Analysis of the SAGES outcomes initiative cholecystectomy registry

Bile Spillage as a Prognostic Factor for Gall Bladder Cancer: A Systematic Review and Meta-Analysis

INTRODUCTION

Biliary spillage (BS) is a common complication following initial cholecystectomy for gall bladder cancer (GBC). Few studies have explored the importance of BS as a long-term prognostic factor. We perform a meta-analysis of the association between BS and survival in GBC.

METHODS

A systematic literature search was performed in February 2023. Studies evaluating the incidence of BS and its association with long-term outcomes in patients undergoing initial laparoscopic or open cholecystectomy for either incidental or resectable GBC were included. Overall survival (OS), disease-free survival (DFS), and rate of peritoneal carcinomatosis (RPC) were the primary end points. Forest plot analyses were used to calculate the pooled hazard ratios (HRs) of OS, DFS, and RPC. Metaregression was used to evaluate study-level association between BS and perioperative risk factors.

RESULTS

Of 181 published articles, 11 met inclusion criteria with a sample size of 1116 patients. The rate of BS ranged between 9% and 67%. On pooled analysis, BS was associated with worse OS (HR = 1.68, 95% confidence interval [CI] = 1.32-2.14), DFS (pooled HR= 2.19, 95% CI = 1.30-3.68), and higher RPC (odds ratio = 9.37, 95% CI = 3.49-25.2). The rate of BS was not associated with higher T stage, lymph node metastasis, higher grade, positive margin status, reresection, or conversion rates.

CONCLUSIONS

Our meta-analysis shows that BS is a predictor of higher peritoneal recurrence and poor survival in GBC. BS was not associated with tumor characteristics or conversion rates. Further research is needed to identify other potential risk factors for BS and investigate the ideal treatment schedule to improve survival.

Safety of laparoscopic cholecystectomy performed by trainee surgeons with different cholangiographic techniques (SCOTCH): a prospective non-randomized trial on the impact of fluorescent cholangiography during laparoscopic cholecystectomy performed by trainees

AIMS

The identification of the anatomical components of the Calot's Triangle during laparoscopic cholecystectomy (LC) might be challenging and its difficulty may increase when a surgical trainee (ST) is in charge, ultimately allegedly affecting also the incidence of common bile duct injuries (CBDIs). There are various methods to help reach the critical view of safety (CVS): intraoperative cholangiogram (IOC), critical view of safety in white light (CVS-WL) and near-infrared fluorescent cholangiography (NIRF-C). The primary objective was to compare the use of these techniques to obtain the CVS during elective LC performed by ST.

METHODS

This was a multicentre prospective observational study (Clinicalstrials.gov Registration number: NCT04863482). The impact of three different visualization techniques (IOC, CVS-WL, NIRF-C) on LC was analyzed. Operative time and time to achieve the CVS were considered. All the participating surgeons were also required to fill in three questionnaires at the end of the operation focusing on anatomical identification of the general task and their satisfaction.

RESULTS

Twenty-nine centers participated for a total of 338 patients: 260 CVS-WL, 10 IOC and 68 NIRF-C groups. The groups did not differ in the baseline characteristics. CVS was considered achieved in all the included case. Rates were statistically higher in the NIR-C group for common hepatic and common bile duct visualization (p = 0.046; p < 0.005, respectively). There were no statistically significant differences in operative time (p = 0.089) nor in the time to achieve the CVS (p = 0.626). Three biliary duct injuries were reported: 2 in the CVS-WL and 1 in the NIR-C. Surgical workload scores were statistically lower in every domain in the NIR-C group. Subjective satisfaction was higher in the NIR-C group. There were no other statistically significant differences.

CONCLUSIONS

These data showed that using NIRF-C did not prolong operative time but positively influenced the surgeon's satisfaction of the performance of LC.

Utility of the Novel SpyGlass^TM DS II System and Laser Lithotripsy for Choledocholithiasis in Pregnancy

