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Operative outcome and patient satisfaction in early and delayed laparoscopic cholecystectomy for acute cholecystitis. Minim Invasive Surg 2014; 2014:162643. [PMID: 25197568 PMCID: PMC4147267 DOI: 10.1155/2014/162643] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 07/29/2014] [Accepted: 08/03/2014] [Indexed: 12/18/2022] Open
Abstract
Introduction. Early laparoscopic cholecystectomy is usually associated with reduced hospital stay, sick leave, and health care expenditures. Early diagnosis and treatment of acute cholecystitis reduce both mortality and morbidity and the accurate diagnosis requires specific diagnostic criteria of clinical data and imaging studies. Objectives. To compare early versus delayed laparoscopic cholecystectomy regarding the operative outcome and patient satisfaction. Patients and Methods. Patients with acute cholecystitis were divided into two groups, early (A) and delayed (B) cholecystectomy. Diagnosis of acute cholecystitis was confirmed by clinical examination, laboratory data, and ultrasound study. The primary end point was operative and postoperative outcome and the secondary was patient's satisfaction. Results. The number of readmissions in delayed treatment group B was three times in 10% of patients, twice in 23.3%, and once in 66.7% while the number of readmissions was once only in patients in group A and the mean total hospital stays were higher in group B than in group A. The overall patient's satisfaction was 92.66 ± 6.8 in group A compared with 75.34 ± 12.85 in group B. Conclusion. Early laparoscopic cholecystectomy resulted in significant reduction in length of hospital stay and accepted rate of operative complications and conversion rates when compared with delayed techniques.
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153
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Pieniowski E, Popowicz A, Lundell L, Gerber P, Gustafsson U, Sinabulya H, Sjödahl K, Tsekrekos A, Sandblom G. Early versus delayed surgery for acute cholecystitis as an applied treatment strategy when assessed in a population-based cohort. Dig Surg 2014; 31:169-76. [PMID: 25034765 DOI: 10.1159/000363659] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 05/13/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aims of this study were to describe the surgical management of acute cholecystitis (AC) in a well-defined population-based patient cohort, in particular adherence to and outcome of the early open/laparoscopic cholecystectomy (EC/ELC) strategy. METHODS The medical records of all patients residing in Stockholm County who were treated for AC during 2003 and 2008 were reviewed according to a standardized protocol. RESULTS In 2003, 799 patients were admitted 850 times for AC, and the respective figures for 2008 were 833 and 919. The number of patients who underwent EC/ELC increased from 42.9% in 2003 to 47.4% in 2008. In multivariate regression analysis adjusting for age, gender, severity of cholecystitis, maximal CRP and maximal WBC, EC/ELC was associated with shorter operation time but higher perioperative blood loss when compared to delayed open/laparoscopic cholecystectomy (DC/DLC). The odds ratio for completing the procedure laparoscopically was significantly higher in DC/DLC when adjusting for the same covariates. There were no significant differences in peri- or postoperative complications between the groups. CONCLUSION Strategies should be implemented in order to secure a more evidence-based approach to the surgical treatment of AC.
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Melloul E, Denys A, Demartines N, Schäfer M. Percutaneous cholecystostomy for acute cholecystitis: who should really benefit from this procedure? HPB (Oxford) 2014; 16:686. [PMID: 24934195 PMCID: PMC4105908 DOI: 10.1111/hpb.12177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Emmanuel Melloul
- Department of Visceral Surgery, University Hospital LausanneLausanne, Switzerland
| | - Alban Denys
- Department of Interventional Radiology, University Hospital LausanneLausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital LausanneLausanne, Switzerland
| | - Markus Schäfer
- Department of Visceral Surgery, University Hospital LausanneLausanne, Switzerland
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Slim K, Launay Savary MV. Ne « refroidissez » plus les cholécystites aiguës lithiasiques ! ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-014-0418-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Morris S, Gurusamy KS, Patel N, Davidson BR. Cost-effectiveness of early laparoscopic cholecystectomy for mild acute gallstone pancreatitis. Br J Surg 2014; 101:828-35. [PMID: 24756933 DOI: 10.1002/bjs.9501] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND A recent Cochrane review suggested that laparoscopic cholecystectomy carried out early following mild gallstone pancreatitis was safe. This study compared the cost-effectiveness of laparoscopic cholecystectomy performed within 3 days of admission, during the same admission but after more than 3 days, or electively in a subsequent admission. METHODS A model-based cost-utility analysis was performed estimating mean costs and quality-adjusted life-years (QALYs) per patient in the UK National Health Service with a 1-year time horizon. A decision tree model was constructed and populated with probabilities, outcomes and cost data from published sources for mild gallstone pancreatitis, including one-way and probabilistic sensitivity analyses. RESULTS The costs of laparoscopic cholecystectomy performed within 3 days of admission, beyond 3 days but in the same admission, and electively in a subsequent admission were € 2748, € 3543 and € 3752 respectively; the QALYs were 0.888, 0.888 and 0.884 respectively. Early laparoscopic cholecystectomy had a 91 per cent probability of being cost-effective at the maximum willingness to pay for a QALY commonly used in the UK. It is acknowledged that many hospitals do not have access to magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography, especially at weekends, and that implementing a 3-day target is unrealistic without allocating new resources that could erode the cost-effectiveness. CONCLUSION Performing laparoscopic cholecystectomy for mild gallstone pancreatitis within 3 days of admission is cost-effective, but may not be feasible without significant resource allocation. After 3 days there is little financial advantage to same-admission operation.
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Affiliation(s)
- S Morris
- Department of Applied Health Research, University College London
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157
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Flexer SM, Peter MB, Durham-Hall AC, Ausobsky JR. Patient outcomes after treatment with percutaneous cholecystostomy for biliary sepsis. Ann R Coll Surg Engl 2014; 96:229-33. [PMID: 24780790 PMCID: PMC4474055 DOI: 10.1308/003588414x13814021679799] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2013] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Acute cholecystitis is among the most common general surgical presentations. There is a cohort of patients who develop systemic sepsis and complications of acute cholecystitis. These patients are often elderly and co-morbid. Conservative management with percutaneous cholecystostomy has been shown to be a safe and effective management option in the acute setting. However, there is currently no consensus for the further management of these patients. In particular, there is a paucity of data on readmission rates and subsequent operative or non-operative management. METHODS A retrospective study was carried out of patients treated with a percutaneous cholecystostomy for biliary sepsis over a three-year period in a UK teaching hospital. Outcome measures were subsequent operative or conservative management, conversion rates, operative complications and readmission rates. RESULTS Twenty-five patients had a percutaneous cholecystostomy for the treatment of acute biliary sepsis. The median follow-up duration was 35 months. Thirteen patients (52%) had operative treatment. In the operative group, 6/13 had a laparoscopic cholecystectomy, 2/13 had a planned open cholecystectomy, 2/13 had abandoned procedures and 3/13 had a converted procedure. Complications in the operative group included: postoperative mortality (1/13), common bile duct injury requiring drainage and endoscopic stenting (1/13) and one patient required readmission with recurrent pain. In the non-operative group, 5/12 patients were readmitted with biliary sepsis, 5/12 had no readmissions, 1/12 died in the community and 1/12 was readmitted with biliary colic. CONCLUSIONS Percutaneous cholecystostomy is a recognised treatment modality for elderly, co-morbid patients with biliary sepsis. Nevertheless, the readmission rate in this group is relatively high at 5/12 (42%). Patients who undergo subsequent operative management have a conversion rate of 3/13 (23%) and a significant complication rate of 2/13 (15%). The further management of patients having undergone percutaneous cholecystostomy requires careful consideration on an individual case basis. The P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) may aid decision making.
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Affiliation(s)
- S M Flexer
- Bradford Teaching Hospitals NHS Foundation Trust, UK.
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158
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Jayakrishnan TT, Groeschl RT, George B, Thomas JP, Pappas S, Gamblin TC, Turaga KK. Management of acute cholecystitis in cancer patients: a comparative effectiveness approach. Surg Endosc 2014; 28:1505-14. [DOI: 10.1007/s00464-013-3344-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 11/04/2013] [Indexed: 01/12/2023]
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Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis. Ann Surg 2014; 259:10-5. [PMID: 23979286 DOI: 10.1097/sla.0b013e3182a5cf36] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To compare the operative outcomes of early and delayed cholecystectomy for acute cholecystitis. BACKGROUND Randomized trials comparing early to delayed cholecystectomy for acute cholecystitis have limited contemporary external validity. Furthermore, no study to date has been large enough to assess the impact of timing of cholecystectomy on the frequency of serious rare complications including bile duct injury and death. METHODS This is a population-based retrospective cohort study of patients emergently admitted to hospital with acute cholecystitis and managed with cholecystectomy over the period of April 1, 2004, to March 31, 2011. We used administrative records for the province of Ontario, Canada. Patients were divided into 2 exposure groups: those who underwent cholecystectomy within 7 days of emergency department presentation on index admission (early cholecystectomy) and those whose cholecystectomy was delayed. The primary outcome was major bile duct injury requiring operative repair within 6 months of cholecystectomy. Secondary outcomes included major bile duct injury or death, 30-day postcholecystectomy mortality, completion of cholecystectomy with an open approach, conversion among laparoscopic cases, and total hospital length of stay. Propensity score methods were used to address confounding by indication. RESULTS From 22,202 patients, a well-balanced matched cohort of 14,220 patients was defined. Early cholecystectomy was associated with a lower risk of major bile duct injury [0.28% vs 0.53%, relative risk (RR)=0.53, 95% confidence interval [CI]: 0.31-0.90], of major bile duct injury or death (1.36% vs 1.88%, RR=0.72, 95% CI: 0.56-0.94), and, albeit non-significant, of 30-day mortality (0.46% vs 0.64%, RR=0.73, 95% CI: 0.47-1.15). Total hospital length of stay was shorter with early cholecystectomy (mean difference 1.9 days, 95% CI: 1.7-2.1). No significant differences were observed in terms, open cholecystectomy (15% vs 14%, RR=1.07, 95% CI: 0.99-1.16) or in conversion among laparoscopic cases (11% vs 10%, RR=1.02, 95% CI: 0.93-1.13). CONCLUSIONS These results support the benefit of early overdelayed cholecystectomy for patients with acute cholecystitis.
