A nationwide analysis of gallbladder surgery in England between 2000 and 2019 (SURGERY, Oct 2021)

1. A nationwide analysis of gallbladder
surgery in England between 2000 and
2019
Lunevicius R, Nzenwa IC, Mesri M
Liverpool University Hospitals NHS Foundation Trust, Aintree Hospital
University of Liverpool
Chole-QuIC meeting, Liverpool
23th November, 2021
24/11/2021 1

2. Hypothesis a substantial increase
in the utilization of STC & c-stomy
for benign gallbladder disease
may be observed in England.
The main objective was to
generate, examine and present
the trends in STC,
cholecystostomy,
cholecystolithotomy, and total
cholecystectomy (TC) in England
over the last 20 years.
One of the secondary objectives
was to assess the effect of the
surgical setting in these trends.
24/11/2021 2
Background

3. Design, adherence, data, procedures
• STROBE statement and checklist
• Data from the HES used
• NHS England Hospitals
• OPCS-4: seven codes (codes for malignant disease excluded)
• Population size: Office for National Statistics
• Rates calculated for 100,000 individuals per annum.
Methods
24/11/2021 3

4. Aims
Flowchart showing seven OPCS-4 codes, the counts and percentage
proportions of gallbladder surgeries between 2000 and 2019 in England:
A total of 1,234,319 gallbladder surgeries were performed. Of these, TC accounted
for 96.8%, and STC, cholecystostomy and cholecystolithotomy accounted for 3.2%.
24/11/2021 4
Results

5. Overview, 2000 - 2019
That estimated that, on average, 0.12%
(min, 0.08% in 2000, max, 0.14% in 2016 [95% CI 0.11-0.13]) of the
English population underwent a gallbladder
surgery per year
• An average of 12 individuals out of 10,000
» 120 out of 100,000 (Southport size, appr)
» 1,200 out of 1 MM (Liverpool size, appr)
Results
24/11/2021 5

6. In terms of percentage change in 4 procedures between
2000 and 2019
• The annual counts of cholecystolithotomies remained stable,
with an average of 48 surgeries per year (range, 38 to 59).
• The total number of all GB surgeries performed annually
increased by 80%: n=39,584  71,416
• The annual number of TC increased by 72%: 39,022  67,204
• The most striking increases were in cholecystostomy and STC
– with cholecystostomy increasing by 723% (290  2,387)
– STC by 717% (217  1,772).
24/11/2021 6
Results

7. Conversion of data into TEMPORAL TRENDS demonstrated an increasing gap
in counts between all gallbladder surgical procedures & total cholecystectomy
which appeared to be significant (P-trend <0.0001, ANOVA)
Unexpectedly and quite shockingly, both trend lines have been declining since 2016
24/11/2021 7
Results

8. Figure presents 4 plots showing the temporal trends in surgery counts,
rates, and proportions annually, by individual surgery code and type
INCREASE
A 6-fold: in open cholecystostomy rates
A 8-fold - in PC rates
A 7-fold - in STC rates.
REDUCTION
An overall reduction in the proportions of
TC, while the proportions of
cholecystostomy and STC increased,
between 2000 and 2019.
ADDITIONAL POINT
From 2017 to 2019, the counts, rates, and
proportions of cholecystostomy rose
sharply, whereas those for TC and STC
decreased or stagnated.
24/11/2021 8
Results
C D

9. Table shows the change in ratios and proportions of TC to STC
and cholecystectomy to cholecystostomy from 2000 to 2019
• A 5-fold decrease in the ratio of TC
to STC was detected:
180:1 in 2000 vs 38:1 in 2019
• Similarly, a decrease of equivalent
magnitude was detected in the
ratio of cholecystectomy to
cholecystostomy:
• 135:1 vs 29:1
24/11/2021 9
Results

10. Fig. presents a heat map
that highlights the percentage
changes in counts, by reference year
2000, for four gallbladder surgeries
between 2000 and 2019
and shows a rapid rise in both
cholecystostomy (since 2009) and
STC (since 2006) in England.
The shades of red color correlate with the
percentage change values.
The intensity of the red color expresses the
magnitude of the percentage change; the more
intense the shade, the greater the percentage
change.
24/11/2021 10

11. Trends by surgery setting
A total of 1,098,233 elective and 136,086 emergency gallbladder operations were performed from 2000 to 2019
24/11/2021 11
Elective: 89%
Emergency: 11%
Results