<b><i>Background and Aim:</i></b> Endoscopic retrograde cholangiopancreatography (ERCP) is considered a safe therapeutic modality even in pregnant women; however, adequate care needs to be taken. The utility of the SpyGlass^TM DS II system in choledocholithiasis among pregnant women is unexplored. <b><i>Methods:</i></b> We retrospectively analyzed patients who underwent<b><i></i></b>ERCP for choledocholithiasis in the absence of fluoroscopy using the SpyGlass DS II system from October 2019 to November 2020. Depending on the size and location of the stones, we used laser lithotripsy (LL) for large impacted stones, the balloon extraction technique for multiple stones, and the SpyGlass retrieval basket for single solitary stones. <b><i>Results:</i></b> A total of 10 (100% female) patients with a mean (±SD) age of 29.5 (±2.5) years underwent ERCP. Abdominal pain was the commonest presenting symptom in all patients. Four (40%) patients had cholangitis and 3 (30%) had pancreatitis. The majority of the patients (9; 90%) were in the second trimester. MRCP was the commonest radiological entity, used in 9 (90%) patients. ERCP was technically successful and the stones were removed from all of the patients in a mean (±SD) time of 30 (±3.5) min. LL was used successfully in 4 (40%) patients, balloon extraction in 3 (30%) patients, and the SpyGlass retrieval basket in 3 (30%) patients. There were no pre- or post-procedural complications. All of the patients had an uneventful childbirth, after which they underwent cholecystectomy and subsequent stent removal 2 weeks later. <b><i>Conclusions:</i></b> Use of the SpyGlass DS II system and LL during ERCP appears safe and effective for the treatment of choledocholithiasis among pregnant women.

Degree of biliary tract violation during treatment of gallbladder adenocarcinoma is independently associated with development of peritoneal carcinomatosis

BACKGROUND

Gallbladder cancer (GBC) is often incidentally diagnosed after cholecystectomy. Intra-operative biliary tract violations (BTV) have been recently associated with development of peritoneal disease (PD). The degree of BTV may be associated with PD risk, but has not been previously investigated.

METHODS

We reviewed patients with initially non-metastatic GBC treated at our institution from 2003 to 2018. Patients were grouped based on degree of BTV during their treatment: major (e.g., cholecystotomy with bile spillage, n = 27, 29%), minor (e.g., intra-operative cholangiogram, n = 18, 19%), and no violations (n = 48, 55%). Overall survival (OS) and peritoneal disease-free survival (PDFS) were evaluated with Kaplan-Meier and Cox proportional hazards modeling.

RESULTS

Ninety-three patients were identified; the median age was 64 years (range 31-87 years). Seventy-six (82%) were incidentally diagnosed. The median follow-up was 23 months; 20 (22%) patients developed PD. The 3-year PDFS for patients with major, minor, and no BTV was 52%, 83%, and 98%, respectively (major vs. none: p <  0.001; minor vs. none: p <  0.01). BTV was not associated with 5-year OS (HR 1.53, p =  0.16).

CONCLUSION

Increasing degree of BTV is associated with higher risk of peritoneal carcinomatosis in patients with GBC and should be considered during preoperative risk stratification. Reporting biliary tract violations during cholecystectomy is encouraged.

Bile Microbiota in Patients with Pigment Common Bile Duct Stones

BACKGROUND

Common bile duct (CBD) stone is one of the most prevalent gastroenterological diseases, but the role played by biliary microbiota in the pathogenesis of CBD stones remains obscure. The aim of this study was to investigate the characteristics of the biliary tract core microbiome and its potential association with the formation of pigment stones.

METHODS

Twenty-eight patients with biliary obstruction of various causes were enrolled. Thirteen had new-onset pigment CBD stone. Of the remaining 15, four had benign biliary stricture, four had gallbladder cancer, three had pancreatic cancer, 3 had distal CBD cancer, and one had hepatocellular carcinoma. Endoscopic retrograde cholangiopancreatography was used to collect bile samples for DNA extraction, 16S ribosomal RNA gene sequencing, and bile microbiota composition analysis.

RESULTS

Proteobacteria (61.7%), Firmicutes (25.1%), Bacteroidetes (5%), Fusobacteria (4.6%), and Actinobacteria (2.6%) were the most dominant phyla in the bile of the 28 study subjects. A comparison between new-onset choledocholithiasis and other causes of biliary obstruction (controls) showed Enterococcus was found to be significantly abundant in the CBD stone group at the genus level (linear discriminant analysis score = 4.38; P = 0.03). However, no other significant compositional difference was observed.

CONCLUSION

This study demonstrates an abundance of microbiota in bile juice and presents a biliary microbiome composition similar to that of duodenum. The study also shows Enterococcus was significantly abundant in the bile juice of patients with a brown pigment stone than in controls, which suggests Enterococcus may play an important role in the development of pigment stones.

Adverse Outcomes After Bile Spillage in Incidental Gallbladder Cancers: A Population-based Study

OBJECTIVE

To determine the effect of bile spillage during cholecystectomy on oncological outcomes in incidental gallbladder cancers.

