Laparoscopic cholecystectomy in 427 adults with sickle cell disease: a single-center experience

Laparoscopic Cholecystectomy Operative Time and Hospital Stay Differences Between Sicklers and Non-sicklers: A Five-Year Comparative Cross-Sectional Study at King Abdulaziz Medical City, Jeddah

Background Sickle cell disease (SCD) is one of the most important hemoglobinopathies that result in the formation of pigment gallstones. Laparoscopic cholecystectomy (LC) is a safe surgical procedure for gallstones in SCD. Currently, there is no standard or guidelines for the preoperative preparation of these patients. This study aims to estimate the difference in pre-operative length of stay, operative time, postoperative length of stay, and total hospitalization length of stay among patients with and without SCD in a tertiary hospital in Jeddah, Saudi Arabia. Such knowledge would aid in establishing a standard for the preoperative preparation of SCD patients for LC. Methods Data from all patients undergoing laparoscopic cholecystectomy between January 2013 and December 2018 were collected retrospectively with a comparative cross-sectional study design. Data included age, sex, BMI, clinical presentation, mode of admission (elective or emergency), preoperative length of stay, operative time, postoperative length of stay, total hospitalization length of stay, and type of surgery (day or inpatient). JMP 15.2.1 was used for statistical analysis. Results From 2013 to 2018, 793 patients underwent LC, and of those, 16 (2.018%) were SCD patients. The results showed significant differences in preoperative (p<0.001), postoperative (p<0.001), and total hospitalization stay time (p<0.001) between the SCD patients and non-SCD patients. However, the data show no significant difference in the operative time of LC between the two studied groups. Conclusion SCD is the most common hemoglobinopathy-causing gallstone. Challenges in these patients are mainly in peri-operative management. Further prospective cohort studies are needed to create a standardized approach for peri-operative management of SCD patients to facilitate delivery of the same level of care and shorten total hospitalization time.

Incidence of Post-Operative Complications and Factors Influencing Their Occurrence in Patients with Sickle Cell Disease in a Low-Income Country: A Case Study of Cameroon

This study aimed to analyse post-operative complications and possible factors influencing their occurrence in the management of patients with sickle cell disease in a low-income country. We prospectively collected data regarding the management of patients with sickle cell disease requiring anesthesia for surgery in 11 Cameroonian hospitals from 1 May 2019 to 30 April 2021. The data were analysed using descriptive statistics and a binary logistic regression was used to determine the dependence between the variables. A total of 124 patients with sickle cell disease were enrolled; 64 were male and 60 female, giving a sex ratio of 0.93. The rate of post-operative complications was 23.4% (29/124) and the death rate was 3.2% (4/124). The female subjects had more complications than the male subjects p < 0.05. The number of vaso-occlusive crises experienced per year showed a significant impact on the occurrence of post-operative complications p < 0.05. Laparoscopic surgery had fewer post-operative complications 5/46 (10.9%) than laparotomy 14/43 (32.5%). The surgical technique for the abdominal procedures had a significant impact on the occurrence of post-operative complications p < 0.05. The type of surgery (p = 0.198) and the anaesthesia technique (p = 0.225) did not show a significant impact on the occurrence of post-operative complications. Particular attention should be paid to female patients with sickle cell disease as they are more likely to experience post-operative complications, as well as to the frequency of vaso-occlusive crises, which are also predictive of post-operative complications. Opting for laparoscopic surgery whenever possible would help to reduce post-operative complications.

The Practices of Anaesthesiologists in the Management of Patients with Sickle Cell Disease: Empirical Evidence from Cameroon

Patients with sickle cell disease are more likely to undergo surgery during their lifetime, especially given the numerous complications they may develop. There is a paucity of data concerning the management of patients with sickle cell disease by anaesthesiologists, especially in Africa. This study aimed to describe the practices of anaesthesiologists in Cameroon concerning the perioperative management of patients with sickle cell disease. A cross-sectional study was carried out over four months and involved 35 out 47 anaesthesiologists working in hospitals across the country, who were invited to fill a data collection form after giving their informed consent. The data were analysed using descriptive statistics and a binary logistic regression model. Among the 35 anaesthesiologists included in the study, most (29 (82.9%)) had managed patients with sickle cell disease for both emergency and elective surgical procedures. Most of them had never asked for a haematology consultation before surgery. Most participants (26 (74.3%)) admitted to having carried out simple blood transfusions, while 4 (11.4%) carried out exchange transfusions. The haemoglobin thresholds for transfusion varied from one practitioner to another, between <6 g/dL and <9 g/dL. Only 6 (17.1%) anaesthesiologists had a treatment guideline for the management of patients with sickle cell disease in the hospitals where they practiced. Only 9 (25.7%) prescribed a search for irregular agglutinins. The percentage of haemoglobin S before surgery was always available for 5 (14.3%) of the participants. The coefficient (0.06) of the occurrence of a haematology consultation before surgery had a significant influence on the probability of management of post-operative complications (coefficient 0.06, 10% level of probability). This study highlights the fact that practices in the perioperative management of patients with sickle cell disease in Cameroon vary greatly from one anaesthesiologist to another. We disclosed major differences in the current recommendations, which support the fact that even in Sub-Saharan countries, guidelines applicable to the local settings should be published.

