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Observational Study
. 2020 Aug;4(4):622-629.
doi: 10.1002/bjs5.50294. Epub 2020 May 17.

Self-reported and actual adherence to the Tokyo guidelines in the European snapshot audit of complicated calculous biliary disease

G A Bass  1   2 , A E Gillis  1 , Y Cao  3 , S Mohseni  2 ; European Society for Trauma and Emergency Surgery (ESTES) Cohort Studies Group
Collaborators, Affiliations
Observational Study

Self-reported and actual adherence to the Tokyo guidelines in the European snapshot audit of complicated calculous biliary disease

G A Bass et al. BJS Open. 2020 Aug.

Abstract
in English, Spanish

Background: Complicated acute biliary calculous disease poses clinical challenges. The European Society of Trauma and Emergency Surgery (ESTES) snapshot audit of complicated biliary calculous disease aims to make novel comparisons between self-reported institutional adherence to the Tokyo guidelines (TG18) and 'real-world' contemporary practice across Europe.

Methods: A preplanned analysis of a prospective observational multicentre audit that captured patients undergoing emergency admission for complicated biliary calculous disease (complicated cholecystitis, biliary pancreatitis, or choledocholithiasis with or without cholangitis) between 1 and 31 October 2018 was performed. An anonymized survey was administered to participating sites.

Results: Following an open call for participation, 25 centres from nine countries enrolled 338 patients. All centres completed the anonymized survey. Fifteen centres (60 per cent) self-reported that a minority of patients were treated surgically on index admission, favouring interval cholecystectomy. This was replicated in the snapshot audit, in which 152 of 338 patients (45·0 per cent) underwent index admission cholecystectomy, 17 (5·0 per cent) had interval cholecystectomy, and the remaining 169 (50·0 per cent) had not undergone surgery by the end of the 60-day follow-up. Centres that employed a dedicated acute care surgery model of care were more likely to perform index admission cholecystectomy compared with a traditional general surgery 'on call' service (57 versus 38 per cent respectively; odds ratio 2·14 (95 per cent c.i. 1·37 to 3·35), P < 0·001). Six centres (24 per cent) self-reported routinely performing blood cultures in acute cholecystitis; patient-level audit data revealed that blood cultures were done in 47 of 154 patients (30·5 per cent). No centre self-reported omitting antibiotics in the management of acute cholecystitis, and 144 of 154 (93·5 per cent) of patients in the snapshot audit received antibiotics during their index admission.

Conclusion: Awareness of TG18 recommendations was high, but self-reported adherence and objective snapshot audit data showed low compliance with TG18 in patients with complicated acute biliary calculous disease.

Antecedentes: La complicación aguda de la litiasis biliar (complicated acute biliary calculous disease, CABCD) plantea retos clínicos. Esta auditoría de la Sociedad Europea de Trauma y Cirugía de Urgencias (European Society of Trauma and Emergency Surgery, ESTES) de la CABCD tuvo como objetivo comparar el conocimiento teórico de las recomendaciones de Tokio (TG18) y la “práctica real” en Europa. MÉTODOS: Se efectuó un análisis pre-establecido de los datos de una auditoría prospectiva, observacional y multicéntrica que incluyó los pacientes ingresados de urgencia por CABCD (es decir, colecistitis complicada, pancreatitis biliar o coledocolitiasis con o sin colangitis) entre el 1 y el 31 de octubre de 2018. Además, se realizó una encuesta anónima en los centros participantes.

Resultados: Tras una convocatoria abierta, 25 centros de 9 países incluyeron 338 pacientes. Todos los centros completaron la encuesta anónima. El 60% de los centros reconocieron que trataban en el mismo ingreso una minoría de los pacientes y que favorecían la colecistectomía diferida. Ello se reprodujo en la auditoria, donde a 152/338 (44,9%) de los pacientes se realizó la colecistectomía en el mismo ingreso, a 17/338 (5%) se realizó una colecistectomía diferida y que a 169/338 (50%) todavía no se había realizado ninguna intervención en los 60 días de seguimiento. Los centros que seguían el Modelo de Atención Quirúrgica Urgente tenían mayores probabilidades de realizar la colecistectomía en el mismo ingreso en comparación con un servicio de cirugía general tradicional 'de guardia' (57% versus 38,4%, razón de oportunidades, odds ratio, OR 2,14 (i.c. del 95% 1,37-3,35), P < 0,001)). El 24% de los centros afirmaron realizar hemocultivos de rutina en la colecistitis aguda. Sin embargo, los datos de la auditoría revelaron que solamente 47/154 (30,5%) de los pacientes tenían hemocultivos. Ningún centro declaró no administrar antibióticos en el tratamiento de la colecistitis aguda, mientras que 144/154 (93,5%) de los pacientes de la auditoría no recibieron antibióticos durante el ingreso.

Conclusiones: El conocimiento de las recomendaciones de TG18 fue alto. Sin embargo, la observancia reconocida por los centros y los datos objetivos de la auditoría muestran que el cumplimiento en los pacientes con CABCD es bajo.

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