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Patcha R, Muppala NY, Malleeswaran S, Gopal PV, Katheresan V, Kumar S, Appusamy E, Varghese J, Srinivas S, Reddy MS. Defining Surgical Difficulty During Open Right Lobe Donor Hepatectomy and its Prediction Using Preoperative Donor Computed Tomography Morphometry. J Clin Exp Hepatol 2024; 14:101446. [PMID: 38946865 PMCID: PMC11214306 DOI: 10.1016/j.jceh.2024.101446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 05/11/2024] [Indexed: 07/02/2024] Open
Abstract
Background There is no accepted way to define difficult donor hepatectomy (DiffDH) during open right live donor hepatectomy (ORLDH). There are also no studies exploring association between DiffDH and early donor outcomes or reliable pre-operative predictors of DiffDH. Methods Consecutive ORLDH performed over 18 months at a single center were included. Intraoperative parameters were used to develop an objective definition of DiffDH. The impact of DiffDH on early postoperative outcomes and achievement of textbook outcome (TO) was evaluated. Donor morphometry data on axial and coronal sections of donor computed tomography (CT) at the level of portal bifurcation were collected. Donor and graft factors predictive of DiffDH were evaluated using univariate and multivariate logistic regression. Results One-hundred-eleven donors (male: 40.5%, age: 34 ± 9.5 years) underwent ORLDH during the study period. The difficulty score was constructed using five intraoperative parameters, i.e., operating time, transection time, estimated blood loss, need for intraoperative vasopressors, and need for Pringle maneuver. Donors were classified as DiffDH (score ≥ 2) or standard donor hepatectomy (StDH) (score <2). Twenty-nine donors (26%) were classified as DiffDH. DiffDH donors suffered greater all-cause morbidity (P = 0.004) but not major morbidity (Clavien-Dindo score >2; P = 0.651), more perioperative transfusion (P = 0.013), increased postoperative systemic inflammatory response syndrome (P = 0.034), delay in achieving full oral diet (P = 0.047), and a 70% reduced chance of achieving TO as compared to StDH (P = 0.007). On logistic regression analysis, increasing right lobe anteroposterior depth (RLdepth) was identified as an independent predictor of DiffDH (Odds ratio: 2.0 (95% confidence interval = 1.2, 3.3), P < 0.006). Receiver operating characteristic curve analysis identified an RLdepth of >14 cm as the best predictor of DiffDH (sensitivity:79%, specificity: 66%, area under curve = 0.803, P < 0.001). Conclusion We report a novel definition of DiffDH and show that it is associated with worse postoperative outcomes, including a lesser chance of achieving TO. We also report that DiffDH can be predicted from readily available donor CT parameters.
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Affiliation(s)
- Rajnikanth Patcha
- Department of Liver Transplantation & Hepatobiliary Surgery, Gleneagles Global Hospital, Chennai, India
| | - Neelendra Y. Muppala
- Department of Liver Transplantation & Hepatobiliary Surgery, Gleneagles Global Hospital, Chennai, India
| | | | - Prasanna V. Gopal
- Department of Liver Transplantation & Hepatobiliary Surgery, Gleneagles Global Hospital, Chennai, India
| | - Vellaichamy Katheresan
- Department of Liver Transplantation & Hepatobiliary Surgery, Gleneagles Global Hospital, Chennai, India
| | - Satish Kumar
- Department of Liver Transplantation & Hepatobiliary Surgery, Gleneagles Global Hospital, Chennai, India
| | - Ellango Appusamy
- Department of Liver Anesthesia & Intensive Care, Gleneagles Global Hospital, Chennai, India
| | - Joy Varghese
- Department of Hepatology & Transplant Hepatology, Gleneagles Global Hospital, Chennai, India
| | - Sripriya Srinivas
- Department of Diagnostic Radiology, Gleneagles Global Hospital, Chennai, India
| | - Mettu S. Reddy
- Department of Liver Transplantation & Hepatobiliary Surgery, Gleneagles Global Hospital, Chennai, India
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Hernández-Bermejo D, García-Vega C, Rubio-García JJ, Villodre-Tudela C, Carbonell-Morote S, Ramia JM. The textbook outcome for cholecystectomy: Is it a good quality tool for a low-morbidity procedure? Cir Esp 2024:S2173-5077(24)00154-6. [PMID: 38908512 DOI: 10.1016/j.cireng.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/23/2024] [Indexed: 06/24/2024]
Abstract