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Abstract
Acute cholecystitis is defined as inflammation of the gallbladder and is usually caused by obstruction of the cystic duct. Cholescintigraphy is the most sensitive imaging modality for cholecystitis. The gold standard treatment of acute cholecystitis is laparoscopic cholecystectomy. Operating early in the disease course decreases overall hospital stay and avoids increased complications, conversion to open procedures, and mortality. Cholecystitis during pregnancy is a challenging problem for surgeons. Operative intervention is generally safe for both mother and fetus, given the improved morbidity of the laparoscopic approach compared with open, although increased caution should be exercised in women with gallstone pancreatitis.
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Affiliation(s)
- Lawrence M Knab
- Department of Surgery, Northwestern University Feinberg School of Medicine, Lurie Building Room 3-250, 303 East Superior Street, Chicago, IL 60611, USA
| | - Anne-Marie Boller
- Department of Surgery, Northwestern University Feinberg School of Medicine, NMH/Arkes Family Pavilion Suite 650, 676 North Saint Clair, Chicago, IL 60611, USA
| | - David M Mahvi
- Department of Surgery, Northwestern University Feinberg School of Medicine, NMH/Arkes Family Pavilion Suite 650, 676 North Saint Clair, Chicago, IL 60611, USA.
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161
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Navez B, Navez J. Laparoscopy in the acute abdomen. Best Pract Res Clin Gastroenterol 2014; 28:3-17. [PMID: 24485251 DOI: 10.1016/j.bpg.2013.11.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 10/09/2013] [Accepted: 11/23/2013] [Indexed: 01/31/2023]
Abstract
Laparoscopy has become a routine procedure in the management of acute abdominal disease and can be considered both an excellent therapeutic and additional diagnostic tool in selected cases. However, a high level of expertise in laparoscopic and emergency surgery is required. Hemodynamic instability, huge abdominal distension, fecal peritonitis and perforated cancer are relative contraindications for the laparoscopic approach. In recent years, abdominal emergencies have increasingly been managed successfully by laparoscopy. In acute appendicitis, acute cholecystitis and perforated peptic ulcer, randomized controlled trials have proven that the laparoscopic approach is as safe and as effective as open surgery, with fewer complications and a quicker postoperative recovery. Other indications such as blunt and penetrating trauma to the abdomen, small bowel occlusion and perforated diverticular disease are under debate, indicating that more randomized controlled trials comparing laparoscopic and open surgery are still necessary.
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Affiliation(s)
- Benoit Navez
- Department of Abdominal Surgery and Transplantation, Cliniques universitaires Saint-Luc, 10 Avenue Hippocrate, 1200 Brussels, Belgium.
| | - Julie Navez
- Department of Abdominal Surgery and Transplantation, Cliniques universitaires Saint-Luc, 10 Avenue Hippocrate, 1200 Brussels, Belgium
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162
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Risk factors for conversion of laparoscopic cholecystectomy to open surgery associated with the severity characteristics according to the Tokyo guidelines. Surg Today 2014; 44:2300-4. [DOI: 10.1007/s00595-014-0838-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 12/16/2013] [Indexed: 01/10/2023]
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163
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Gelbard R, Karamanos E, Teixeira PG, Beale E, Talving P, Inaba K, Demetriades D. Effect of delaying same-admission cholecystectomy on outcomes in patients with diabetes. Br J Surg 2013; 101:74-8. [DOI: 10.1002/bjs.9382] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2013] [Indexed: 12/13/2022]
Abstract
Abstract
Background
Recent studies have suggested that same-admission delayed cholecystectomy is a safe option. Patients with diabetes have been shown to have less favourable outcomes after cholecystectomy, but the impact of timing of operation for acute cholecystitis during the same admission is unknown.
Methods
This was a retrospective analysis of patients undergoing laparoscopic cholecystectomy for acute cholecystitis between 2004 and 2010, from the American College of Surgeons National Surgical Quality Improvement Program database. Patients with no significant co-morbidities (American Society of Anesthesiologists grade I or II) were included. Propensity score matching (PSM) was used to match patients with diabetes with those who did not have diabetes, in a ratio of 1 : 3, to ensure homogeneity of the two groups. Logistic regression models were applied to adjust for differences between early (within 24 h) and delayed (24 h or more) surgical treatment. The primary outcome was development of local and systemic infectious complications. Secondary outcomes were duration of operation and length of hospital stay.
Results
From a total of 2892 patients, 144 patients with diabetes were matched with 432 without diabetes by PSM. Delaying cholecystectomy for at least 24 h after admission in patients with diabetes was associated with significantly higher odds of developing surgical-site infections (adjusted odds ratio 4·11, 95 per cent confidence interval 1·11 to 15·22; P = 0·034) and a longer hospital stay. For patients with no diabetes, however, delaying cholecystectomy had no impact on complications or length of hospital stay.
Conclusion
Patients with diabetes who undergo laparoscopic cholecystectomy 24 h or more after admission may have an increased risk of postoperative surgical-site infection and a longer hospital stay than those undergoing surgery within 24 h of admission.
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Affiliation(s)
- R Gelbard
- Department of Surgery, Division of Acute Care Surgery, Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA
| | - E Karamanos
- Department of Surgery, Division of Acute Care Surgery, Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA
| | - P G Teixeira
- Department of Surgery, Division of Acute Care Surgery, Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA
| | - E Beale
- Division of Endocrinology, Department of Medicine, Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA
| | - P Talving
- Department of Surgery, Division of Acute Care Surgery, Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA
| | - K Inaba
- Department of Surgery, Division of Acute Care Surgery, Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA
| | - D Demetriades
- Department of Surgery, Division of Acute Care Surgery, Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA
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Sankarankutty A, da Luz LT, De Campos T, Rizoli S, Fraga GP, Nascimento B. Uncomplicated acute cholecystitis: early or delayed laparoscopic cholecystectomy? Rev Col Bras Cir 2013; 39:436-40. [PMID: 23174798 DOI: 10.1590/s0100-69912012000500017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 09/15/2012] [Indexed: 01/05/2023] Open
Abstract
Recent meta-analyses suggested that early laparoscopic cholecystectomy (within 1 week of symptom onset) for uncomplicated acute gallbladder disease is safe and feasible. However, surveys on surgical practices indicated that early laparoscopic cholecystectomy is performed by only a minority of surgeons. Furthermore, the exact time-point for performing this procedure as well as its cost-effectiveness remain a matter of debate. The TBE - CiTE Journal Club performed a critical appraisal of the most relevant evidence recently published on timing of laparoscopic cholecystectomy and its cost-effectiveness for the management of uncomplicated acute cholecystitis and provides evidence-based recommendations on the topic. The literature encompasses small trials with high risk of biases. It suggests that early laparoscopic cholecystectomy is safe and shortens hospital stay. There is scarcity of well-designed and large cost-utility analyses. The following main recommendations were generated: (1) Early laparoscopic cholecystectomy should be attempted as the first-line treatment within one week of symptoms onset; and (2) The cost-effectiveness of early laparoscopic cholecystectomy should be evaluated at the individual hospital level, taking into consideration local resources such as the availability of trained personal, operating room and laparoscopic equipment.
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Affiliation(s)
- Ajith Sankarankutty
- Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP,Brazil
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165
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Emir S, Bali İ, Sözen S, Yazar FM, Kanat BH, Gürdal SÖ, Özkan Z. The efficacy of fibrin glue to control hemorrhage from the gallbladder bed during laparoscopic cholecystectomy. ULUSAL CERRAHI DERGISI 2013; 29:158-61. [PMID: 25931869 DOI: 10.5152/ucd.2013.2319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 11/24/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of the study is to report our experience with fibrin glue application in the management of bleeding from the gallbladder bed during laparoscopic cholecystectomy, which could not be controlled by conventional methods. MATERIAL AND METHODS Three hundred eighty-two patients underwent laparoscopic cholecystectomy. Fourteen patients with bleeding from the gallbladder bed, which could not be controlled by conventional methods, were analyzed retrospectively. RESULTS Fibrin glue was used in 10 patients. Six (71%) were female and 4 were (29%) male. The mean age was 55.7 years. Fourteen patients were operated for the presence of symptomatic gallstones. Thirteen patients (92%) had a concomitant pathology. The mean time spent to maintain hemostasis was 23.9 minutes (15-35). Blood products were used in two patients with hemoglobin values under 8 mg/dL. Hemostasis could not be achieved in a patient despite fibrin glue application, and the operation was converted to open surgery. CONCLUSION The application of fibrin glue for bleeding from the gallbladder bed during laparoscopic cholecystectomy can reduce conversion rates, further studies including more patients are required.