Perioperative care of children with sickle cell disease: A systematic review and clinical recommendations

Children with sickle cell disease (SCD) require specific perioperative care, and clinical practice in this area remains poorly defined. We aimed to conduct a systematic, PRISMA-based review of the literature, available clinical guidelines and practice recommendations. We also aimed to extract any valuable information for the "best of available-evidence"-based prevention of perioperative adverse events in children with SCD, and highlight the most urgent priorities in clinical research. As data sources, US National Library of Medicine, Medline, National Guideline Clearinghouse, International Guideline Network, TRIP databases were searched for any content until January 2019. We also included institutional, consortia and expert group guidelines. Included were reports/guidelines in English, French, German, and Italian. Excluded were reports on obstetrical and fetal management. We identified 202 reports/guidelines fulfilling the criteria outlined above. A majority focused on visceral, cardiovascular and orthopedic surgery procedures, and only five were multicenter randomized controlled trials and two prospective randomized studies. After grading of the quality of the evidence, the extracted data was summarized into clinical recommendations for daily practice. Additionally, we designed a risk-grading algorithm to identify contexts likely to be associated with adverse outcomes. In conclusion, we provide a systematic PRISMA-based review of the existing literature and ancillary practice and delineate a set of clinical recommendations and priorities for research.

The Inflammatory Response to Surgery in Sickle Cell Disease Patients Undergoing Cholecystectomy

Background and Objectives:

Patients with sickle cell anemia (SCA) may have elevated inflammatory markers in health, and this may be heightened after open operations. The inflammatory response of patients with SCA after minimally invasive surgeries has not been fully explored.

Patients and Methods:

Consecutive patients with SCA and with hemoglobin AA (HbAA) undergoing laparoscopic cholecystectomy for acute cholecystitis were recruited into the study. Blood samples were taken before induction of anesthesia (0-h); at 4, 12, 24, and 48 h; and on postoperative day 7. Samples were analyzed for serum C-reactive protein and interleukin (IL)-1 through IL-18.

Results:

Twenty-three patients, including 9 with SCA and 14 with HbAA, were recruited with 4 cases performed by open laparotomy. At 0-h, proinflammatory IL-1 levels (6.1 versus 4.8) and C-reactive protein levels (32.5 versus 26.6) were higher in patients with hemoglobin SS (HbSS) than in patients with HbAA, respectively. Over time, inflammatory markers were generally higher at each time-point for patients with HbSS compared with patients with HbAA for both proinflammatory and anti-inflammatory cytokines, rising immediately after surgery and up to 48 hours, then returning to baseline by postoperative day 7. There was a higher mean IL-1 level across all time-points in the HbSS group than in the HbAA group (P = .04).

Conclusion:

This exploratory study found an enhanced inflammatory response to cholecystectomy in patients with SCA compared with patients with HbAA. Minimally invasive surgical strategies for this patient group may help to mediate this response.

Perioperative Management of Sickle Cell Disease

Over 30 million people worldwide have sickle cell disease (SCD). Emergent and non-emergent surgical procedures in SCD have been associated with relatively increased risks of peri-operative mortality, vaso-occlusive (painful) crisis, acute chest syndrome, post-operative infections, congestive heart failure, cerebrovascular accident and acute kidney injury. Pre-operative assessment must include a careful review of the patient’s known crisis triggers, baseline hematologic profile, usual transfusion requirements, pre-existing organ dysfunction and opioid use. Use of preoperative blood transfusions should be selective and decisions individualized based on the baseline hemoglobin, surgical procedure and anticipated volume of blood loss. Intra- and post-operative management should focus on minimizing hypoxia, hypothermia, acidosis, and intravascular volume depletion. Pre- and post-operative incentive spirometry use should be encouraged.

A case series of cholecystectomy in Jamaican sickle cell disease patients - The need for a new strategy

High morbidity rates related to cholecystectomy in sickle cell disease (SCD) patients have been previously reported in the region. This study serves to assess the current outcomes related to cholecystectomy in a Jamaican SCD population. METHODS: A retrospective chart review of SCD patients undergoing elective cholecystectomy at the University Hospital of the West Indies over a 6-year period was performed providing relevant information for analysis. Patients were grouped on an intention-to-treat basis into an open and laparoscopic group. RESULTS: A total of 27 patients were included (18 laparoscopic and 9 open). Both groups were matched for age, gender and steady state hemoglobin. Only one patient (in the open group) received preoperative blood transfusion. The conversion rate for laparoscopy was 28%. Operative time was significantly longer in the open group (175.3 ± 62.1 vs. 125.9 ± 54.4 min, p = 0.0355). Bile duct exploration was undertaken in 66.7% of patients in the open group compared to 0% in the laparoscopic group. There was no significant difference between groups with respect to hospital stay, morbidity or mortality. The overall 30-day morbidity was 48.1% with acute chest syndrome being diagnosed in 6 patients and pneumonia in 7 patients. CONCLUSION: Morbidity rates related to cholecystectomy in the Jamaican SCD population remain high. Further studies to evaluate the factors contributing to such high morbidity in this population are warranted, with particular focus on laparoscopic cholecystectomy. Strategies such as preoperative transfusion and prophylactic cholecystectomy also need to be evaluated and considered in this patient group.