INTRODUCTION Cholelithiasis is the most common hospital diagnosis of the digestive system, and its treatment, if symptomatic, is laparoscopic cholecystectomy. There is a growing need for comprehensive determination of postoperative outcomes and the efficiency of healthcare facilities. The "textbook outcome"(TO) indicates the quality of care commonly used in oncological procedures, obtained by adding several postoperative parameters, which informs whether a perfect result has been obtained. The main objective of this study is to determine the TO for cholecystectomy and to see the factors that influence its achievement. METHODS Retrospective observational unicentric cohort study on patients who underwent cholecystectomy between 2018-2020. We defined TO as those patients who met the following premises: Clavien-Dindo complications < III, postsurgical stay less than the 75th percentile (<3 days), and no readmissions or mortality in the first ninety days. Perioperative characteristics were analyzed, and the patients were divided into two groups according to whether or not they achieved TO. We defined criteria for difficult cholecystectomy according to the operative report. RESULTS The percentage of TO was 72% (342/475) (82.6% in elective surgery and 60.5% in urgent surgery). The univariate analysis showed that the following factors are associated with achieving TO: female sex, age <63 years, ASA risk < III, elective surgery, laparoscopic approach, and not difficult cholecystectomy. After multivariate analysis ASA < III (OR 2.39 CI95% 1.37-4.16), elective surgery (OR 2.77 CI95% 1.64-4.67), laparoscopic approach (OR 5.71 CI95% 2.89-11.30) and not to be difficult cholecystectomy (OR 0.42 CI95% 0.259-0.71) remained statistically significant. CONCLUSIONS The TO is a healthcare quality tool that is simple to perform, easily interpretable, and helpful for evaluating quality in healthcare and comparing centers. It applies not only to oncological procedures but also to cholecystectomy.
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Affiliation(s)
| | - Celia García-Vega
- Departamento de Cirugía, Hospital General Universitario Dr. Balmis, Alicante, Spain
| | - Juan Jesús Rubio-García
- Departamento de Cirugía, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL: Instituto de Investigación Sanitaria y Biomédica, Alicante, Spain
| | - Celia Villodre-Tudela
- Departamento de Cirugía, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL: Instituto de Investigación Sanitaria y Biomédica, Alicante, Spain; Departamento de Patología y Cirugía, Universidad Miguel Hernández, Campus Sant Joan, Alicante, Spain
| | - Silvia Carbonell-Morote
- Departamento de Cirugía, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL: Instituto de Investigación Sanitaria y Biomédica, Alicante, Spain
| | - José Manuel Ramia
- Departamento de Cirugía, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL: Instituto de Investigación Sanitaria y Biomédica, Alicante, Spain; Departamento de Patología y Cirugía, Universidad Miguel Hernández, Campus Sant Joan, Alicante, Spain
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Chen Y, jiang J, He M, Zhong K, Tang S, Deng L, Wang Y. Nomogram for predicting difficult total laparoscopic hysterectomy: a multi-institutional, retrospective model development and validation study. Int J Surg 2024; 110:3249-3257. [PMID: 38537077 PMCID: PMC11175783 DOI: 10.1097/js9.0000000000001406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/12/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Total laparoscopic hysterectomy (TLH) is the most commonly performed gynaecological surgery. However, the difficulty of the operation varies depending on the patient and surgeon. Subsequently, patient's outcomes and surgical efficiency are affected. The authors aimed to develop and validate a preoperative nomogram to predict the operative difficulty in patients undergoing TLH. METHODS This retrospective study included 663 patients with TLH from Southwest Hospital and 102 patients from 958th Hospital in Chongqing, China. A multivariate logistic regression analysis was used to identify the independent predictors of operative difficulty, and a nomogram was constructed. The performance of the nomogram was validated internally and externally. RESULTS The uterine weight, history of pelvic surgery, presence of adenomyosis, surgeon's years of practice, and annual hysterectomy volume were identified as significant independent predictors of operative difficulty. The nomogram demonstrated good discrimination in the training dataset [area under the receiver operating characteristic curve (AUC), 0.827 (95% CI, 0.783-0.872], internal validation dataset [AUC, 0.793 (95% CI, 0.714-0.872)], and external validation dataset [AUC, 0.756 [95% CI, 0.658-0.854)]. The calibration curves showed good agreement between the predictions and observations for both internal and external validations. CONCLUSION The developed nomogram accurately predicted the operative difficulty of TLH, facilitated preoperative planning and patient counselling, and optimized surgical training. Further prospective multicenter clinical studies are required to optimize and validate this model.