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Affiliation(s)
- Seyfi Emir
- Department of General Surgery, Faculty of Medicine, Namık Kemal University, Tekirdağ, Turkey
| | - İlhan Bali
- Department of General Surgery, Faculty of Medicine, Namık Kemal University, Tekirdağ, Turkey
| | - Selim Sözen
- Department of General Surgery, Faculty of Medicine, Namık Kemal University, Tekirdağ, Turkey
| | - Fatih Mehmet Yazar
- Department of General Surgery, Elazığ Teaching and Training Hospital, Elazığ, Turkey
| | - Burhan Hakan Kanat
- Department of General Surgery, Elazığ Teaching and Training Hospital, Elazığ, Turkey
| | - Sibel Özkan Gürdal
- Department of General Surgery, Faculty of Medicine, Namık Kemal University, Tekirdağ, Turkey
| | - Zeynep Özkan
- Department of General Surgery, Elazığ Teaching and Training Hospital, Elazığ, Turkey
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166
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Wang CH, Chou HC, Liu KL, Lien WC, Wang HP, Wu YM. Long-Term Outcome of Patients with Acute Cholecystitis Receiving Antibiotic Treatment: A Retrospective Cohort Study. World J Surg 2013; 38:347-54. [DOI: 10.1007/s00268-013-2311-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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167
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Degrate L, Ciravegna AL, Luperto M, Guaglio M, Garancini M, Maternini M, Giordano L, Romano F, Gianotti L, Uggeri F. Acute cholecystitis: the golden 72-h period is not a strict limit to perform early cholecystectomy. Results from 316 consecutive patients. Langenbecks Arch Surg 2013; 398:1129-36. [PMID: 24132801 DOI: 10.1007/s00423-013-1131-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 10/07/2013] [Indexed: 01/05/2023]
Abstract
PURPOSE Early laparoscopic cholecystectomy (ELC) is the treatment of choice for acute cholecystitis (AC), but the optimal surgical timing is controversial. The aim of this study was to retrospectively verify the outcome of patients with AC according to different timing of cholecystectomy. METHODS Patients undergoing cholecystectomy for AC from 2006 to 2012 were stratified into two groups: initial admission cholecystectomy (IAC) and delayed cholecystectomy (DC, after at least 4 weeks). Among IAC, a subgroup undergoing immediate cholecystectomy (IC, within 72 h of symptom onset) was further analyzed. RESULTS Three-hundred and sixteen consecutive patients were studied. IAC group included 262 patients (82.9 %) and DC group included 54 patients (17.1 %). The two groups were similar in conversion rate, operation length, and overall complication rate. The total length of hospitalization was longer in DC patients (p = 0.005). Among DC patients, 25.9 % required re-hospitalization while waiting an elective procedure. In the group undergoing IC (66 patients), conversion rate, length of operation, and postoperative morbidity were similar to that of the IAC group. Length of stay was shorter in IC group (p < 0.001). Multivariate analysis identified moderate-severe AC grading and ASA score ≥ 3 as predictors of postoperative complications. CONCLUSIONS The timing of cholecystectomy for AC does not seem to affect conversion rate and postoperative morbidity. Therefore the 72-h period should not be considered a strict limit to perform LC, provided that the operation is carried out during the initial hospital admission.
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Affiliation(s)
- Luca Degrate
- Department of Surgery, University of Milano-Bicocca, San Gerardo Hospital, Via Pergolesi 33, 20900, Monza, MB, Italy,
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168
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Abstract
Acute cholecystitis is one of the most common acute surgical diseases. There is a consensus that laparoscopic cholecystectomy is recommended as the treatment of choice; however, there is a controversy about the best time for surgery. In contrast to delayed cholecystectomy after initial antibiotic treatment, early or immediate cholecystectomy seems to have some advantages. Recent studies and meta-analyses have several limitations due to small patient numbers and inhomogeneity in treatment design. Nevertheless, international guidelines tend to recommend early cholecystectomy but the most recent concept of immediate cholecystectomy within 24 h after diagnosis independent of the onset of symptoms is not considered. A current prospective multicenter, randomized controlled trial will shortly bring more clarity to this topic (ACDC trial).
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Affiliation(s)
- C N Gutt
- Allgemein,- Viszeral,- Thorax- und Gefäßchirurgie, Klinikum Memmingen, Deutschland.
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169
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Changes in the therapeutic strategy for acute cholecystitis after the Tokyo guidelines were published. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:348-55. [PMID: 22869101 DOI: 10.1007/s00534-012-0536-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND This study examined the feasibility of early laparoscopic cholecystectomy (ELC) for acute cholecystitis (AC) according to the Tokyo guidelines severity grade, and analyzed the changes in the therapeutic strategy for AC after the Tokyo guidelines were published. METHODS A total of 225 patients were enrolled in this study. The therapeutic period was divided into two periods: before and after the publication of the Tokyo guidelines (prior to and including 2007, and from 2008, respectively). RESULTS Comparing the surgical strategy between ELC and delayed laparoscopic cholecystectomy (DLC), significant differences were found in the length of preoperative hospital stay and total hospital stay for cases of mild AC compared with moderate AC. With conversion to open surgery, postoperative complications including postoperative bile leak were not significantly different. Since ELC was performed significantly more often after publication of the guidelines, preoperative, postoperative, and total hospital stays were significantly shorter in the later period. CONCLUSION ELC is a safe and effective therapeutic strategy for both mild and moderate AC. The Tokyo guidelines resulted in a significant increase in the performance of ELC and significantly reduced preoperative and total hospital stays without increasing intra- and postoperative complications.
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170
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Shibasaki S, Takahashi N, Toi H, Tsuda I, Nakamura T, Hase T, Minagawa N, Homma S, Kawamura H, Taketomi A. Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy in patients with moderate acute cholecystitis under antithrombotic therapy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:335-42. [PMID: 24027011 DOI: 10.1002/jhbp.28] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Standard treatment for acute cholecystitis (AC) in patients receiving antithrombotic drugs has not been established. We evaluated the safety of percutaneous transhepatic gallbladder drainage (PTGBD) followed by elective laparoscopic cholecystectomy (LC) in patients with moderate AC who were receiving antithrombotics. METHODS Seventy-five patients received PTGBD from January 2006 to March 2013 followed by elective LC for moderate AC. Patients were divided into Group A, which consisted of patients receiving antithrombotic therapy (n = 23), and Group B, which included the remaining patients (n = 52). We analyzed clinical outcomes and perioperative complications between groups. RESULTS No hemorrhagic events occurred during PTGBD insertion regardless of antithrombotic treatment. The open conversion rate was not significantly different between the two groups. Postoperative complications were found in 10 patients (13.3%). The rate of postoperative complications in Group A was slightly higher than that in Group B, but the difference was not significant (21.7% vs. 9.6%; P = 0.15). Complications associated with PTGBD occurred in six patients (8%). There were no significant differences in the incidence of these complications, operation time, intraoperative blood loss, or length of postoperative hospital stay. CONCLUSIONS Percutaneous transhepatic gallbladder drainage followed by elective LC may be an effective therapeutic strategy for moderate AC in patients receiving antithrombotic therapy.
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Affiliation(s)
- Susumu Shibasaki
- Department of Surgery, Hokushinkai Megumino Hospital, Eniwa, Hokkaido, Japan; Department of Gastroenterological Surgery I, Graduate School of Medicine, Hokkaido University, N15 W7 Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
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Multivariate analysis of factors influencing length of hospitalization and medical costs of cholecystectomy for acute cholecystitis in Japan: a national database analysis. Keio J Med 2013; 62:83-94. [PMID: 23912168 DOI: 10.2302/kjm.2012-0015-oa] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Little information is available on the factors influencing length of stay (LOS) in hospital and medical costs during hospitalization associated with cholecystectomy for acute cholecystitis. We determined the independent factors affecting LOS and medical costs of patients who underwent cholecystectomy for acute cholecystitis based on data from the Diagnosis Procedure Combination (DPC) database. In 2008, a total of 2176 patients with acute cholecystitis were referred for cholecystectomy to 624 hospitals in Japan. We collected patient characteristics and data on treatments for acute cholecystitis using the DPC database and identified independent factors affecting LOS and medical costs during hospitalization using multiple linear regression models. Analysis revealed that early cholecystectomy was significantly associated with a decrease in LOS, whereas longer preoperative antimicrobial therapy was significantly associated with an increase of LOS: the standardized coefficient for early cholecystectomy was -0.372 and that for preoperative antimicrobial therapy was 0.353 (P < 0.001). These procedures were also significant independent factors with regard to medical costs during hospitalization: the standardized coefficient for early cholecystectomy was -0.391 and that for preoperative antimicrobial therapy was 0.335 (P < 0.001). Early cholecystectomy significantly reduces the LOS and medical costs of cholecystectomy for acute cholecystitis, while preoperative antimicrobial therapy increases LOS and medical costs during hospitalization. These results highlight the need for health care implementations such as promotion of early cholecystectomy, appropriate use of antimicrobial drugs, and centralization of patients with cholecystectomy for acute cholecystitis in Japan.
