystitis (AC). Summary Background Data Laparoscopic cholecystectomy (LC), when performed efficiently and safety, o ffers patients with AC a more rapid recovery and decreases the length of st ay, thus reducing the health care utilization. Numerous studies have focuse d on the characteristics of patients with AC that may predict the conversio n of LC to open cholecystectomy. However, analysis of these factors offers little insight for improving the outcome of patients with AC, because patie nt-controlled Variables are difficult to influence. In the present study, t reatment variables that were under the surgeon's control were standardized and the effects of these changes on the outcome of patients with AC were qu antified. Methods Beginning in August 1997, a standardized treatment protocol was initiated f or patients with suspected AC. LC was initiated as early as practical from the time of admission. All operations were performed in a specially equippe d and staffed laparoscopic surgery suite, and all patients were supervised by one of two attending surgeons with a special interest in laparoscopic in terventions. Two cohorts of patients with AC were retrospectively analyzed: 39 patients from the 12 months betore initiation of this protocol (period 1) and 49 patients from the 12 months after its inception (period 2). Medic al records were reviewed for demographic, perioperative, and outcome data. Surgical reports were reviewed to ascertain the reason for conversion and w hether laparoscopic technical modifications were used. Results No significant difference was noted between the groups with regard to patie nt demographics, clinical presentation, or radiologic or laboratory paramet ers. After protocol initiation, patients received definitive treatment clos er to the time of admission and had a greater percentage of laparoscopicall y completed cholecystectomies. Furthermore, the patients in period 2 had a significantly decreased postoperative length of stay and hospital charges t han the earlier ones. Complications were infrequent and not significantly d ifferent between the groups. Two or more laparoscopic technical medications were used in 95% of the successful LCs during period 2 versus 33.3% during period 1. Conclusions By controlling when, where, and by whom LC for AC was performed, the author s have significantly improved the percentage of cholecystectomies that were completed laparoscopically. This has led to improved outcomes and lower ho spital charges for patients with AC at this municipal hospital.