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Affiliation(s)
- Yin Chen
- Department of Obstetrics and Gynecology, The 958th Army Hospital of the Chinese People’s Liberation Army (958th Hospital)
| | - Jiahong jiang
- Department of Obstetrics and Gynecology, The 958th Army Hospital of the Chinese People’s Liberation Army (958th Hospital)
| | - Min He
- Department of Obstetrics and Gynecology, The 958th Army Hospital of the Chinese People’s Liberation Army (958th Hospital)
| | - Kuiyan Zhong
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
| | - Shuai Tang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
| | - Li Deng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
| | - Yanzhou Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
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Patel M, Tranter-Entwistle I, Sirimanna P, Hugh TJ. 3D visualization systems improve operator efficiency during difficult laparoscopic cholecystectomy: a retrospective blinded review of surgical videos. ANZ J Surg 2024; 94:1114-1121. [PMID: 38486432 DOI: 10.1111/ans.18949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/29/2024] [Accepted: 03/06/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND 3D visualization systems in laparoscopic surgery have been proposed to improve manual task handling compared to 2D, however, few studies have compared the intra-operative efficacy in laparoscopic cholecystectomy (LC). The aim of this study is to determine if there is a benefit in intra-operative efficiency when using a 3D visualization system in difficult LC compared to traditional 2D visualization systems. METHODS Retrospective analysis of 'difficult' LCs (Grades 3 or 4) was completed. The assessor was blinded as all cases were recorded and viewed in 2D only. Variables collected included time to complete steps, missed hook diathermy attempts, failed grasp attempts, missed clip attempts and preparation steps for intra-operative cholangiogram (IOC). Multiple linear regression was undertaken for time variables, Poisson regression or negative binomial regression was completed for continuous variables. RESULTS Fifty-two operative videos of 'difficult' LC were reviewed. 3D systems were associated with reduced operative times, although this was not statistically significant (CI: -2.93-14.93, P-value = 0.183). Dissection of the anterior fold to achieve the critical view of safety was significantly faster by 3.55 min (CI: 1.215-9.206, P-value = 0.002), and with considerably fewer errors when using 3D systems. Fewer IOC preparation errors were observed with a 3D system compared with a 2D system. CONCLUSIONS 3D systems appear to enhance operator efficiency, allowing faster completion of critical steps with fewer errors. This pilot study underscores the utility of video annotation for intra-operative assessment and suggests that, in larger multi-centre studies, 3D systems may demonstrate superior intra-operative efficiency over 2D systems during a 'difficult' LC.
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Affiliation(s)
- Meet Patel
- Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- Northern Beaches Hospital, Frenches Forrest, New South Wales, Australia
| | | | - Pramudith Sirimanna
- Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Thomas J Hugh
- Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital, St Leonards, New South Wales, Australia
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Dhanasekara CS, Shrestha K, Grossman H, Garcia LM, Maqbool B, Luppens C, Dumas RP, Taveras Morales LR, Brahmbhatt TS, Haqqani M, Lunevicius R, Nzenwa IC, Griffiths E, Almonib A, Bradley NL, Lerner EP, Mohseni S, Trivedi D, Joseph BA, Anand T, Plevin R, Nahmias JT, Lasso ET, Dissanaike S. A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study. Surgery 2024:S0039-6060(24)00226-5. [PMID: 38777659 DOI: 10.1016/j.surg.2024.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/27/2024] [Accepted: 03/27/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Dense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder. METHODS A multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created. RESULTS In 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%. CONCLUSION Laparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.
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Affiliation(s)
| | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Holly Grossman
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Liza M Garcia
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Baila Maqbool
- Department of Surgery, University of New Mexico, Albuquerque, NM
| | - Carolyn Luppens
- Department of Surgery, University of New Mexico, Albuquerque, NM
| | - Ryan P Dumas
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Maha Haqqani
- Department of Surgery, Boston Medical Center, Boston, MA
| | - Raimundas Lunevicius
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ikemsinachi C Nzenwa
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; Department of Surgery, Massachusetts General Hospital, MA
| | - Ewen Griffiths
- Queen Elizabeth Hospital, University Hospitals NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Ahmed Almonib
- Queen Elizabeth Hospital, University Hospitals NHS Foundation Trust, Edgbaston, Birmingham, UK
| | | | - E Paul Lerner
- Department of Surgery, University of Alberta, Canada
| | - Shahin Mohseni
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City-Mayo Clinic, Abu Dhabi, UAE; School of Medical Sciences, Orebro University, Sweden
| | - Dhanisha Trivedi
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City-Mayo Clinic, Abu Dhabi, UAE; School of Medical Sciences, Orebro University, Sweden
| | | | - Tanya Anand
- Department of Surgery, University of Arizona, Tucson, AZ
| | - Rebecca Plevin
- Department of Surgery, University of California San Francisco, CA
| | - Jeffry T Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA
| | - Erika Tay Lasso
- Department of Surgery, University of California, Irvine, Orange, CA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX.