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TG13 current terminology, etiology, and epidemiology of acute cholangitis and cholecystitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:8-23. [PMID: 23307004 DOI: 10.1007/s00534-012-0564-0] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While referring to the evidence adopted in the Tokyo Guidelines 2007 (TG07) as well as subsequently obtained evidence, further discussion took place on terminology, etiology, and epidemiological data. In particular, new findings have accumulated on the occurrence of symptoms in patients with gallstones, frequency of severe cholecystitis and cholangitis, onset of cholecystitis and cholangitis after endoscopic retrograde cholangiopancreatography and medications, mortality rate, and recurrence rate. The primary etiology of acute cholangitis/cholecystitis is the presence of stones. Next to stones, the most significant etiology of acute cholangitis is benign/malignant stenosis of the biliary tract. On the other hand, there is another type of acute cholecystitis, acute acalculous cholecystitis, in which stones are not involved as causative factors. Risk factors for acute acalculous cholecystitis include surgery, trauma, burn, and parenteral nutrition. After 2000, the mortality rate of acute cholangitis has been about 10 %, while that of acute cholecystitis has generally been less than 1 %. After the publication of TG07, diagnostic criteria and severity assessment criteria were standardized, and the distribution of cases according to severity and comparison of clinical data among target populations have become more subjective. The concept of healthcare-associated infections is important in the current treatment of infection. The treatment of acute cholangitis and cholecystitis substantially differs from that of community-acquired infections. Cholangitis and cholecystitis as healthcare-associated infections are clearly described in the updated Tokyo Guidelines (TG13). Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.
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Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Gomi H, Dervenis C, Windsor JA, Kim SW, de Santibanes E, Padbury R, Chen XP, Chan ACW, Fan ST, Jagannath P, Mayumi T, Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe AN. TG13 surgical management of acute cholecystitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:89-96. [PMID: 23307007 DOI: 10.1007/s00534-012-0567-x] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is now accepted as a surgical procedure for acute cholecystitis when it is performed by an expert surgeon. There are several lines of strong evidence, such as randomized controlled trials (RCTs) and meta-analyses, supporting the introduction of laparoscopic cholecystectomy for patients with acute cholecystitis. The updated Tokyo Guidelines 2013 (TG13) describe the surgical treatment for acute cholecystitis according to the grade of severity, the timing, and the procedure used for cholecystitis in a question-and-answer format using the evidence concerning surgical management of acute cholecystitis. METHODS AND MATERIALS Forty-eight publications were selected for a careful examination of their full texts, and the types of surgical management of acute cholecystitis were investigated using this evidence. The items concerning the surgical management of acute cholecystitis were the optimal surgical treatment for acute cholecystitis according to the grade of severity, optimal timing for the cholecystectomy, surgical procedure used for cholecystectomy, optimal timing of the conversion of cholecystectomy from laparoscopic to open surgery, and the complications of laparoscopic cholecystectomy. RESULTS There were eight RCTs and four meta-analyses concerning the optimal timing of the cholecystectomy. Consequently, it was found that cholecystectomy is preferable early after admission. There were three RCTs and two meta-analyses concerning the surgical procedure, which concluded that laparoscopic cholecystectomy is preferable to open procedures. Literature concerning the surgical treatment according to the grade of severity could not be quoted, because there have been no publications on this topic. Therefore, the treatment was determined based on the general opinions of professionals. CONCLUSION Surgical management of acute cholecystitis in the updated TG13 is fundamentally the same as in the Tokyo Guidelines 2007 (TG07), and the concept of a critical view of safety and the existence of extreme vasculobiliary injury are added in the text to call the surgeon's attention to the need to reduce the incidence of bile duct injury. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.
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Affiliation(s)
- Yuichi Yamashita
- Department of Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka University School of Medicine, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
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Sanjay P, Mittapalli D, Marioud A, White RD, Ram R, Alijani A. Clinical outcomes of a percutaneous cholecystostomy for acute cholecystitis: a multicentre analysis. HPB (Oxford) 2013; 15:511-6. [PMID: 23750493 PMCID: PMC3692020 DOI: 10.1111/j.1477-2574.2012.00610.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 09/27/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to review a series of consecutive percutaneous cholecystostomies (PC) to analyse the clinical outcomes. METHODS All patients who underwent a PC between 2000 and 2010 were reviewed retrospectively for indications, complications, and short- and long-term outcomes. RESULTS Fifty-three patients underwent a PC with a median age was 74 years (range 14-93). 92.4% (n = 49) of patients were American Society of Anesthesiologists (ASA) III and IV. 82% (43/53) had ultrasound-guided drainage whereas 18% (10/53) had computed tomography (CT)-guided drainage. 71.6% (n = 38) of PC's employed a transhepatic route and 28.4% (n = 15) transabdominal route. 13% (7/53) of patients developed complications including bile leaks (n = 5), haemorrhage (n = 1) and a duodenal fistula (n = 1). All bile leaks were noted with transabdominal access (5 versus 0, P = 0.001). 18/53 of patients underwent a cholecystectomy of 4/18 was done on the index admission. 6/18 cholecystectomies (33%) underwent a laparoscopic cholecystectomy and the remaining required conversion to an open cholecystectomy (67%). 13/53 (22%) patients were readmitted with recurrent cholecystitis during follow-up of which 7 (54%) had a repeated PC. 12/53 patients died on the index admission. The overall 1-year mortality was 37.7% (20/53). CONCLUSIONS Only a small fraction of patients undergoing a PC proceed to a cholecystectomy with a high risk of conversion to an open procedure. A quarter of patients presented with recurrent cholecystitis during follow-up. The mortality rate is high during the index admission from sepsis and within the 1 year of follow-up from other causes.
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Affiliation(s)
| | | | - Aseel Marioud
- HPB Unit, Auckland City HospitalAuckland, New Zealand
| | - Richard D White
- Department of Radiology, Ninewells Hospital and Medical SchoolDundee, UK
| | - Rishi Ram
- HPB Unit, Auckland City HospitalAuckland, New Zealand
| | - Afshin Alijani
- Upper GI & HPB Unit, Ninewells Hospital and Medical SchoolDundee, UK
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Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst Rev 2013:CD005440. [PMID: 23813477 DOI: 10.1002/14651858.cd005440.pub3] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gallstones are present in about 10% to 15% of the adult western population. Between 1% and 4% of these adults become symptomatic in a year (the majority due to biliary colic but a significant proportion due to acute cholecystitis). Laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute cholecystitis episode settles because of the fear of higher morbidity and of need for conversion from laparoscopic to open cholecystectomy. However, delaying surgery exposes the people to gallstone-related complications. OBJECTIVES The aim of this systematic review was to compare early laparoscopic cholecystectomy (less than seven days of clinical presentation with acute cholecystitis) versus delayed laparoscopic cholecystectomy (more than six weeks after index admission with acute cholecystitis) with regards to benefits and harms. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and World Health Organization International Clinical Trials Registry Platform until July 2012. SELECTION CRITERIA We included all randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy in participants with acute cholecystitis. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We identified seven trials that met the inclusion criteria. Out of these, six trials provided data for the meta-analyses. A total of 488 participants with acute cholecystitis and fit to undergo laparoscopic cholecystectomy were randomised to early laparoscopic cholecystectomy (ELC) (244 people) and delayed laparoscopic cholecystectomy (DLC) (244 people) in the six trials. Blinding was not performed in any of the trials and so all the trials were at high risk of bias. Other than blinding, three of the six trials were at low risk of bias in the other domains such as sequence generation, allocation concealment, incomplete outcome data, and selective outcome reporting. The proportion of females ranged between 43.3% and 80% in the trials that provided this information. The average age of participants ranged between 40 years and 60 years. There was no mortality in any of the participants in five trials that reported mortality. There was no significant difference in the proportion of people who developed bile duct injury in the two groups (ELC 1/219 (adjusted proportion 0.4%) versus DLC 2/219 (0.9%); Peto OR 0.49; 95% CI 0.05 to 4.72 (5 trials)). There was no significant difference between the two groups (ELC 14/219 (adjusted proportion 6.5%) versus DLC 11/219 (5.0%); RR 1.29; 95% CI 0.61 to 2.72 (5 trials)) in terms of other serious complications. None of the trials reported quality of life from the time of randomisation. There was no significant difference between the two groups in the proportion of people who required conversion to open cholecystectomy (ELC 49/244 (adjusted proportion 19.7%) versus DLC 54/244 (22.1%); RR 0.89; 95% CI 0.63 to 1.25 (6 trials)). The total hospital stay was shorter in the early group than the delayed group by four days (MD -4.12 days; 95% CI -5.22 to -3.03 (4 trials; 373 people)). There was no significant difference in the operating time between the two groups (MD -1.22 minutes; 95% CI -3.07 to 0.64 (6 trials; 488 people)). Only one trial reported return to work. The people belonging to the ELC group returned to work earlier than the DLC group (MD -11.00 days; 95% CI -19.61 to -2.39 (1 trial; 36 people)). Four trials did not report any gallstone-related morbidity during the waiting period. One trial reported five gallstone-related morbidities (cholangitis: two; biliary colic not requiring urgent operation: one; acute cholecystitis not requiring urgent operation: two). There were no reports of pancreatitis during the waiting time. Gallstone-related morbidity was not reported in the remaining trials. Forty (18.3%) of the people belonging to the delayed group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy in five trials. The proportion with conversion to open cholecystectomy was 45% (18/40) in this group of people. AUTHORS' CONCLUSIONS We found no significant difference between early and late laparoscopic cholecystectomy on our primary outcomes. However, trials with high risk of bias indicate that early laparoscopic cholecystectomy during acute cholecystitis seems safe and may shorten the total hospital stay. The majority of the important outcomes occurred rarely, and hence the confidence intervals are wide. It is unlikely that future randomised clinical trials will be powered to measure differences in bile duct injury and other serious complications since this might involve performing a trial of more than 50,000 people, but several smaller randomised trials may answer the questions through meta-analyses.