12. Elective vs emergency
p < 0.05: Cholecystolithotomy, STC and TC
are the more common surgical
procedures in elective surgery setting
(see plots A, C and D).
Although cholecystostomies were more
frequently performed in an emergency
setting, there was no statistically
significant association between surgery
setting and cholecystostomy counts (as
well as in rates) – see plot B.
It is important as this finding stresses the
trend towards rescue surgical procedures
in elective gallbladder surgery setting in
England.
24/11/2021 12
Results
E
m
e
r
g
e
n
c
y
E
l
e
c
t
i
v
e
0.00
0.02
0.04
0.06
0.08
Mean
with
95%
CI
Cholecystolithotomy
Emergency
Elective
E
m
e
r
g
e
n
c
y
E
l
e
c
t
i
v
e
0.0
0.5
1.0
1.5
2.0
Subtotal cholecystectomy
Mean
with
95%
CI
Emergency
Elective
E
m
e
r
g
e
n
c
y
E
l
e
c
t
i
v
e
0.0
0.5
1.0
1.5
Cholecystostomy
Mean
with
95%
CI
Emergency
Elective
E
m
e
r
g
e
n
c
y
E
l
e
c
t
i
v
e
0
50
100
150
Total cholecystectomy
Mean
with
95%
CI
Emergency
Elective
B
A
C D

13. Interpretations
24/11/2021 13
(1) Generating and assessing national trends is paramount for describing a
surgical epidemiology in the country
It is a tool to forecast the future of gallbladder surgery for benign disease in
England.
(2) There was a steady decline in the proportion of TC performed annually, and a
dramatic expansion in cholecystostomies and STCs.
A further research question is quite essential:
does it correlate with the incidence of BDI in the country?
(3) We observed a decline, by 10%, in both TC counts and rates, 2016-2019
Question is provocative:
what is the value of countless AUGIS, TOKYO, NICE, WSES, SAGES, etc. guidelines
and consensus statements for management of symptomatic gallstone disease?
Discussion

14. Interpretations
24/11/2021 14
(4) As the rates of emergency TCs were relatively low
throughout the entire study period, a significant
proportion of discharged patients with acute biliary
pain underwent rescue surgeries in the elective
surgery setting due to increased difficulty in
cholecystectomy related to ongoing chronic
inflammation
(5) This led to a massive rise in the rates and counts of
STC in the country, especially in elective setting
Discussion

15. A retrospective cohort study conducted in Liverpool showed that several preoperative
factors were associated with conversion to STC in an elective surgery setting:
• Charlson Comorbidity Index 3 or 4
• Referrals to regional hepatobiliary surgery
centers with specific problem
• Previous emergency admissions with
acute cholecystitis
• A prolonged interval between
presentation and surgery
• Therapeutic ERCP before gallbladder
surgery
These factors could have contributed to the
significant increase in the rates of elective
STCs in the country
24/11/2021 15
Lunevicius, Haagsma, J Laparoendosc Adv Surg Tech A, 2021
Discussion

16. Possible reasons for the apparent shift towards
the STC and cholecystostomy
1. The lack of timely treatment
2. The impact of socioeconomic deprivation
3. The utility of cholecystostomy to control the source
of biliary sepsis in the elderly or severity ill patients
4. The fear of litigation
24/11/2021 16
Discussion

17. Conclusions
1. The provision of surgery for benign biliary disease has improved in England over
the last two decades, especially between 2000 and 2016
2. It translates, however, to disproportionately high numbers of STC and
cholecystostomy
3. This novel study calls for action to establish a comprehensive prospective registry
to regularly monitor the trends in gallbladder surgical procedures and their
associated clinical outcomes, especially bile duct injury (SWORD does not cover it)
4. The framework for acute biliary surgery provision requires a substantial revision
nationwide; it is a job for all, as rescue gallbladder surgical procedures are
associated with a significant burden and massive costs for the patients and the
providers of the surgical care
Nzenwa, Mesri, Lunevicius, SURGERY 2021,
Lunevicius, Haagsma, J Laparoendosc Adv Surg Tech A, 2021
24/11/2021 17

18. A Nationwide Analysis of Gallbladder Surgery in
England Between 2000 and 2019
Data on cholecystolithotomy, cholecystostomy, subtotal and total
cholecystectomies retrieved from Hospital Episode Statistics via NHS Digital.
1,234,319 gallbladder
surgeries performed, of
which 96.8% were total
cholecystectomies (TC).
Total number of surgeries
performed annually
increased by 80.4% from
2000 to 2019.
Lunevicius, Nzenwa and Mesri,
2021
The annual counts of subtotal
cholecystectomies (STC) and
cholecystostomies increased by
716.6% and 723.1%,
respectively.
STC is significantly more
likely to be performed
electively.
No difference in rates of
STC and cholecystostomy
in male vs. female
patients.
Advancing age increases
the likelihood of
undergoing STC and
cholecystostomy.
Ratio of TC to STC
180:1 in 2000 vs. 38:1 in 2019.
Ratio of Cholecystectomy to
Cholecystostomy
135:1 in 2000 vs. 29:1 in 2019.
@RayLunevicius
@SurgJournal