BACKGROUND

Gallbladder cancer (GBC) is rare, but lethal. Achieving complete resection offers the best chance of survival. About 30% of GBCs are discovered incidentally after cholecystectomy for benign pathology. There is an anecdotal association between peritoneal dissemination and bile spillage during the index cholecystectomy. However, no population-based studies are available that measure the consequences of bile spillage on patient outcomes.

METHODS

We conducted a retrospective cohort comparison of patients with incidental GBC. All cholecystectomies and cases of GBC in Alberta, Canada, from 2001 to 2015, were identified. GBCs discovered incidentally were included. Operative events leading to bile spillage were reviewed. Patient outcomes were compared between cases of bile spillage versus no contamination.

RESULTS

In all, 115,484 cholecystectomies were performed, and a detailed analysis was possible in 82 incidental GBC cases. In 55 cases (67%), there was bile spillage during the index cholecystectomy. Peritoneal carcinomatosis occurred more frequently in those with bile spillage (24% vs 4%; P = 0.0287). Patients with bile spillage were less likely to undergo a radical re-resection (25% vs 56%; P = 0.0131) and were less likely to achieve an R0 resection margin [odds ratio 0.19, 95% confidence interval (CI) 0.06-0.55]. On Cox regression modeling, bile spillage was an independent predictor of shorter disease-free survival (hazard ratio 1.99, 95% CI 1.07-3.67).

CONCLUSION

For incidentally discovered GBC, bile spillage at the time of index cholecystectomy has measureable adverse consequences on patient outcomes. Early involvement of a hepatobiliary specialist is recommended where concerning features for GBC exist.

Choledocholithiasis recurrence following laparoscopic common bile duct exploration

INTRODUCTION

Choledocholithiasis may be treated following an endoscopic approach or by laparoscopic common bile duct exploration (LCBDE). Stone recurrence following endoscopic management has been extensively investigated. We analyze the risk factors associated with stone recurrence following LCBDE.

METHODS

Patients who underwent LCBDE from February 2004 to July 2016 were examined in an univariate and multivariate analysis to assess the association of stone recurrence with the following variables: gender; age; hepatopathy; dyslipidemia, obesity or diabetes mellitus; previous abdominal surgery; presence of cholecystitis, cholangitis or pancreatitis; preoperative liver function tests, number of retrieved stones; method of common bile duct clearance and closure; presence of impacted or intrahepatic stones; conversion to open surgery and postoperative morbidity.

RESULTS

A total of 156 patients were included. Recurrence rate for choledocholithiasis was 14.1% with a mean time to recurrence of 38.18 month. Age was the only independent risk factor for stone recurrence at univariate and multivariate analysis. No patient aged under 55 years developed new common bile duct stones, and 86.4% of the recurrences occurred in patients aged above 65.

CONCLUSIONS

Age is the only independent risk factor associated to choledocholithiasis recurrence following LCBDE. Different mechanism in common bile duct stone development may be present for younger and older patients.

Efficacy of fibrin-sealants in reducing biliary leakage following laparoscopic common bile duct exploration

INTRODUCTION

In spite of the acquired experience with laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis management, there is still a risk of biliary leakage of 5% to 15% following choledochotomy closure. We evaluate the usefulness of fibrin-collagen sealants to reduce the incidence of biliary fistula after laparoscopic choledochorrhaphy.

METHODS

We report a retrospective analysis of 96 patients undergoing LCBDE from March 2009 to March 2017, whose closure of the bile duct was completed by antegrade stenting and choledochorraphy or by performing a primary suture. The study population was divided into two groups according to whether they received a collagen-fibrin sealant covering the choledochorrhaphy or not, analyzing the incidence of postoperative biliary fistula in each group.

RESULTS

Thirty-nine patients (41%) received a fibrin-collagen sponge while the bile duct closure was not covered in the remaining 57 patients (59%). The incidence of biliary fistula was 7.7% (3 patients) in the first group and 14% (8 patients) in the second group (P=.338). In patients who underwent primary choledochorraphy, the fibrin-collagen sealant reduced the incidence of biliary leakage significantly (4.5% vs. 33%, P=.020), which was a protective factor with an odds ratio of 10.5.

CONCLUSION

Fibrin-collagen sealants may decrease the incidence of biliary fistula in patients who have undergone primary bile duct closure following LCBDE.

Comparative Study of Three Bile Duct Closure Methods Following Laparoscopic Common Bile Duct Exploration for Choledocholithiasis

BACKGROUND

There are three choledochotomy closure methods available following laparoscopic common bile duct exploration: T-tube insertion, antegrade stenting, and primary choledochorrhaphy. We reviewed the experience of 12 years at our center searching for the optimal closure technique.