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Double-blind randomized sham controlled trial of intraperitoneal bupivacaine during emergency laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 2013; 12:310-6. [PMID: 23742777 DOI: 10.1016/s1499-3872(13)60049-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intraperitoneal local anesthesia (IPLA) during elective laparoscopic cholecystectomy (el-LC) decreases post-operative pain. None of the studies have explored the efficacy of IPLA at emergency laparoscopic cholecystectomy (em-LC). A longer operative duration, the greater frequency of washing, and the inflammation associated with cholecystitis or pancreatitis are a few reasons why it cannot be assumed that a benefit in pain scores will be seen in em-LC with IPLA. This study was undertaken to assess the efficacy of IPLA in patients undergoing em-LC. METHODS Double-blind randomized sham controlled trial was conducted of 41 consecutive subjects undergoing em-LC. IPLA was delivered by a combination of injection to the diaphragmatic and topical wash over the liver and gallbladder with bupivacaine or saline. The primary outcome was visual analogue scale pain scores until discharge. Secondary outcomes included pain scores in theatre recovery and analgesic consumption. RESULTS One patient had a procedure converted to open and was excluded. There was no significant difference in pain scores in the ward or theatre recovery. Analgesic use, respiratory rate, oxygen saturation, duration to ambulation, eating, satisfaction scores, and time to discharge were comparable between the two groups. CONCLUSIONS IPLA during em-LC does not influence postoperative pain. Other modalities of analgesia should be explored for decreasing the interval between diagnosis of acute admission and em-LC.
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de Mestral C, Laupacis A, Rotstein OD, Hoch JS, Haas B, Gomez D, Zagorski B, Nathens AB. Early cholecystectomy for acute cholecystitis: a population-based retrospective cohort study of variation in practice. CMAJ Open 2013; 1:E62-7. [PMID: 25077105 PMCID: PMC3985913 DOI: 10.9778/cmajo.20130001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Despite evidence in favour of early cholecystectomy for most patients with acute cholecystitis, variation in practice has been reported across hospitals worldwide. We sought to characterize the extent and potential sources of variation in the performance of early cholecystectomy for acute cholecystitis within a large regional health care system. METHODS We used a population-based retrospective cohort design. The cohort was limited to adults with a first episode of acute cholecystitis, admitted through the emergency department. Patients were identified using administrative databases comprising all emergency department visits and hospital admissions in Ontario from 2004 to 2010. Patient and hospital characteristics associated with early cholecystectomy (within 7 d of emergency department presentation) were identified using multilevel logistic regression. RESULTS We identified 24 437 patients admitted to 106 hospitals with a first episode of acute cholecystitis. Most (58%, n = 14 286) underwent early cholecystectomy. Rates of early cholecystectomy varied widely across hospitals (median 51%, interquartile range [IQR] 25%-72%), even among healthy patients aged 18-49 years with uncomplicated cholecystitis (median 74%, IQR 41%-88%). Multivariable multilevel analysis showed that hospitals in the lowest quartile for volume of acute cholecystitis admissions had the lowest adjusted odds of early cholecystectomy (odds ratio 0.53, 95% confidence interval 0.35-0.78) and that hospital effects accounted for half (27%) of the explained variation (53%) in early cholecystectomy. INTERPRETATION Across the hospitals of a regional health care system, similar patients with acute cholecystitis did not receive comparable care. Hospital-specific initiatives should be considered to facilitate early cholecystectomy for patients with acute cholecystitis.
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Affiliation(s)
- Charles de Mestral
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
- Institute for Clinical Evaluative Sciences, Toronto, Ont
| | - Andreas Laupacis
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ont
- Institute for Clinical Evaluative Sciences, Toronto, Ont
| | - Ori D. Rotstein
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ont
| | - Jeffrey S. Hoch
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ont
- Institute for Clinical Evaluative Sciences, Toronto, Ont
| | - Barbara Haas
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
| | - David Gomez
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
| | | | - Avery B. Nathens
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ont
- Institute for Clinical Evaluative Sciences, Toronto, Ont
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Comparison of laparoscopic cholecystectomy for acute cholecystitis within and beyond 72 h of symptom onset during emergency admissions. World J Surg 2013; 36:2654-8. [PMID: 22806207 DOI: 10.1007/s00268-012-1709-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) performed for acute cholecystitis (AC) is usually advised within 72 h of symptom onset. It can be difficult to accommodate all these patients within 72 h. LC beyond this early phase potentially increases the chances of LC-related complications. The aim of this study was to evaluate the outcomes of LC both within and beyond 72 h of presentation during the emergency admission. METHODS A retrospective clinical study was performed from February 2004 to December 2009. A total of 133 patients underwent LC for AC during the emergency admission according to the protocol: 34 patients underwent early LC (ELC) (i.e., operation within 72 h of symptom onset) and 99 underwent late LC (LLC) (i.e., operation beyond 72 h of symptom onset). Pathologic type of cholecystitis, duration of the procedure, conversion rate, complications, length of hospital stay (LOS), and total charges were compared between the two groups. RESULTS Patients undergoing ELC experienced a significantly shorter operating time (44.1 ± 5.32 vs. 66.4 ± 3.05 min, p < 0.01). Most of the AC (95/133, 71 %) was pathologically simple cholecystitis. There was no significant difference regarding wound infection rates [1/34 (2.94 %) vs. 2/99 (2.02 %), p > 0.05] or postoperative hospital stay (6.50 ± 1.31 vs. 6.67 ± 0.73, p > 0.05) between groups. There were no conversions to open cholecystectomy, no biliary tract injury or biliary leak, no other complications, and no 30-day readmission rates in either group. ELC was less costly than LLC (6,692 ± 794 vs. 8,378 ± 802 RMB, p < 0.05). CONCLUSIONS Both ELC and LLC are safe for treating of AC, but the operative difficulty of LLC is greater. ELC is superior to LLC as it tends to shorten the total LOS and is less expensive.
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Sandzén B, Haapamäki MM, Nilsson E, Stenlund HC, Oman M. Surgery for acute gallbladder disease in Sweden 1989-2006--a register study. Scand J Gastroenterol 2013; 48:480-6. [PMID: 23356689 DOI: 10.3109/00365521.2012.763177] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Since early 1970s, prospective randomized controlled trials have emphasized the advantages of early cholecystectomy in patients with acute cholecystitis, compared to elective delayed cholecystectomy. The aim of this investigation was to study surgery for acute gallbladder disease in Sweden during a 15-year period when open cholecystectomy was replaced by a laparoscopic procedure. MATERIAL AND METHODS Data from the Swedish National Patient Register and the Cause of Death Register 1988-2006 comprising hospital stays with a primary diagnosis of gallbladder/gallstone disease in Sweden were retrieved. Patients were analyzed with reference to timing of cholecystectomy, length of hospital stay, and mortality. RESULTS Emergency cholecystectomy at index (first) admission or at readmission within 2 years of index admission was performed in 32.2% and 6.1% of patients, respectively. Elective cholecystectomy within 2 years of index admission was performed in 20.3% patients, whereas 41.3% of all patients did not undergo cholecystectomy within 2 years. Standardized mortality ratio did not significantly change during the audit period. Total hospital stay (days at index stay and subsequent stay(s) for biliary diagnoses within 2 years) was shorter for patients who had emergency cholecystectomy at first admission compared to patients with later or no cholecystectomy within 2 years. CONCLUSIONS Around 30% of patients with acute gallbladder disease were operated with cholecystectomy during the first admission with no time trend from 1990 through 2004. A total of 40% of patients with acute gallbladder disease were not cholecystectomized within 2 years. Analysis of outcome of long-term conservative treatment is warranted.