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Ito R, Yoshioka R, Gyoda Y, Miyashita M, Furuya R, Fujisawa M, Kawano F, Takeda Y, Ichida H, Mise Y, Saiura A. Utilization of the modified Kama scoring system for predicting bail-out cholecystectomy: a valuable tool in the era of rising laparoscopic surgery prevalence. Surg Today 2024:10.1007/s00595-024-02854-6. [PMID: 38734830 DOI: 10.1007/s00595-024-02854-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/02/2024] [Indexed: 05/13/2024]
Abstract
PURPOSE Recently, bail-out cholecystectomy (BOC) during laparoscopic cholecystectomy to avoid severe complications, such as vasculobiliary injury, has become widely used and increased in prevalence. However, current predictive factors or scoring systems are insufficient. Therefore, in this study, we aimed to test the validity of existing scoring systems and determine a suitable cutoff value for predicting BOC. METHODS We retrospectively assessed 305 patients who underwent laparoscopic cholecystectomy and divided them into a total cholecystectomy group (n = 265) and a BOC group (n = 40). Preoperative and operative findings were collected, and cutoff values for the existing scoring systems (Kama's and Nassar's) were modified using a prospectively maintained database. RESULTS The BOC rate was 13% with no severe complications. A logistic regression analysis revealed that the Kama's score (odds ratio, 0.93; 95% confidence interval 0.91-0.96; P < 0.01) was an independent predictor of BOC. A cutoff value of 6.5 points gave an area under the curve of 0.81, with a sensitivity of 87% and a specificity of 67%. CONCLUSIONS Kama's difficulty scoring system with a modified cutoff value (6.5 points) is effective for predicting BOC.
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Affiliation(s)
- Ryota Ito
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Ryuji Yoshioka
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yu Gyoda
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Mamiko Miyashita
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Ryoji Furuya
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Masahiro Fujisawa
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Fumihiro Kawano
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yoshinori Takeda
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Hirofumi Ichida
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yoshihiro Mise
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan.
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Tongyoo A, Liwattanakun A, Sriussadaporn E, Limpavitayaporn P, Mingmalairak C. New Proposed Classification of Difficulty in Laparoscopic Cholecystectomy. J Laparoendosc Adv Surg Tech A 2024; 34:407-414. [PMID: 38574306 DOI: 10.1089/lap.2024.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
Background: Difficult laparoscopic cholecystectomy (LC) has been challenging for surgeons. Randhawa's system used operative time, complications, and conversion to define three difficulty grades. However, using fixed numbers of operative time as dividers among three groups might not be applicable universally. This study aimed to propose new classification with more flexible parameters. Methods: This retrospective cohort study was conducted with patients who underwent LC because of gallstone-related diseases between January 2017 and December 2021 at Thammasat University Hospital. The exclusion criteria were (1) emergent LC for acute cholecystitis, (2) other procedures performed in the same setting of LC, (3) incomplete information, and (4) LC converted to open cholecystectomy. Patients were categorized into three groups using Randhawa's classification. Thereafter, new classification using mean and standard deviation was applied to reclassify patients into three new groups. The comparison between two grading results was performed to prove the advantage of new classification. Results: Total of 523 patients who underwent LC were included with median age 59.3 years old and 60.8% female. By Randhawa classification, proportions of easy, difficult, and very difficult groups were 39%, 53.7%, and 7.3%, respectively. Then, the new operative-time dividers among three groups were changed from 60 and 120 minutes to mean and mean + 2SD, respectively. Reclassified three difficult groups were 38.9%, 57.1%, and 4%. The comparison demonstrated new classification as more flexible and more compatible with each individual surgeon. Conclusions: New surgeon-referenced grading system of difficult LC included surgeon's factors, not only unfavorable operative findings. This classification should be more flexible than the previous criterion-referenced one. Thai Clinical Trials Registry at https://www.thaiclinicaltrials.org with Number TCTR20220426003.