METHODS

We analyzed retrospectively 146 patients that underwent one of the three closure methods from February 2004 to March 2016. Hospital stay, need for readmission, incidence of early and long-term complications, and biliary leakage development and their clinical impact were determined for each technique.

RESULTS

Hospital stay was more prolonged, and need for readmission was higher in the T-tube group. Nine patients of the T-tube group (17.3%), 5 patients (8.6%) of the antegrade stenting group, and 1 patient of the primary suture group (2.8%) developed Dindo-Clavien ≥3 complications (P = .076). The incidence of biliary leakage was 3.8%, 8.6%, and 16.7% for the T-tube group, antegrade stenting group, and primary suture group, respectively. There was no grade C biliary fistula in the primary suture group, and all grade B leaks in these patients were only due to prolonged duration. The T-tube removal caused adverse events in 21.1% of the patients, and complications directly related with stents occurred in 9.6%.

CONCLUSION

Antegrade stents or T-tube insertion do not provide any added value for choledochotomy closure but are charged with specific morbidity. On the contrary, despite biliary leaks being more frequent after primary suture, they are of little clinical consequence and may be managed on an outpatient basis.

Fluorescent incisionless cholangiography as a teaching tool for identification of Calot's triangle

BACKGROUND

Intraoperative incisionless fluorescent cholangiogram (IOIFC) has been demonstrated to be a useful tool to increase the visualization of Calot's triangle. This study evaluates the identification of extrahepatic biliary structures with IOIFC by medical students and surgery residents.

METHODS

Two pictures were taken, one with xenon light and one with near-infrared (NIR) light, at the same stage during dissection of Calot's triangle in ten different cases of laparoscopic cholecystectomy (LC). All twenty pictures were organized in a random fashion to remove any imagery bias. Twenty students and twenty residents were asked to identify the biliary anatomy.

RESULTS

Medical students were able to accurately identify the cystic duct on an average 33.8 % under the xenon light versus 86 % under NIR light (p = 0.0001), the common hepatic duct (CHD) on an average 19 % under the xenon light versus 88.5 % under NIR light (p = 0.0001), and the junction on an average 24 % under xenon light versus 80.5 % under NIR light (p = 0.0001). Surgery residents were able to accurately identify the cystic duct on an average 40 % under the xenon light versus 99 % under NIR light (p = 0.0001), the CHD on an average 35 % under the xenon light versus 96 % under NIR light (p = 0.0001), and the junction on an average 24 % under the xenon light versus 95.5 % under NIR light (p = 0.0001).

CONCLUSIONS

IOIFC increases the visualization of Calot's triangle structures when compared to xenon light. IOIFC may be a useful teaching tool in residency programs to teach LC.

Systematic review and meta-analysis of minimally invasive techniques for the management of cholecysto-choledocholithiasis

BACKGROUND

The optimal management of patients with symptomatic gallstones and possible or proven common bile duct (CBD) stones and gallstones is still evolving. Today a number of options exist: preoperative endoscopic retrograde cholangiopancreatography (pre-op ERCP), laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic sphincterotomy (IOES), laparoscopic common bile duct exploration (LCBDE) and postoperative ERCP (post-op ERCP). This meta-analysis was done to compare these management options and determine if any single option was clearly superior.

METHODS

A systematic search was conducted using several electronic databases. The search revealed 15 randomized controlled trials (RCTs). Six comparing pre-op ERCP with LCBDE, five comparing pre-op ERCP with IOES, two comparing IOES with LCBDE and two comparing post-op ERCP with LCBDE, comprising a total of 1992 patients.

RESULTS

The pre-op ERCP group had a significantly higher incidence of ERCP related complications (odds ratio: 2.40, 95% confidence interval: 1.21-4.75).

CONCLUSIONS

The evidence provided by this meta-analysis suggests that both of these approaches would appear comparable. To fully address which would be the better approach would require an RCT as discussed above.

Inflammation in laparoendoscopic single-site surgery versus laparoscopic cholecystectomy

INTRODUCTION

Laparoendoscopic single-site surgery (LESS) uses a multiple-entry portal in a single 3.0- to 4.0-cm incision in a natural scar, the umbilicus. The present study aimed to compare the inflammatory impact of classic video laparoscopic cholecystectomy (LC) versus LESS cholecystectomy.

METHODS

A prospective randomized controlled study was conducted from January to June 2011 at 2 university hospitals in Rio de Janeiro, Brazil. Fifty-seven patients (53 women, 4 men; mean age = 48.7 years) were randomly assigned to receive LC (n = 29) or LESS (n = 28) cholecystectomy. C-reactive protein (CRP) and interleukin 6 (IL-6) were measured from blood samples collected during induction of anesthesia and at 3 and 24 hours postoperatively.