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Affiliation(s)
- Birger Sandzén
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
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Laparoscopic cholecystectomy within one week from the onset of acute cholecystitis: A 6-year experience. J Taibah Univ Med Sci 2013. [DOI: 10.1016/j.jtumed.2013.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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183
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Brooks KR, Scarborough JE, Vaslef SN, Shapiro ML. No need to wait: an analysis of the timing of cholecystectomy during admission for acute cholecystitis using the American College of Surgeons National Surgical Quality Improvement Program database. J Trauma Acute Care Surg 2013; 74:167-73; 173-4. [PMID: 23271092 DOI: 10.1097/ta.0b013e3182788b71] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The objective of our analysis was to determine the optimal timing of cholecystectomy during admission for acute cholecystitis. METHODS All patients from the American College of Surgeons National Surgical Quality Improvement Program Participant User Files from 2005 through 2010 who underwent emergency cholecystectomy within 7 days of hospital admission for acute cholecystitis were included for analysis. The association between timing of cholecystectomy and postoperative outcomes was determined using multivariate logistic regression analyses after adjustment for patient demographics, acute and chronic comorbid medical conditions, preoperative sepsis classification, American Society of Anesthesiologists physical status classification, and preoperative liver function tests. RESULTS A total of 5,268 patients were included for analysis. The timing of operation was day of admission for 49.7% of these patients, 1 day after admission for 33.4%, 2 days after admission for 9.5%, 3 days after admission for 3.9%, and 4 days to 7 days after admission for 3.6%. Multivariate logistic regression analyses revealed no significant association between timing of operation and 30-day postoperative mortality or overall morbidity. Patients who underwent operation later in the course of admission were more likely to require an open procedure and sustained significantly longer postoperative and overall lengths of hospitalization. Similar findings were demonstrated for a subgroup of patients who exhibited characteristics that placed them at higher risk for surgical intervention. CONCLUSION Immediate cholecystectomy is preferred for patients who require hospitalization for acute cholecystitis. LEVEL OF EVIDENCE Economic/decision analysis, level III.
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Affiliation(s)
- Kelli R Brooks
- Division of Trauma, Surgical Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina 27701, USA.
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A population-based analysis of the clinical course of 10,304 patients with acute cholecystitis, discharged without cholecystectomy. J Trauma Acute Care Surg 2013; 74:26-30; discussion 30-1. [PMID: 23271073 DOI: 10.1097/ta.0b013e3182788e4d] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Randomized trials and expert opinion support early laparoscopic cholecystectomy for most patients with acute cholecystitis (AC); however, practice patterns remain variable worldwide, and delayed cholecystectomy remains a common practice. We therefore present a population-based analysis of the clinical course of patients with AC discharged without cholecystectomy. METHODS Using administrative databases capturing all emergency department (ED) visits and hospital admissions within a geographic region encompassing 13 million persons, we identified adults with a first emergency admission for uncomplicated AC during the period of 2004 to 2011. In those discharged without cholecystectomy, the probability of a subsequent gallstone-related event (gallstone-related ED visit or hospital admission) was evaluated using Kaplan-Meier methods. The association of patient characteristics with time to first gallstone-related event after discharge was explored through multivariable time to event analysis. RESULTS Of 25,397 patients with AC, 10,304 (41%) did not undergo cholecystectomy on first admission. The probability of a gallstone-related event by 6 weeks, 12 weeks, and 1 year after discharge was 14%, 19%, and 29% respectively. Of these events, 30% were for biliary tract obstruction or pancreatitis. When controlling for sex, income, and comorbidity level, the risk of a gallstone-related event was highest for patients 18 years to 34 years old. CONCLUSION For patients who do not undergo cholecystectomy on first admission for AC, the probability of a gallstone-related ED visit or hospital admission within 12 weeks of discharge is 19%. The increased risk in younger patients reinforces the value of early cholecystectomy in the nonelderly. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.
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Gunay Y, Bircan HY, Emek E, Cevik H, Altaca G, Moray G. The management of acute cholecystitis in chronic hemodialysis patients: percutaneous cholecystostomy versus cholecystectomy. J Gastrointest Surg 2013; 17:319-25. [PMID: 23132628 DOI: 10.1007/s11605-012-2067-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 10/15/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Treatment of acute cholecystitis in chronic hemodialysis (HD) patients still remains controversial. Because of underlying disease that can influence surgical results, less invasive alternative managements have been tried over the last decades. The goal of this study was to analyze the results of cholecystectomy versus percutaneous cholecystostomy for acute cholecystitis (AC) in chronic HD patients. METHODS All patients with end-stage renal disease who were treated for AC were identified retrospectively from our medical records. Between July 2007 and September 2011, 47 patients were treated for AC while they were on chronic HD. The records of these patients were reviewed for documented AC and its treatment. RESULTS Of the 47 HD patients, 26 (55.3 %) underwent cholecystectomy (CC), while 21 (44. 7 %) had a percutaneous cholecystostomy (PC) for AC as an initial treatment. The mean length of follow-up was 20.4 ± 16 months in PC and 18 ± 15 months in CC patients. The success rate was higher in CC patients compared to PC patients (92. 3 versus 66.7 %, p = 0.0698). Eleven (52. 4 %) patients who had PC subsequently underwent CC; six open CC and five delayed laparoscopic CC were performed. Of the 26 patients who underwent CC, 18 were performed emergently due to the persistence of AC-related symptoms and gangrenous and perforated gallbladders. Eight were initially treated conservatively and then underwent elective cholecystectomy at an interval of 32 ± 24 (range = 14-59) days following initial treatment. In emergent CC, 10 (55.6 %) were completed laparoscopically, three were open, and five (33.3 %) had conversions. In elective CC patients, two were conversions, but the remainder (75 %) had laparoscopic CC. Readmission rates were higher in the PC group (33.3 versus 12.5 %, p = 0.1732). Although AC-related mortality was higher in PC patients, there was no statistically significant difference in the patient survival rate between the two groups (Kaplan-Meier analysis, Fig. 1, 19 versus 7.7 %; p = 0.4035), and the overall mortality rate was higher in the PC group (33.7 versus 15.7 %, p = 0.2737). CONCLUSION This study confirms that the safety and effectiveness of CC has a higher success rate and lower morbidity and mortality rate compared with percutaneous cholecystostomy for acute cholecystitis in chronic HD patients.
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Sartelli M, Viale P, Catena F, Ansaloni L, Moore E, Malangoni M, Moore FA, Velmahos G, Coimbra R, Ivatury R, Peitzman A, Koike K, Leppaniemi A, Biffl W, Burlew CC, Balogh ZJ, Boffard K, Bendinelli C, Gupta S, Kluger Y, Agresta F, Di Saverio S, Wani I, Escalona A, Ordonez C, Fraga GP, Junior GAP, Bala M, Cui Y, Marwah S, Sakakushev B, Kong V, Naidoo N, Ahmed A, Abbas A, Guercioni G, Vettoretto N, Díaz-Nieto R, Gerych I, Tranà C, Faro MP, Yuan KC, Kok KYY, Mefire AC, Lee JG, Hong SK, Ghnnam W, Siribumrungwong B, Sato N, Murata K, Irahara T, Coccolini F, Lohse HAS, Verni A, Shoko T. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg 2013; 8:3. [PMID: 23294512 PMCID: PMC3545734 DOI: 10.1186/1749-7922-8-3] [Citation(s) in RCA: 165] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 01/02/2013] [Indexed: 12/11/2022] Open
Abstract
Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.