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Affiliation(s)
- Assanee Tongyoo
- Hepato-Pancreato-Biliary Surgery and Transplantation Unit, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Thailand
| | - Aekkaphod Liwattanakun
- Hepato-Pancreato-Biliary Surgery and Transplantation Unit, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Thailand
| | - Ekkapak Sriussadaporn
- Hepato-Pancreato-Biliary Surgery and Transplantation Unit, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Thailand
| | - Palin Limpavitayaporn
- Hepato-Pancreato-Biliary Surgery and Transplantation Unit, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Thailand
| | - Chatchai Mingmalairak
- Hepato-Pancreato-Biliary Surgery and Transplantation Unit, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Thailand
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Stefanova I, Kyle E, Wilson I, Tobbal M, Veeramootoo D, De'Ath HD. Laparoscopic Cholecystectomy vs Endoscopic Retrograde Cholangiopancreatography With Sphincterotomy in Elderly Patients With Acute Gallstone Pancreatitis. Am Surg 2024:31348241248564. [PMID: 38636538 DOI: 10.1177/00031348241248564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND Gallstone pancreatitis (GSP) is common in elderly patients and carries worse outcomes. Laparoscopic cholecystectomy (LC) is recommended for prevention of recurrent GSP. In frail populations, an endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-s) is an alternative. Management guidelines of GSP in the elderly are lacking. This study aimed to investigate and compare management strategies for GSP in the elderly. MATERIALS AND METHODS A retrospective comparison of outcome of patients aged ≥65 years with first presentation of GSP treated either with (1) LC only, (2) ERCP-s, (3) ERCP-S followed by LC, or (4) no intervention. RESULTS 216 patients were included. Median age was 76 years (interquartile range 70-83). Most (80%, n = 172) had mild pancreatitis, whilst 12% (n = 26) had severe disease. 24% (n = 55) were treated with ERCP-s; 40% (n = 87) underwent LC alone; 11% (n = 23) had ERCP-s followed by LC; and 25% (n = 55) received no intervention. Patients without intervention were older (P < .001) and frailer (P < .001). The LC-only group had lower post-procedure re-admission rates of 6% (n = 5) compared to 27% (n = 14) for ERCP-s, 33% (n = 7) for ERCP-S + LC, and 31% (n = 17) for the no intervention group (P = .0001). Biliary cause mortality was highest in the no intervention group (n = 11, 20%). CONCLUSION Laparoscopic cholecystectomy represents the gold standard for elderly patients with GSP.
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Affiliation(s)
- Irena Stefanova
- Department of Upper Gastrointestinal Surgery, Royal Surrey County Hospital, Egerton Road, Guildford, UK
| | - Ewan Kyle
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, UK
| | - Iain Wilson
- Department of Upper Gastrointestinal Surgery, Wexham Park Hospital, Wexham St, Slough, UK
| | - Muhammad Tobbal
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, UK
| | - Darmarajah Veeramootoo
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, UK
| | - Henry D De'Ath
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, UK
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9
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Zhang C, Guo D, Lv G, Lin F, Wang Q, Lin J, Xiao D, Wang R, Gong Q. Application of 3-Step Laparoscopic Cholecystectomy in Acute Difficult Cholecystitis. Surg Laparosc Endosc Percutan Tech 2024; 34:201-205. [PMID: 38571322 DOI: 10.1097/sle.0000000000001272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/09/2023] [Indexed: 04/05/2024]
Abstract
BACKGROUND With the aging of the global population, the incidence rate of acute cholecystitis is increasing. Laparoscopic cholecystectomy is considered as the first choice to treat acute cholecystitis. How to effectively avoid serious intraoperative complications such as bile duct and blood vessel injury is still a difficult problem that puzzles surgeons. This paper introduces the application of laparoscopic cholecystectomy, a new surgical concept, in acute difficult cholecystitis. METHODS This retrospective analysis was carried out from January 2019 to January 2021. A total of 36 patients with acute difficult cholecystitis underwent 3-step laparoscopic cholecystectomy. The general information, clinical features, surgical methods, surgical results, and postoperative complications of the patients were analyzed. RESULTS All patients successfully completed the surgery, one of them was converted to laparotomy, and the other 35 cases were treated with 3-step laparoscopic cholecystectomy. Postoperative bile leakage occurred in 2 cases (5.56%), secondary choledocholithiasis in 1 case (2.78%), and hepatic effusion in 1 case (2.78%). No postoperative bleeding, septal infection, and other complications occurred, and no postoperative colon injury, gastroduodenal injury, liver injury, bile duct injury, vascular injury, and other surgery-related complications occurred. All 36 patients were discharged from hospital after successful recovery. No one died 30 days after surgery, and there was no abnormality in outpatient follow-up for 3 months after surgery. CONCLUSIONS Three-step laparoscopic cholecystectomy seems to be safer and more feasible for acute difficult cholecystitis patients. Compared with traditional laparoscopic cholecystectomy or partial cholecystectomy, 3-step laparoscopic cholecystectomy has the advantages of safe surgery and less complications, which is worth trying by clinicians.
