Informed consent and choice in cholecystectomy

What surgical approach would provide better outcomes in children and adolescents undergoing cholecystectomy? Results of a systematic review and meta-analysis

Background

There is a lack of evidence on the surgical approach for children and adolescents undergoing cholecystectomy. Therefore, the aim of this systematic review is to compare the safety and efficacy of minimally invasive cholecystectomy to open cholecystectomy in children and/or adolescents.

Main body

A search was conducted on MEDLINE, PubMed, Cochrane and Embase from inception to October 2018. We included comparative studies investigating outcomes following robotic-assisted, laparoscopic and/or open cholecystectomy in children and/or adolescents. The outcomes of interest included post-operative complication rate, operation time, length of hospital stay, post-operative pain and conversion to open procedure. The Newcastle-Ottawa Scale was used to assess the risk of bias. Meta-analysis was performed using random-effect models.

Twenty-one studies were included involving 927 children and/or adolescents. All, but one, compared outcomes between laparoscopic versus open cholecystectomy. The great majority of the included studies presented a low risk of bias. Patients undergoing laparoscopic cholecystectomy had less post-operative complications (RR: 0.57; 95%CI 0.35 to 0.94), reduced length of hospital stay (MD − 3.73; 95%CI − 4.88 to − 2.59), but longer operative time (MD 26.61; 95%CI 9.35 to 43.86) when compared to open cholecystectomy. The average conversion from laparoscopic to open cholecystectomy was 7% across studies.

Conclusions

The current evidence suggested that laparoscopic cholecystectomy in children and/or adolescents is safe resulting in lower rates of postoperative complications and length of stay, but longer operative times, when compared to the open approach.

PROSPERO registration

CRD42017067641

Level of evidence

Level III

Laparoscopic management and its outcomes in cases with nonpalpable testis

OBJECTIVE

Diagnostic laparoscopy is the gold standard in the algorithm of nonpalpable testis. Testicular tissue is examined and treatment is planned accordingly. In this study we reviewed the place of diagnostic laparoscopy, and evaluated the results and effectiveness of laparoscopy in the diagnosis and management of nonpalpable testis.

MATERIAL AND METHODS

Children who had diagnostic laparoscopy for nonpalpable testes were included in the study. Physical examination results, ultrasonography (USG) reports, age at surgery, laparoscopic and inguinal exploration findings, surgical procedures, orchiopexy results, early and late-term complications were evaluated. Follow-up visits were performed at 3-month intervals for the first, at 6-month intervals for the 2. year, then at yearly intervals. Testicular size and location was evaluated by during control examination.

RESULTS

Overall 58 boys, and 68 testes (26 left: 44.8%; 22 right: 37.9%, and 10 bilateral: 17.2%) were included in the study. Mean age at surgery was 5.5 years (10 months-17 years). Diagnostic value of USG was 15.7%. Diagnostic laparoscopy findings were as follows: Group 1: blind-ended vessels, n=7 (10.2%); Group 2: intraabdominal testes, n=8 (11.7%); Group 3: vas and vessels entering internal ring, n=53 (77.9%). Overall 43 testes underwent orchiopexy, which were normal (n=8) or hypoplastic (n=35). Mean follow-up period was 19 months (1-12 years), and on an average 7 visits were performed (5-14). On follow-up, 5 testes were normal-sized and located in the scrotum, while 4 testes were atrophic and underwent orchiectomy. Two testes were found in the inguinal canal and redo orchiopexy was performed. Control USG revealed reduced testicular blood supply and volume.

CONCLUSION

Laparoscopic surgery is safe and effective in the management of nonpalpable testes. In the majority, routine use of diagnostic laparoscopy in the algorithma does not confer any additional contributions in many patients.

Estimating Adverse Events After Gastrostomy Tube Placement

OBJECTIVE

Gastrostomy feeding tube placement in children is associated with a high frequency of adverse events. This study sought to preoperatively estimate postoperative adverse events in children undergoing gastrostomy feeding tube placement.

METHODS

This was an observational study of children who underwent gastrostomy with or without fundoplication at 1 of 50 participating hospitals, using 2011-2013 data from the American College of Surgeons' National Surgical Quality Improvement Program Pediatric. The outcome was the occurrence of any postoperative complications or mortality at 30 days after gastrostomy tube placement. The preoperative clinical characteristics significantly associated with occurrence of adverse events were included in a multivariate logistic model. The area under the receiver operating characteristic curve was computed to assess model performance and split-set validated.

RESULTS

A total of 2817 children were identified as having undergone gastrostomy tube placement. The unadjusted rate of adverse events within 30 days after gastrostomy tube placement was 11%. Thirteen predictor variables were identified. Notable preoperative variables associated with a greater than 75% increase in adverse event rate were preoperative sepsis/septic shock (odds ratio [OR], 10.76, 95% confidence interval [CI], 3.84-30.17), central nervous system tumor (OR, 3.36; 95% CI, 1.42-7.95), the primary procedure as indicated by the current procedural terminology (CPT) linear risk variable (OR, 1.93; 95% CI, 1.50-2.49), severe cardiac risk factors (OR, 1.88; 95% CI, 1.17-3.03), and preoperative seizure history (OR, 1.90; 95% CI, 1.38-2.62). The area under the receiver operating characteristic curve was 0.71 with the derivation data set and 0.71 upon split-set validation.

CONCLUSIONS

Preoperatively estimating postoperative adverse events in children undergoing gastrostomy tube placement is feasible.

Paediatric cholecystectomy: Shifting goalposts in the laparoscopic era

BACKGROUND

Laparoscopic cholecystectomy is the treatment of choice in symptomatic paediatric cholelithiasis. However, controversy exists about its role in asymptomatic cholelithiasis and biliary dyskinesia. We have reviewed the experiences of two UK paediatric centres with laparoscopic cholecystectomy over an 8.5 year period and critically evaluated the indications and outcomes of surgery.

METHODS

Patients who underwent laparoscopic cholecystectomy by a single surgeon at the Royal Aberdeen and Royal Alexandra Hospitals between May 1996 to August 2003 and September 2003 to December 2005, respectively, were studied. Information was extracted from prospectively held databases and analysed.

RESULTS

A total of 27 cholecystectomies were performed during the period of study. The mean age of patients was 11.7 years with a female preponderance. Symptomatic idiopathic cholelithiasis was the main indication for surgery (14). Cholecystectomy was also performed for haemolytic disease (3), acute recurrent pancreatitis of unknown cause (2), gallbladder trauma (1), and for asymptomatic calcific non-resolving stones (7). All patients were investigated with ultrasound scans with four patients undergoing magnetic resonance cholangiopancreatography (MRCP) for suspected common bile duct (CBD) stones. A standard four-port approach was used with the gallbladder extracted through the umbilical port. The mean operative time in the latter 13 cases was 105 minutes with a median postoperative stay of one day for the whole series. Histology revealed chronic cholecystitis in all but three cases. All patients were discharged after a six-month follow-up period.

CONCLUSIONS

The advent of laparoscopy has resulted in an expansion of the traditional indications for cholecystectomy. MRCP is a useful investigation in selected children to exclude choledocholithiasis and avoid intraoperative cholangiography. There appears to be no clear correlation between histology and presenting symptoms. The natural history of asymptomatic gallstones in children is not known although a consensus is emerging to support cholecystectomy for all calcific non-resolving gallstones.