RESULTS

Median IL-6 levels in the LESS and LC groups, respectively, were 2.96 and 4.5 pg/mL preoperatively, 11.6 and 28.05 pg/mL at 3 hours postoperatively (P = .029), and 13.18 and 15.1 pg/mL at 24 hours postoperatively (P = .52). Median CRP levels in the LESS and LC groups, respectively, were 0.33 and 0.44 mg/mL preoperatively, 0.40 and 0.45 mg/mL (P = .73) at 3 hours postoperatively, and 1.7 and 1.82 mg/mL (P = .84) at 24 hours postoperatively. We did not find a significant association between IL-6 (and CRP) and body mass index in the LESS group.

CONCLUSIONS

LESS cholecystectomy requires a larger size incision than LC. We found a tendency of less postoperative pain following LESS cholecystectomy than LC. There was also a tendency toward lower early inflammatory impact following LESS cholecystectomy versus LC.

Role of intraoperative cholangiography in patients whose biliary tree was evaluated preoperatively by magnetic resonance cholangiopancreatography

BACKGROUND

Routine performance of intraoperative cholangiography (IOC) during cholecystectomy is controversial. The aim of this study was to evaluate the role of IOC during cholecystectomy in addition to preoperative magnetic resonance cholangiopancreatography (MRCP) in our institution over a 12-year period.

METHODS

A total of 425 consecutive patients who underwent IOC during cholecystectomy were included in this study. MRCP was performed preoperatively for bile duct evaluation in all patients. When common bile duct (CBD) stones were detected, they were removed endoscopically before the operation. We estimated the results of IOC in terms of the success rate, the detection rate of anatomic abnormality of the biliary system, and the incidence of residual CBD stones.

RESULTS

MRCP preoperatively identified 6 (1.4 %) patients with abnormal biliary systems and 56 with CBD stones, which were endoscopically removed. The success rate of IOC was 93.8 % (399/425). Abnormalities of the biliary system were detected in 12 patients (12/399, 3.0 %) and CBD stones in 8 (8/399, 2.0 %). Of the eight patients with stones, seven had been examined by endoscopy preoperatively and found to have CBD stones. The detection rate of bile duct stones in patients with preoperative endoscopic removal of CBD stones (7/56, 12.5 %) was significantly higher than those with CBD stones first detected during IOC (1/365, 0.3 %) (p < 0.01). Moreover, no residual CBD stones were detected in patients who were operated on within fewer than 12 days from endoscopic treatment to the operation.

CONCLUSIONS

IOC is indicated even after preoperative sphincterotomy for CBD stones. In our study, it resulted in a 12.5 % incidence of persistent stones after sphincterotomy. IOC plays an additional role in detecting CBD stones and in revealing abnormalities of the biliary tree in patients whose biliary tree was preoperatively evaluated by MRCP.

Preoperative versus intraoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones: system review and meta-analysis

BACKGROUND

Conducting preoperative versus intraoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones remains controversial. We conducted a meta-analysis to evaluate the outcomes of preoperative endoscopic sphincterotomy (POES) versus intraoperative endoscopic sphincterotomy (IOES).

METHODS

We searched multiple electronic databases for prospective, randomized, controlled trials related to safety and effectiveness of POES versus IOES. Relative risk ratios (RRs) were estimated with 95 % confidence intervals (CI) based on an intention-to-treat analysis. We considered the following outcomes: clearance rate, postprocedural complications, and hospital stay.

RESULTS

Five trials with 631 patients (318 with POES, 313 with IOES) were analyzed. Although the overall rates of common bile duct stone clearance were similar between POES and IOES (RR 0.96, 95 % CI 0.91-1.01; p = 0.13), the failure rate of common bile duct cannulation during endoscopic retrograde cholangiopancreatography (ERCP) was significantly higher for IOES (RR 2.54, 95 % CI 1.23-5.26; p = 0.01). The pooled RR after POES for overall complication rates was similar to that for IOES (RR 1.56, 95 % CI 0.94-2.59; p = 0.09). However, compared with IOES, the RR risk of ERCP-related complications was significantly higher for POES (RR 2.27, 95 % CI 1.18-4.40, p = 0.01), especially in the patients at high risk of developing post-ERCP pancreatitis. There was no significant difference in morbidity after laparoscopic cholecystectomy or required subsequent open surgery between the two groups. In the subgroup analyses, the RR risks of post-ERCP pancreatitis were significantly higher for POES (RR 4.85, 95 % CI 1.41-16.66, p = 0.01), and mean hospital stay was longer in the POES group (RR 2.22, 95 % CI 1.98-246; p < 0.01). However, the rates of bleeding, perforation, cholangitis, cholecystitis, and gastric ulceration did not differ significantly between POES and IOES.