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Affiliation(s)
- Chun Zhang
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
- Shengli Clinical Medical College of Fujian Medical University
| | - Dengfang Guo
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Guifang Lv
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Feng Lin
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Qinglin Wang
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Jianyuan Lin
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Dexian Xiao
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Ruotao Wang
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Qingquan Gong
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
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10
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Serrano-González R, Rivero Y, Hernandez-Velasquez A, Rodriguez-Rugel T, Mendez-Meneses G, Vidal-Gallardo A, Garcia-Sánchez E, Gonzalez-Quinde G, Antigua-Herrera J, Zelaya-Ochoa Y, Paz-Castillo M. Predicting Difficulty in Laparoscopic Cholecystectomies: An Evaluation of the Labbad-Vivas Score and Its Correlation With the Parkland Grading Scale. Cureus 2024; 16:e56185. [PMID: 38618440 PMCID: PMC11015945 DOI: 10.7759/cureus.56185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2024] [Indexed: 04/16/2024] Open
Abstract
Background Difficult laparoscopic cholecystectomy (DLC) denotes the surgical extraction of the gallbladder under circumstances where associated conditions within the same organ, adjacent structures, or patient-specific conditions impede a smooth, expeditious, and comfortable dissection. It is imperative to utilize tools that aid in anticipating this challenging surgical scenario, enabling the implementation of appropriate measures. Objective This study aimed to assess the effectiveness of the Labbad-Vivas score (LVS) in predicting DLC and its correlation with the Parkland Grading Scale (PGS). Methodology A prospective study was conducted, including patients diagnosed with gallstone disease undergoing LC (laparoscopic cholecystectomy) at the "Dr. Luis Razetti" University Hospital in Barcelona, Venezuela, between September and December 2023. Results Forty patients were studied, with 80% (n=32) being female and 95% (n=38) under the age of 65; surgeries were elective in 72.5% (n=29) of cases; 35% (n=14) had an LVS ≥16 (difficult cholecystectomy); and 62.5% (n=25) of patients presented Grades 1 and 2 on the PGS. Total cholecystectomy was performed in 95% (n=38) of the patients. The LVS showed a sensitivity of 80%, specificity of 92%, positive predictive value of 85.7%, and negative predictive value of 88.5% to predict DLC, with an area under the receiver operating characteristic curve of 0.897 (95% confidence interval (CI) = 0.792-1.003). A Pearson correlation coefficient of 0.805 (95% CI = 0.656 - 0.904) was obtained between both scores. Conclusion The use of the LVS score in the preoperative setting is feasible as a predictor of DLC, given its effectiveness and high correlation with the PGS.
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Affiliation(s)
| | - Yeisson Rivero
- Department of Surgery, Universidad de Oriente Núcleo Anzoátegui, Barcelona, VEN
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11
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Mishima K, Fujiyama Y, Wakabayashi T, Tsutsui A, Okamoto N, Marescaux J, Kitagawa Y, Wakabayashi G. Combining preoperative C-reactive protein values with the Tokyo Guidelines 2018 grading criteria can enhance the prediction of surgical difficulty in early laparoscopic cholecystectomy for acute cholecystitis. HPB (Oxford) 2024; 26:426-435. [PMID: 38135551 DOI: 10.1016/j.hpb.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/23/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Early laparoscopic cholecystectomy (ELC) is the standard treatment for acute cholecystitis (AC). However, predicting the difficulty of this procedure remains challenging. The present study aimed to develop an improved prediction model for surgical difficulty during ELC, surpassing the current Tokyo Guidelines 2018 (TG18) grading system. METHODS We analyzed data from 201 consecutive patients who underwent ELC for AC between 2019 and 2021. Surgical difficulty was defined as the failure to achieve the critical view of safety (non-CVS). We developed a scoring system by conducting multivariate analysis on demographics, symptoms, laboratory data, and radiographic findings. The predictive accuracy of our scoring system was compared to that of the TG18 grading system (Grade I vs. Grade II/III). RESULTS Through multivariate logistic regression analysis, a novel scoring system was formulated. This system incorporated preoperative C-reactive protein (CRP) values (≥5: 1 pt, ≥10: 2 pts, ≥15: 3 pts) and TG18 grading score (duration >72 h: 1 pt, image criteria for Grade II AC: 1 pt). Our model, a cutoff score of ≥3, exhibited a significantly elevated area under the curve (AUC) of 0.721 compared to the TG18 grading system alone (AUC 0.609) (p = 0.001). CONCLUSION Combining preoperative CRP values with TG18 grading criteria can enhance the accuracy of predicting intraoperative difficulty in ELC for AC.