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Affiliation(s)
| | - Pierluigi Viale
- Clinic of Infectious Diseases, Department of Internal Medicine Geriatrics and Nephrologic Diseases, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Fausto Catena
- Emergency Surgery, Maggiore Parma Hospital, Parma, Italy
| | - Luca Ansaloni
- Department of General Surgery, Ospedali Riuniti, Bergamo, Italy
| | - Ernest Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | | | | | - George Velmahos
- Harvard Medical School, Division of Trauma, Emergency Surgery and Surgical Critical Care Massachusetts General Hospital, Boston, MA, USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, CA, USA
| | - Rao Ivatury
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Andrew Peitzman
- Division of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kaoru Koike
- Department of Primary Care & Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ari Leppaniemi
- Department of Abdominal Surgery, University Hospital Meilahti, Helsinki, Finland
| | - Walter Biffl
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | | | - Zsolt J Balogh
- Department of Surgery, University of Newcastle, Newcastle, NSW, Australia
| | - Ken Boffard
- Department of Surgery, Charlotte Maxeke Johannesburg Hospital University of the Witwatersrand, Johannesburg, South Africa
| | - Cino Bendinelli
- Department of Surgery, University of Newcastle, Newcastle, NSW, Australia
| | - Sanjay Gupta
- Department of Surgery, Govt Medical College and Hospital, Chandigarh, India
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | | | - Imtiaz Wani
- Department of Digestive Surgery Faculty of Medicine Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alex Escalona
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Carlos Ordonez
- Department of Surgery, Universidad del Valle, Fundacion Valle del Lili, Cali, Colombia
| | - Gustavo P Fraga
- Division of Trauma Surgery, Hospital de Clinicas - University of Campinas, Campinas, Brazil
| | | | - Miklosh Bala
- Department of General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Sanjay Marwah
- Department of Surgery, Pt BDS Post-graduate Institute of Medical Sciences, Rohtak, India
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital /UMBAL/ St George Plovdiv, Plovdiv, Bulgaria
| | - Victor Kong
- Department of Surgery, Edendale Hospital, Pietermaritzburg, Republic of South Africa
| | - Noel Naidoo
- Department of Surgery, Port Shepstone Hospital, Kwazulu Natal, South Africa
| | - Adamu Ahmed
- Department of Surgery, Ahmadu Bello University Teaching Hospital Zaria, Kaduna, Nigeria
| | - Ashraf Abbas
- Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | | | | | - Rafael Díaz-Nieto
- Department of General and Digestive Surgery, University Hospital, Malaga, Spain
| | - Ihor Gerych
- Department of General Surgery, Lviv Emergency Hospital, Lviv, Ukraine
| | | | - Mario Paulo Faro
- Division of General and Emergency Surgery, Faculdade de Medicina da Fundação do ABC, São Paulo, Santo André, Brazil
| | - Kuo-Ching Yuan
- Department of Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | | | - Jae Gil Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Suk-Kyung Hong
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Ulsan, Seoul, Republic of Korea
| | - Wagih Ghnnam
- Wagih Ghnnam, Department of Surgery, Khamis Mushayt General Hospital, Khamis Mushayt, Saudi Arabia
| | - Boonying Siribumrungwong
- Boonying Siribumrungwong, Department of Surgery, Thammasat University Hospital, Pathumthani, Thailand
| | - Norio Sato
- Division of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kiyoshi Murata
- Department of Acute and Critical Care Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takayuki Irahara
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Emergency and Critical Care Center of Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | | | | | - Alfredo Verni
- Department of Surgery, Cutral Co Clinic, Neuquen, Argentina
| | - Tomohisa Shoko
- The Shock Trauma and Emergency Medical Center, Matsudo City Hospital, Chiba, Japan
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Reply to letter: "Population-based analysis of 4113 patients with acute cholecystitis: defining the optimal time point for laparoscopic cholecystectomy". Ann Surg 2012; 259:e3. [PMID: 23246928 DOI: 10.1097/sla.0b013e31827ba054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mazeh H, Mizrahi I, Dior U, Simanovsky N, Shapiro M, Freund HR, Eid A. Role of antibiotic therapy in mild acute calculus cholecystitis: a prospective randomized controlled trial. World J Surg 2012; 36:1750-9. [PMID: 22456803 DOI: 10.1007/s00268-012-1572-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Current recommendations for treating acute calculus cholecystitis include the use of intravenous antibiotics, although these recommendations were never tested scientifically. The aim of this study was to evaluate the role of intravenous antibiotic therapy in patients with mild acute calculus cholecystitis. METHODS In this prospective, randomized controlled trial, 84 patients with a diagnosis of mild acute calculus cholecystitis were randomly assigned to supportive treatment only or supportive treatment with intravenous antibiotic treatment (42 patients in each arm). Patients were followed through their index admission and until delayed laparoscopic cholecystectomy was performed. RESULTS The two study groups did not differ in their demographic data or in the clinical presentation and disease severity. Analysis was conducted on the intent-to-treat basis. Patients in the intravenous antibiotics arm resumed a liquid diet earlier (1.7 vs. 2.2 days, p = 0.02) but did not significantly differ in resumption of regular diet (2.8 vs. 3.2 days, p = 0.16) or hospital length of stay (LOS) (3.9 vs. 3.8 days, p = 0.89). Patients in the intravenous antibiotics arm had rates of percutaneous cholecystostomy tube placement (12 vs. 5 %, p = 0.43), readmissions (19 vs. 13 %, p = 0.73), and perioperative course similar to those not receiving antibiotics. The overall hospital LOS, including initial hospitalization and subsequent cholecystectomy, was similar for both groups (5.6 vs. 5.1 days, p = 0.29). Eight (19 %) patients in the supportive arm were crossed over to the intravenous antibiotic arm during the index admission. CONCLUSIONS Intravenous antibiotic treatment does not improve the hospital course or early outcome in most of the patients with mild acute calculus cholecystitis.
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Affiliation(s)
- Haggi Mazeh
- Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, P.O.B. 24035, 91240, Jerusalem, Israel.
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Siddique K, Elsayed SEA, Cheema R, Mirza S, Basu S. One-stop cholecystectomy clinic: an application of lean thinking--can it improve the outcomes? J Perioper Pract 2012; 22:360-365. [PMID: 23311022 DOI: 10.1177/175045891602201103] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Lean thinking principles were utilised to set up 'One-stop cholecystectomy clinics' at which patients underwent the surgical and the preoperative assessment during the same visit. The main aims were to reduce the number of patient hospital visits, preoperative admissions and the waiting time to surgery. The results showed a significant reduction in the number of patient visits as well as the waiting time to surgery thus highlighting that patientcare can be improved by good team working and lean management.
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190
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Schmidt M, Dumot JA, Søreide O, Søndenaa K. Diagnosis and management of gallbladder calculus disease. Scand J Gastroenterol 2012; 47:1257-65. [PMID: 22935027 DOI: 10.3109/00365521.2012.704934] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The number and rate of cholecystectomy are increasing worldwide, although indications for operative treatment remain empirical, and several issues in the understanding of the condition are not concisely outlined. Our intention is to summarize and interpret current opinion regarding the indications and timing of cholecystectomy in calculous gallbladder disease. METHODS Publications concerned with gallstone disease and related topics were searched for in MEDLINE using PubMed and summarized according to clinical scenarios with an emphasis on recent research. RESULTS Only one randomized controlled trial has investigated the management (conservative vs. surgery) of patients with acute cholecystitis and several have compared early with deferred surgery. Two RCTs have examined treatment of uncomplicated, symptomatic gallstone disease. Apart from these, the overwhelming majority of publications are retrospective case series. CONCLUSIONS Recent literature confirms that cholecystectomy for an asymptomatic or incidental gallstone is not justified. Symptomatic, uncomplicated gallstone disease may be classified into four severity groups based on severity and frequency of pain attacks, which may guide indication for cholecystectomy. Most patients below the age of 70 seem to prefer operative treatment. Acute cholecystitis may be treated with early operation if reduction of hospital days is an issue. Patients older than 70 years with significant comorbidities may forego surgical treatment without undue hazard. Symptoms following cholecystectomy remain in 25% or more and recent evidence suggest these are caused by a functional gastrointestinal disorder.
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Affiliation(s)
- Malte Schmidt
- Department of Surgery, Haraldsplass Deaconess Hospital University of Bergen, Bergen, Norway
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191
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Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc 2012; 26:3003-39. [PMID: 23052493 DOI: 10.1007/s00464-012-2511-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 07/29/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is one of the most common surgical procedures in Europe (and the world) and has become the standard procedure for the management of symptomatic cholelithiasis or acute cholecystitis in patients without specific contraindications. Bile duct injuries (BDI) are rare but serious complications that can occur during a laparoscopic cholecystectomy. Prevention and management of BDI has given rise to a host of publications but very few recommendations, especially in Europe. METHODS A systematic research of the literature was performed. An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. Statements and recommendations were drafted after a consensus development conference in May 2011, followed by presentation and discussion at the annual congress of the EAES held in Torino in June 2011. Finally, full guidelines were consented and adopted by the expert panel via e-mail and web conference. RESULTS A total of 1,765 publications were identified through the systematic literature search and additional submission by panellists; 671 publications were selected as potentially relevant. Only 46 publications fulfilled minimal methodological criteria to support Clinical Practice Guidelines recommendations. Because the level of evidence was low for most of the studies, most statements or recommendations had to be based on consensus of opinion among the panel members. A total of 15 statements and recommendations were developed covering the following topics: classification of injuries, epidemiology, prevention, diagnosis, and management of BDI. CONCLUSIONS Because BDI is a rare event, it is difficult to generate evidence for prevention, diagnosis, or the management of BDI from clinical studies. Nevertheless, the panel has formulated recommendations. Due to the currently limited evidence, a European registry should be considered to collect and analyze more valid data on BDI upon which recommendations can be based.
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192
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Panagiotopoulou IG, Carter N, Lewis MC, Rao S. Early laparoscopic cholecystectomy in a district general hospital: is it safe and feasible? INT J EVID-BASED HEA 2012; 10:112-6. [PMID: 22672600 DOI: 10.1111/j.1744-1609.2012.00260.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Early laparoscopic cholecystectomy (ELC) is becoming the accepted treatment for the management of acute gallstone disease in specialist centres. It has also been achieved safely in the district general hospital (DGH) setting. We audited the management of acute gallstone disease in our DGH and set about to see if we could implement ELC safely and effectively. PATIENTS AND METHODS A retrospective audit of 2 years of practice was performed using our hospital-computerised systems. Following this, departmental education regarding the benefits of early cholecystectomy was widely disseminated. Management guidelines were altered to promote and consider ELC for all suitable patients. A prospective audit of practice was then performed for 6 months. RESULTS The first cycle revealed that only 10.42% of emergency patients admitted with gallstone-related disease had ELC. In the second cycle, 63 patients were admitted with acute gallstone disease. Three died from acute pancreatitis. Twenty-one (58%) of the 36, who were deemed suitable, had ELC. Fifteen (42%) had planned delayed laparoscopic cholecystectomy (DLC), with six (40%) being readmitted whilst waiting for their elective surgery (all undergoing ELC during their readmission). Conversion rates were similar between all groups. One of the patients having DLC had a bile leak, which settled following Endoscopic Retrograde Cholangiopancreatography and stent. CONCLUSION We were able to increase ELC rates following the implementation of necessary changes. There did not appear to be any difference in conversion or morbidity rates between ELC and DLC. We conclude ELC is safe and feasible in the DGH setting.
