Pisano Michele, Ceresoli Marco, Allegri Andrea, Belotti Eugenia, Coccolini Federico, Colombi Renata, Manfredi Roberto, Margarito Francesco, Merli Cecilia, Montori Giulia, Piazzalunga Dario, Ansaloni Luca
Department of General Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
Department of Emergency, Papa Giovanni XXIII Hospital, Bergamo, Italy.
Ulus Travma Acil Cerrahi Derg. 2015 Sep;21(5):373-9. doi: 10.5505/tjtes.2015.62679.
Treatment option and timing for surgery in case of acute calculous cholecystitis (ACC) is still a matter of discussion. Tokyo Guidelines (TG13) offers some rules but they don't reflect entirely the information of Evidence Based Medicine (EBM). This study aimed to draw some consideration from our practice in the application of the guidelines and put forward the clinical, economic and organizational effect of it.
The study is a single center retrospective study based on administrative database formed by gathering information from clinical registry. Data were collected between January 1st, 2008 and April 30th, 2013. A cutoff point was established on May 15th, 2010 when we moved from a single surgeon method to a shared EBM method to treat ACC. The economic aspect was developed considering health service reimburse and hospital costs.
Five hundred and two patients were selected, 203 patients before the organizational change (Group 0) and 299 after (Group 1). In Group 0, 24.63% of the patients were treated with early laparoscopic cholecystectomy (ELC) and 39.4% received surgery delayed in second admission (DLC). After the change, 57.5% of the patients were treated with ELC while 13% were treated with DLC. Median length of stay (LOS) was significantly lower after the change (9.5 vs. 7.3, p<0.0001), and no difference in terms of complication was noticed.
Application of evidence based medicine in clinical practice resulted in better results. Economically, the clinical change resulted in a proper use of resources with a positive gap between the costs and refund to the hospital.
急性结石性胆囊炎（ACC）手术的治疗方案及时机仍存在争议。东京指南（TG13）提供了一些规则，但它们并未完全反映循证医学（EBM）的信息。本研究旨在从我们应用该指南的实践中得出一些思考，并提出其临床、经济和组织效果。
本研究是一项单中心回顾性研究，基于通过收集临床登记信息形成的行政数据库。数据收集时间为2008年1月1日至2013年4月30日。2010年5月15日设立了一个分界点，当时我们从单一外科医生方法转变为共享循证医学方法来治疗ACC。经济方面是从医疗服务报销和医院成本的角度进行分析的。
共选取了502例患者，组织变革前203例（0组），变革后299例（1组）。在0组中，24.63%的患者接受了早期腹腔镜胆囊切除术（ELC），39.4%的患者在第二次入院时接受了延迟手术（DLC）。变革后，57.5%的患者接受了ELC治疗，而13%的患者接受了DLC治疗。变革后中位住院时间（LOS）显著缩短（9.5天对7.3天，p<0.0001），且并发症方面无差异。
循证医学在临床实践中的应用取得了更好的效果。在经济方面，临床变革导致了资源利用更加合理，医院成本与退款之间存在正向差距。