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Affiliation(s)
- Kohei Mishima
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan; Department of Surgery, Keio University School of Medicine, Tokyo, Japan; Research Institute against Digestive Cancer (IRCAD), Strasbourg, France.
| | - Yoshiki Fujiyama
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Taiga Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Atsuko Tsutsui
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Nobuhiko Okamoto
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Jacques Marescaux
- Research Institute against Digestive Cancer (IRCAD), Strasbourg, France
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
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12
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Stoica PL, Serban D, Bratu DG, Serboiu CS, Costea DO, Tribus LC, Alius C, Dumitrescu D, Dascalu AM, Tudor C, Simion L, Tudosie MS, Comandasu M, Popa AC, Cristea BM. Predictive Factors for Difficult Laparoscopic Cholecystectomies in Acute Cholecystitis. Diagnostics (Basel) 2024; 14:346. [PMID: 38337862 PMCID: PMC10855974 DOI: 10.3390/diagnostics14030346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024] Open
Abstract
Laparoscopic cholecystectomy (LC) is the gold standard treatment in acute cholecystitis. However, one in six cases is expected to be difficult due to intense inflammation and suspected adherence to and involvement of adjacent important structures, which may predispose patients to higher risk of vascular and biliary injuries. In this study, we aimed to identify the preoperative parameters with predictive value for surgical difficulties. A retrospective study of 255 patients with acute cholecystitis admitted in emergency was performed between 2019 and 2023. Patients in the difficult laparoscopic cholecystectomy (DLC) group experienced more complications compared to the normal LC group (33.3% vs. 15.3%, p < 0.001). Age (p = 0.009), male sex (p = 0.03), diabetes (p = 0.02), delayed presentation (p = 0.03), fever (p = 0.004), and a positive Murphy sign (p = 0.007) were more frequently encountered in the DLC group. Total leukocytes, neutrophils, and the neutrophil-to-lymphocyte ratio (NLR) were significantly higher in the DLC group (p < 0.001, p = 0.001, p = 0.001 respectively). The Tongyoo score (AUC ROC of 0.856) and a multivariate model based on serum fibrinogen, thickness of the gallbladder wall, and transverse diameter of the gallbladder (AUC ROC of 0.802) showed a superior predictive power when compared to independent parameters. The predictive factors for DLC should be assessed preoperatively to optimize the therapeutic decision.
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Affiliation(s)
- Paul Lorin Stoica
- Doctoral School, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania;
| | - Dragos Serban
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
| | - Dan Georgian Bratu
- Faculty of Medicine, University Lucian Blaga Sibiu, 550169 Sibiu, Romania
- Department of Surgery, Emergency County Hospital Sibiu, 550245 Sibiu, Romania
| | - Crenguta Sorina Serboiu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
| | - Daniel Ovidiu Costea
- Faculty of Medicine, Ovidius University Constanta, 900470 Constanta, Romania
- General Surgery Department, Emergency County Hospital Constanta, 900591 Constanta, Romania
| | - Laura Carina Tribus
- Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania;
- Department of Internal Medicine, Ilfov Emergency Clinic Hospital Bucharest, 022104 Bucharest, Romania
| | - Catalin Alius
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
| | - Dan Dumitrescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
| | - Ana Maria Dascalu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
| | - Corneliu Tudor
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
| | - Laurentiu Simion
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
- Department of Surgical Oncology, Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Mihail Silviu Tudosie
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
| | - Meda Comandasu
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
| | - Alexandru Cosmin Popa
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
- Department of General Surgery, Colentina Clinic Hospital, 020125 Bucharest, Romania
| | - Bogdan Mihai Cristea
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.S.S.); (C.A.); (D.D.); (A.M.D.); (C.T.); (L.S.); (M.S.T.); (B.M.C.)
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13
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Bakhtiar Khan H, Shiraz A, Haseeb A, Hamayun S, Ali A, Zahid MJ, Alizai Q, Karim M, Rehman SU, Ali I. Scale and Safety: Analyzing the Association Between Intraoperative Difficulty and Achieving the Critical View of Safety in Laparoscopic Cholecystectomy. Cureus 2024; 16:e53408. [PMID: 38435198 PMCID: PMC10908434 DOI: 10.7759/cureus.53408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the preferred method for gallstone removal, but bile duct injuries remain a concern. Achieving the critical view of safety (CVS) is pivotal in preventing such injuries. The aim of this study was to compare the rates of difficult LC in those with CVS achieved compared to those with CVS not achieved. METHODS We performed a single-center prospective study on all patients with ultrasound-confirmed symptomatic gallstones. Patients were excluded if they refused to consent or if they underwent LC for indications other than gallstone disease. Patients were stratified into two groups as CVS not achieved and CVS achieved groups and compared for outcomes. Our primary outcome was the rate of intraoperative difficulty on the modified Nassar scale (MNS). Statistical analysis was performed using SPSS version 25.0 (IBM Corp., Armonk, NY). RESULTS We included 70 patients who underwent LC for gallstones (CVS not achieved = 24 and CVS achieved = 46). The mean (SD) age was 42.2 (12.3) years, and 73.5% were females. The mean (SD) weight in our study cohort was 74.1 (10.9) kg, and there was no difference between the two groups in terms of the baseline demographic characteristics, disease characteristics, and comorbid conditions (p > 0.05). On univariate analyses, achieving CVS was associated with lower rates of higher-grade operative difficulty on the MNS and lower rates of length of stay of more than one day. CONCLUSION Achieving CVS is associated with easy LC based on significantly lower Nassar scores. These findings highlight the role of the MNS in the successful identification of the operative difficulty of LC and its correlation with achieving CVS.