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193
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Ohta M, Iwashita Y, Yada K, Ogawa T, Kai S, Ishio T, Shibata K, Matsumoto T, Bandoh T, Kitano S. Operative timing of laparoscopic cholecystectomy for acute cholecystitis in a Japanese institute. JSLS 2012; 16:65-70. [PMID: 22906333 PMCID: PMC3407460 DOI: 10.4293/108680812x13291597716023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
These authors suggest that the best timing of laparoscopic cholecystectomy for acute cholecystitis in Japan may be within 24 hours of the onset of the disease. Background and Objectives: In patients with acute cholecystitis who cannot undergo early laparoscopic cholecystectomy (within 72 hours), 6 weeks to 12 weeks after onset is widely considered the optimal timing for delayed laparoscopic cholecystectomy. However, there has been no clear consensus about it. We aimed to determine optimal timing for delayed laparoscopic cholecystectomy for acute cholecystitis. Methods: Medical records of 100 patients who underwent standard laparoscopic cholecystectomy were reviewed retrospectively. Patients were divided into group 1, patients undergoing laparoscopic cholecystectomy within 72 hours of onset; group 2, between 4 days to 14 days; group 3, between 3 weeks to 6 weeks; group 4, >6 weeks. Results: No significant differences existed between groups in conversion rate to open surgery, operation time, blood loss, or postoperative morbidity, and hospital stay. However, total hospital stay in groups 1 and 2 was significantly shorter than that in groups 3 and 4 (P<.01). In addition, the total hospital stay in group 3 was also significantly shorter than that in group 4 (P<.01). Conclusions: Best timing of laparoscopic cholecystectomy for acute cholecystitis may be within 72 hours, and the delayed timing of laparoscopic cholecystectomy in patients who cannot undergo early laparoscopic cholecystectomy is probably as soon as possible after they can tolerate laparoscopic cholecystectomy.
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Affiliation(s)
- Masayuki Ohta
- Department of Surgery I, Oita University Faculty of Medicine, Oita, Japan.
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194
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Yang GPC, Chan CTY, Lai ECH, Chan OCY, Tang CN, Li MKW. Laparoscopic versus open repair for strangulated groin hernias: 188 cases over 4 years. Asian J Endosc Surg 2012; 5:131-7. [PMID: 22776668 DOI: 10.1111/j.1758-5910.2012.00138.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 01/14/2012] [Accepted: 03/27/2012] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Currently transabdominal pre-peritoneal and totally extraperitoneal repairs are the two standard laparoscopic approaches for groin hernia repair. However, they are still largely reserved for uncomplicated elective cases. To determine whether laparoscopic groin hernia repair can achieve similar results for acute strangulated hernias as laparoscopic cholecystectomy for acute cholecystitis, we analyzed and compared the results of emergency laparoscopic surgery and open repair for strangulated groin hernias performed by our team over the past 4 years. METHODS This is a retrospective analysis of prospectively collected data. We analyzed the results of patients admitted between January 2007 and January 2011 who were diagnosed with acute strangulated groin hernia and underwent emergency open or laparoscopic hernia repair during the same admission. Patients' demographic details, mode of presentation, type of hernia, intraoperative findings, operative time, postoperative course and complications were compared. RESULTS In total, 188 patients fulfilled the criteria for emergency surgical repair of strangulated groin hernias; 57 received laparoscopic and 131 received open repairs. The mean operative time was 79.82 ± 29.571 min and 80.75 ± 35.161 min, respectively. More laparotomies were performed in the open group (19 vs 0). The wound infection rate was significantly higher in the open group (12 vs 0). The mean hospital stay was shorter in the laparoscopic group (4.39 days vs 7.34 days). There was no mesh infection in either group. Recurrence occurred one case in the laparoscopic group and in three cases in the open group. CONCLUSIONS Emergency laparoscopic repair for strangulated groin hernias is feasible and appears to have a lower morbidity relative to open repair. Further study should be performed to evaluate its full potential.
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Affiliation(s)
- G P C Yang
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China.
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195
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Epidemiological study of provision of cholecystectomy in England from 2000 to 2009: retrospective analysis of Hospital Episode Statistics. Surg Endosc 2012; 27:162-75. [DOI: 10.1007/s00464-012-2415-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 05/18/2012] [Indexed: 12/21/2022]
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196
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Cost utility of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Surg Endosc 2012; 27:256-62. [PMID: 22773234 DOI: 10.1007/s00464-012-2430-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/31/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Early laparoscopic cholecystectomy for acute cholecystitis is safe and effective. However, the potential cost savings of this management strategy have not been well studied in a North American context. This study aimed to estimate the cost effectiveness of early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy in Canada. METHODS A decision analytic model estimating and comparing costs from a Canadian providing institution after either early or delayed laparoscopic cholecystectomy was used. The health care resources consumed were calculated using local hospital data, and outcomes were measured in quality-adjusted life years (QALYs) gained during 1 year. Uncertainty was investigated with one-way sensitivity analyses, varying the probabilities of the events and utilities. RESULTS Early laparoscopic cholecystectomy was estimated to cost approximately $2,000 (Canadian dollars) less than delayed laparoscopic cholecystectomy per patient, with an incremental gain of approximately 0.03 QALYs. Sensitivity analysis showed that only extreme values of bile duct injury or bile leak altered the direction of incremental gain. CONCLUSIONS Adoption of a policy in favor of early laparoscopic cholecystectomy will result in better patient quality of life and substantial savings to the Canadian health care system.
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197
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[Analysis of the most appropriate surgical treatment for acute cholecystitis by applying the RAND/UCLA method]. Cir Esp 2012; 90:453-9. [PMID: 22771292 DOI: 10.1016/j.ciresp.2012.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 02/19/2012] [Accepted: 04/08/2012] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Acute cholecystitis (AC) is a common indication for cholecystectomy. Local circumstances and certain patient characteristics lead to high failure rates and complications in laparoscopic cholecystectomy (LC), and despite the experience gained, we still do not have a detailed list of indications which could minimise them. MATERIAL AND METHOD We used the RAND/UCLA Appropriateness Method (RAM) to evaluate 2 options, LC and open cholecystectomy (OC). An expert panel analysed its suitability after a literature review, a consensus meeting, and 2 rounds of scores on different clinical situations. The score of each scenario was analysed to establish the appropriateness level of each option. RESULTS At the end of the meeting there were 64 defined scenarios, with an agreement being reached on the indications in 67.18% of them. In 86.04% of the scenarios, the agreement was due to the appropriateness of the indications. When cholecystectomy was indicated, it was always by laparoscopy, while it was only occasionally by laparotomy. In patients with less than 72 h of onset, LC was always considered appropriate when there was sepsis, or even without this if the ultrasound data showed complicated AC. CONCLUSIONS There is still uncertainty as regards the management of AC, especially as regards the timing of the operation and the surgical approach, particularly in frail patients and with a clinical onset greater than 72 h. The RAND method can help to make decisions on the appropriateness of different therapeutic options.
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198
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Dixon E, Fowler DL, Ghitulescu G. CAGS and ACS Evidence Based Reviews in Surgery. 41. Cost-utility analysis of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Can J Surg 2012; 55:204-6. [PMID: 22630063 DOI: 10.1503/cjs.012012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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199
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Acute cholecystitis in high surgical risk patients: percutaneous cholecystostomy or emergency cholecystectomy? Am J Surg 2012; 204:54-9. [DOI: 10.1016/j.amjsurg.2011.05.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 05/13/2011] [Accepted: 05/13/2011] [Indexed: 01/10/2023]
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200
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Agresta F, Ansaloni L, Baiocchi GL, Bergamini C, Campanile FC, Carlucci M, Cocorullo G, Corradi A, Franzato B, Lupo M, Mandalà V, Mirabella A, Pernazza G, Piccoli M, Staudacher C, Vettoretto N, Zago M, Lettieri E, Levati A, Pietrini D, Scaglione M, De Masi S, De Placido G, Francucci M, Rasi M, Fingerhut A, Uranüs S, Garattini S. Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES). Surg Endosc 2012; 26:2134-64. [PMID: 22736283 DOI: 10.1007/s00464-012-2331-3] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 04/16/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases. METHODS Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011. RESULTS A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer). CONCLUSIONS Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.
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Affiliation(s)
- Ferdinando Agresta
- Department of General Surgery, Presidio Ospedaliero di Adria, Piazza degli Etruschi, 9, 45011 Adria, RO, Italy.
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