2022 General Surgery Presentations

Brittany Strahan, MS1; Rathnayaka M. K Gunasingha, MD2; Sydney Dishman, MD2; Elliot Jessie, MD2; Carolyn Gosztyla, MD2; Matthew J Bradley, MD2; 1Uniformed Services University of Health Sciences; 2Walter Reed National Military Medical Center

Introduction: Cholelithiasis is a common disease. While symptomatic cholelithiasis and cholecystitis require surgical management for definitive management, patients with cholelithiasis are often referred to non-surgical providers for further work up of right upper quadrant and/or epigastric pain. The purpose of this project was to determine if referrals to non-surgical providers after initial presentation led to a delay in surgical management.

Methods: All adult patients at our institution who underwent a cholecystectomy in 2015 and 2016 were queried.  Inpatient and outpatient chart reviews were completed to determine symptoms, laboratory and imaging workup, referrals, procedural information, and final pathology. Non-surgical providers were defined as emergency medicine, gastroenterology, family medicine, or internal medicine physicians. Patients were excluded if they had missing data. Qualitative data was analyzed using Chi square test and quantitative data was analyzed using independent t-tests. All analysis was completed in R Version 4.0.3.

Results: Over 2015 and 2016, 210 patients underwent a cholecystectomy. The average age was 46 years and two-thirds of the patients were female. Of those, 197 (93.8%) patients underwent a laparoscopic cholecystectomy and 13 (6.2%) underwent open cholecystectomy. The majority of patients (91.4%) had cholecystitis on pathology with 83.8% chronic cholecystitis, 5.2% acute on chronic, and 2.4% acute cholecystitis. Of those with cholecystitis on pathology, referrals to surgery mainly came from primary care (44.2%), gastroenterology (20%), and the emergency department (17.6%). Those who were referred to non-surgical providers or asked to follow up in the same clinic had a significantly longer time to surgical evaluation that those who were referred directly to surgery after initial presentation (90.3 days vs. 21.4 days, p <0.001). Furthermore, the group undergoing further evaluation with non-surgical providers had a significantly longer time to cholecystectomy from initial symptom presentation compared to those evaluated by surgery sooner (118.3 days vs 52.6 days, p <0.003).  Patients with acute cholecystitis were evaluated by surgery as the first referral significantly more often than those with chronic cholecystitis (X2(1,N=192)=5.3, p<0.02). There was no difference in time to OR once the patient was evaluated by surgery.

Conclusion: This is the first study to show how definitive surgical management of cholecystitis/symptomatic cholelithiasis is significantly delayed if patients were sent to non-surgical providers for workup after presentation. This delay leads to prolonged periods of discomfort for the patient, repeat visits to clinics and the emergency room, and increased healthcare costs. Ongoing process improvement aims to identify patients for surgical referral sooner.