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Morbidity rates for cholecystectomy in Jamaican sickle cell patients remain high.

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There is a trend to higher morbidity for laparoscopic over open cholecystectomy.

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Preoperative transfusion is rarely employed in this patient population.

Prophylactic laparoscopic cholecystectomy in adult sickle cell disease patients with cholelithiasis: A prospective cohort study

INTRODUCTION

Prophylactic laparoscopic cholecystectomy remains controversial and has been discussed for selected subgroups of patients with asymptomatic cholelithiasis who are at high risk of developing complications such as chronic haemolytic conditions. Cholelithiasis is a frequent condition for patients with sickle cell disease (SCD). Complications from cholelithiasis may dramatically increase morbidity for these patients. Our objective was to evaluate the effectiveness of prophylactic cholecystectomy in SCD patients with asymptomatic gallbladder stones.

METHODS

From January 2000 to June 2014, we performed 103 laparoscopic cholecystectomies on SCD patients. Fifty-two patients had asymptomatic cholelithiasis. The asymptomatic patients were prospectively enrolled in this study, and all underwent a prophylactic cholecystectomy with an intraoperative cholangiography. The symptomatic patients were retrospectively studied. Upon admission, all patients were administered specific perioperative management including intravenous hydration, antibiotic prophylaxis, oxygenation, and intravenous painkillers, as well as the subcutaneous administration of low-molecular-weight heparin. During the same period, 51 patients with SCD underwent a cholecystectomy for symptomatic cholelithiasis. We compared these 2 groups in terms of postoperative mortality, morbidity, and hospital stay.

RESULTS

There were no postoperative deaths or injuries to the bile ducts in either group. In the asymptomatic group, we observed 6 postoperative complications (11.5%), and in the symptomatic group, there were 13 (25.5%) postoperative complications.

DISCUSSION

Regarding the SCD complications, we observed 1 case (2%) of acute chest syndrome in an asymptomatic cholelithiasis patient, while there were 3 cases (6%) in the symptomatic group. Vaso-occlusive crisis was observed in 1 patient (2%) with asymptomatic cholelithiasis, and in 4 patients (8%) in the other group. The mean hospital stay averaged 5.8 (4-17) days for prophylactic cholecystectomy and 7.96 (4-18) days for the comparative symptomatic group.

CONCLUSIONS

Postoperative complications related to SCD were less frequent for asymptomatic patients who had a laparoscopic prophylactic cholecystectomy. This intervention, if performed with perioperative specific management, is safe and helps avoid emergency operations for acute complications including cholecystitis, choledocholithiasis, and cholangitis. For SCD patients, a prophylactic cholecystectomy reduces hospital stays.

Laparoscopic cholecystectomy in adult patients with sickle cell disease

SUMMARY BACKGROUND DATA

A gallstone is a common disease in sickle cell disease (SCD) patients, and cholecystectomy is the most common surgical procedure performed in patients with SCD. We conducted this study to determine the outcome of laparoscopic cholecystectomy (LC) as the standard surgical treatment for gallstones in adult patients with sickle cell anemia over a long period.

PATIENTS AND METHODS

Data of all the SCD patients who were operated between April 1994 and December 2008 were collected retrospectively. We analyzed data including age, sex, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis), operation time, length of hospital stay, and complications.

RESULTS

: During 1994 to 2008, there were 6014 patients who underwent LC; of those, 496 (8.25%) patients were SCD patients. The results showed significant differences in the outcome, operative time, hospital stay, and complication rate between 1994 and 2008.

CONCLUSIONS

LC is a safe procedure in sickle cell patients with a low morbidity rate.

Epidural anesthesia for laparoscopic cholecystectomy in a patient with sickle cell anemia, beta thalassemia, and Crohn's disease -A case report-

A 37-year-old woman diagnosed with sickle cell anemia (SCA), beta (+) thalassemia, Crohn's disease, and liver dysfunction was scheduled for laparoscopic cholecystectomy (LC) due to acute cholecystitis with gall bladder. Regional anesthesia was performed. An epidural catheter was inserted into the 9-10 thoracal epidural space and then 15 ml of 0.5% bupivacaine was injected through the catheter. The level of sensorial analgesia tested with pinprick test reached up to T4. Here we describe the first case of the combination of sickle cell anemia (SCA), beta (+) thalassemia, and Crohn's disease successful anesthetic management with attention to hemodynamics, particularly with regards to liver dysfunction.