CONCLUSIONS

With regard to the stone clearance and overall complication rates, POES is equal to IOES in patients with gallbladder and common bile duct stones. However, IOES is associated with a reduced incidence of ERCP-related pancreatitis and results in a shorter hospital stay.

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

OBJECTIVE

To compare short-term surgical outcomes and quality of life (QOL) between single-port laparoscopic cholecystectomy (SPLC) and classic 4-port laparoscopic cholecystectomy (CLC).

BACKGROUND

There is significant interest in further reducing the trauma associated with surgical procedures. Although a number of observational studies have suggested that SPLC is a feasible alternative to CLC, there is a lack of data from randomized studies validating any benefit over CLC.

METHODS

Eligible patients were randomized to receive SPLC or CLC. Operative and perioperative outcomes, including cosmesis and QOL were analyzed.

RESULTS

Forty-three patients were randomized to SPLC (n = 21) or CLC (n = 22). There were no significant differences between groups for most preoperative demographics, American Society of Anesthesiology score, gallstone characteristics, local inflammation, blood loss, or length of stay. Patients undergoing SPLC were older than those receiving CLC (57.3 years vs. 45.8 years, P < 0.05). Operative times for SPLC were greater than CLC (88.5 minutes vs. 44.8 minutes, P < 0.05). Overall and cosmetic satisfaction, QOL as determined by the SF-36 survey, postoperative complications, and post-operative pain scores between discharge and 2-week postoperative visit were not significantly different between groups. Wound infection rates were similar in both groups. The SPLC group contained 1 retained bile duct stone, 1-port site hernia, and 1 postoperative port site hemorrhage.

CONCLUSIONS

SPLC procedure time was longer and incurred more complications than CLC without significant benefits in patient satisfaction, postoperative pain and QOL. SPLC may be offered in carefully selected patients. Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another.

Nationwide quality improvement of cholecystectomy: results from a national database

OBJECTIVE

To evaluate whether quality improvements in the performance of cholecystectomy have been achieved in Denmark since 2006, after revision of the Danish National Guidelines for treatment of gallstones.

DESIGN

A national database that monitors the quality of cholecystectomy was established, and registration of all cholecystectomies in Denmark was mandatory since 1 January 2006. Indicators describing the operation, the postoperative course, the surgical outcome and various risk factors were followed for 4 years.

RESULTS

from 2006 were defined as reference values and indicator values, and covariates were stratified by year and tested for trend. Logistic regression models were used to adjust for changes in the prevalence of risk factors/covariates in the study period.

SETTING

Nationwide, prospective clinical database in Denmark. Data from 2006 to 2009.

PARTICIPANTS

23,672 patients undergoing cholecystectomy where a laparoscopic procedure was considered the standard operation according to national guidelines.

MAIN OUTCOME MEASURES

The rate of conversion from laparoscopic to open operation, the frequency of primary open operations where laparoscopic procedure was the standard, length of postoperative stay including frequency of same-day surgery, additional surgical procedures within 30 days, readmission and mortality. Results Conversion rate and frequency of primary open cholecystectomy were reduced in the study period. Same-day surgery increased by 14.6%, without an increase in readmission rate (9.4%). The frequency of 'additional procedures within 30 days' was also reduced (2.8%). The frequency of injuries requiring reconstructive bile-duct surgery was unaffected (0.15%).

CONCLUSION

The study demonstrates nationwide quality improvements of cholecystectomy in Denmark from 2006 to 2009.

The outcome of laparoscopic cholecystectomy in diabetic patients: a prospective study

BACKGROUND

Diabetes mellitus is considered a risk factor associated with morbidity in patients who undergo laparoscopic cholecystectomy (LC), in comparison with nondiabetics. The aim of this study was to evaluate this risk factor in Saudi patients and evaluate the outcome LC in diabetic patients with nondiabetics.

PATIENTS AND METHODS

We analyzed data from 968 patients with symptomatic gallbladder stones who underwent an LC between January 2005 and June 2008. Age, sex, operative records, morbidity, and length of hospital stay for each patient were analyzed.

RESULTS

There were 175 (18%) diabetic and 793 nondiabetic patients. There was no significant difference between the two groups regarding complication, conversion to open, or operative time. Length of hospital stay was significantly different in the two groups.

CONCLUSIONS

LC in diabetic patients had the same outcome in nondiabetic patients. Careful preoperative preparations, meticulous intraoperative surgical technique, and cautious postoperative care are mandatory to achieve this outcome.

Simultaneous/Incidental cholecystectomy during gastric/esophageal resection: systematic analysis of risks and benefits

BACKGROUND

After esophageal/gastric resection with resulting truncal vagotomy, the incidence of gallstone formation seems to increase. The clinical relevance of gallstones and the role of simultaneous/incidental cholecystectomy in this setting are controversially discussed.

METHODS

Systematic analysis has been performed for retrospective/prospective studies on the incidence/symptoms of gallstone formation after esophageal/gastric resection. Pooled estimates of the incidence of cholecystectomies were calculated by random effect models. Risk analyses of simultaneous, acute postoperative cholecystectomy and long-term cholecystectomy were performed.

RESULTS

Sixteen studies on gallstone formation after upper gastrointestinal (GI) surgery (3,735 patients) reported increased incidences of 5-60% with a pooled estimate of 17.5% (95% confidence interval (CI), 14.1-21.2%; inconsistency statistic (I (2)) = 86%) compared with 4-12% in the control population. In 113 of 3,011 patients (12 studies), late cholecystectomies were performed for symptomatic cholecystolithiasis, corresponding to an estimated overall proportion of 4.7% (95% CI, 2.1-8.2%; I (2) = 92%). In 1.2% (95% CI, >0-3.7%; I (2) = 93%) of patients undergoing upper GI surgery, a cholecystectomy was performed because of acute postoperative biliary problems (4 studies, 8,748 patients). Simultaneous cholecystectomy had a higher morbidity of 0.95% (95% CI, 0.54-1.49%; I (2) = 28%) compared with the calculated additional morbidity of early and late cholecystectomy of 0.45%.

CONCLUSIONS

Approximately 6% of patients undergoing upper GI surgery are expected to require cholecystectomy during follow-up. Because late cholecystectomies can be performed safely and because the additional calculated morbidity for these operations is lower than the morbidity for simultaneous cholecystectomy, it cannot generally be recommended to remove a normal acalculous gallbladder during upper GI surgery.

Effectiveness and safety of total endoscopic left internal mammary artery bypass graft to the left anterior descending artery

Totally endoscopic coronary artery bypass grafting (CABG) has become a feasible option using robotic technology and remote access perfusion techniques. The aim of this study was to determine the progression of the procedure's performance in the currently largest single-center series of arrested-heart totally endoscopic CABG. From 2001 to 2007, arrested-heart totally endoscopic CABG was performed in 100 patients (median age 59 years, range 46 to 70; 81 men, 19 women). All patients received left internal mammary artery grafts to the left anterior descending artery using the da Vinci Surgical System. Remote-access femoral perfusion and aortic balloon endo-occlusion were used in all patients. The series was divided into 4 phases: phase 1 (patients 1 to 25), phase 2 (patients 26 to 50), phase 3 (patients 51 to 75), and phase 4 (patients 76 to 100). The conversion rates to larger thoracic incisions were 7 of 25 (28%) in phase 1, 2 of 25 (8%) in phase 2, 1 of 25 (4%) in phase 3, and 1 of 25 (4%) in phase 4 (p = 0.018). Operative times and hospital stays decreased significantly with each subsequent phase, and clinical outcome showed corresponding improvements. There was no perioperative mortality. For the whole patient series, 5-year postoperative survival, freedom from angina, and freedom from major adverse cardiac and cerebral events were 100%, 91%, and 89%, respectively. In conclusion, after an initial steep learning curve, completely endoscopic left internal mammary artery-to-left anterior descending CABG can be performed safely, with low conversion rates. The learning curve for operative times and improvements in clinical outcome continued even at 100 procedures.

Management of preoperatively suspected choledocholithiasis: a decision analysis

BACKGROUND

The management of symptomatic or incidentally discovered common bile duct (CBD) stones is still controversial. Of patients undergoing elective cholecystectomy for symptomatic cholelithiasis, 5-15% will also harbor CBD stones, and those with symptoms suggestive of choledocholithiasis will have an even higher incidence. Options for treatment include preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram (LC/IOC), followed by either laparoscopic common bile duct exploration (LCBDE) or placement of a common bile duct double-lumen catheter with postoperative management. The purpose of this analysis was to determine the optimal management of such patients.

METHODS

A decision analysis was performed to analyze the management of patients with suspected common bile duct stones. The basic choice was between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE, or common duct double-lumen catheter (Fitzgibbons tube) placement with either expectant management or postoperative ERCP/ES. Data on morbidity and mortality was obtained from the literature. Sensitivity analysis was done varying the incidence of positive CBD stones on IOC with associated morbidity and mortality.

RESULTS

One-stage management of symptomatic CBD stones with LC/LCBDE is associated with less morbidity and mortality (7% and 0.19%) than two-stage management utilizing preoperative ERCP/ES (13.5% and 0.5%). Sensitivity analysis shows that there is an increase in morbidity and mortality for LC/LCBDE as the incidence of positive IOC increases but are still less than two-stage management even with a 100% positive IOC (9.4%, 0.5%). If a double-lumen catheter is to be used for positive IOC, the morbidity would be higher than two-stage management only if the positive IOC incidence is more than 65% but still with no mortality.

CONCLUSION

LCBDE has lower morbidity and mortality rates compared to preoperative ERCP/ES in the management of patients with suspected CBD stones even if the chance of CBD stones reaches 100%. Using a common duct double-lumen catheter may be considered if LCBDE is not feasible and the chance of CBD stone is less than 65%.

The routine use of laparoscopic ultrasound decreases bile duct injury: a multicenter study

OBJECTIVE

Laparoscopic ultrasound (LUS) has been used for over 15 years to screen the bile duct (BD) for stones and to delineate anatomy during laparoscopic cholecystectomy (LC). LUS as a modality to prevent BD injury has not been investigated in a large series. This study evaluated the routine use of LUS to determine its effect on preventing BD injury.

METHODS

A multicenter retrospective study was performed by reviewing clinical outcome of LC in which LUS was used routinely.

RESULTS

In five centers, 1,381 patients underwent LC with LUS. LUS was successful to delineate and evaluate the BD in 1,352 patients (98.0%), although it was unsuccessful or incomplete in 29 patients (2.0%). LUS was considered remarkably valuable to safely complete LC, avoiding conversion to open, in 81 patients (5.9%). The use of intraoperative cholangiography (IOC) varied depending on centers; IOC was performed in 504 patients (36.5%). For screening of BD stones (which was positive in 151 patients, 10.9%), LUS had a false-positive result in two patients (0.1%) and a false-negative result in five patients (0.4%). There were retained BD stones in three patients (0.2%). There were minor bile leaks from the liver bed in three patients (0.2%). However, there were no other BD injuries including BD transection (0%). Retrospectively, IOC was deemed necessary in 25 patients (1.8%) to complete LC in spite of routine LUS.

CONCLUSION

LUS can be performed successfully to delineate BD anatomy in the majority of patients. The routine use of LUS during LC has obviated major BD injury, compared to the reported rate (1 out of 200-400 LCs). LUS improves the safety of LC by clarifying anatomy and decreasing BD injury.

Male gender is not a risk factor for the outcome of laparoscopic cholecystectomy: a single surgeon experience

BACKGROUND/AIM

Previous studies regarding the outcome of laparoscopic cholecystectomy (LC) in men have reported inconsistent findings. We conducted this prospective study to test the hypothesis that the outcome of LC is worse in men than women.

MATERIALS AND METHODS

Between 1997 and 2002, a total of 391 consecutive LCs were performed by a single surgeon at King Fahd Hospital of the University. We collected and analyzed data including age, gender, body mass index (kg/m(2)), the American Society of Anesthesiologists (ASA) class, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis [AC]), comorbid disease, previous abdominal surgery, conversion to open cholecystectomy, complications, operation time, and length of postoperative hospital stay.

RESULTS

Bivariate analysis showed that both genders were matched for age, ASA class and mode of admission. The incidences of AC (P = 0.003) and comorbid disease (P = 0.031) were significantly higher in men. Women were significantly more obese than men (P < 0.001) and had a higher incidence of previous abdominal surgery (P = 0.017). There were no statistical differences between genders with regard to rates of conversion (P = 0.372) and complications (P = 0.647) and operation time (P = 0.063). The postoperative stay was significantly longer in men than women (P = 0.001). Logistic regression analysis showed that male gender was not an independent predictor of conversion (Odds ratio [OR] = 0.37 and P = 0.43) or complications (OR = 0.42, P = 0.42). Linear regression analysis showed that male gender was not an independent predictor of the operation time, but was associated with a longer postoperative stay (P = 0.02).

CONCLUSION

Male gender is not an independent risk factor for satisfactory outcome of LC in the experience of a single surgeon.