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Affiliation(s)
| | - Ahmad Shiraz
- General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Abdul Haseeb
- General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Sana Hamayun
- General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Aiman Ali
- General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | | | - Qaidar Alizai
- General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Maryam Karim
- General Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Sajid Ur Rehman
- General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Irfan Ali
- General Surgery, Mardan Medical Complex, Mardan, PAK
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14
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Arumugaswamy PR, Chumber S, Rathore YS, Maitra S, Bhattacharjee HK, Bansal VK, Aggarwal S, Dhar A, Asuri K, Kataria K, Ranjan P. Low-pressure pneumoperitoneum with deep neuromuscular blockade versus standard pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy for gallstone disease: a non-inferiority randomized control trial. Surg Endosc 2024; 38:449-459. [PMID: 38012441 DOI: 10.1007/s00464-023-10558-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Low-pressure pneumoperitoneum (LPP) is an attempt at improving laparoscopic surgery. However, it has the issue of poor working space for which deep neuromuscular blockade (NMB) may be a solution. There is a lack of literature comparing LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB. METHODOLOGY This was a single institutional prospective non-inferiority RCT, with permuted block randomization of subjects into group A and B [Group A: LPP; 8-10 mmHg with deep NMB [ Train of Four count (TOF): 0, Post Tetanic Count (PTC): 1-2] and Group B: SPP; 12-14 mmHg with moderate NMB]. The level of NMB was monitored with neuromuscular monitor with TOF count and PTC. Cisatracurium infusion was used for continuous deep NMB in group A. Primary outcome measures were the surgeon satisfaction score and the time for completion of the procedure. Secondarily important clinical outcomes were also reported. RESULTS Of the 222 patients screened, 181 participants were enrolled [F: 138 (76.2%); M: 43 (23.8%); Group A n = 90, Group B n = 91]. Statistically similar surgeon satisfaction scores (26.1 ± 3.7 vs 26.4 ± 3.4; p = 0.52) and time for completion (55.2 ± 23.4 vs 52.5 ± 24.9 min; p = 0.46) were noted respectively in groups A and B. On both intention-to-treat and per-protocol analysis it was found that group A was non-inferior to group B in terms of total surgeon satisfaction score, however, non-inferiority was not proven for time for completion of surgery. Mean pain scores and incidence of shoulder pain were statistically similar up-to 7 days of follow-up in both groups. 4 (4.4%) patients in group B and 2 (2.2%) in group A had bradycardia (p = 0.4). Four (4.4%) cases of group A were converted to group B. One case of group B converted to open surgery. Bile spills and gallbladder perforations were comparable. CONCLUSION LPP with deep NMB is non-inferior to SPP with moderate NMB in terms of surgeon satisfaction score but not in terms of time required to complete the procedure. Clinical outcomes and safety profile are similar in both groups. However, it could be marginally costlier to use LPP with deep NMB.
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Affiliation(s)
- Prasanna Ramana Arumugaswamy
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sunil Chumber
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Yashwant Singh Rathore
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| | - Souvik Maitra
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Hemanga Kumar Bhattacharjee
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Virinder Kumar Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sandeep Aggarwal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Anita Dhar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Krishna Asuri
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Kamal Kataria
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Piyush Ranjan
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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15
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Kaoukabani G, Gokcal F, Fanta A, Liu X, Shields M, Stricklin C, Friedman A, Kudsi OY. A multifactorial evaluation of objective performance indicators and video analysis in the context of case complexity and clinical outcomes in robotic-assisted cholecystectomy. Surg Endosc 2023; 37:8540-8551. [PMID: 37789179 DOI: 10.1007/s00464-023-10432-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND The increased digitization in robotic surgical procedures today enables surgeons to quantify their movements through data captured directly from the robotic system. These calculations, called objective performance indicators (OPIs), offer unprecedented detail into surgical performance. In this study, we link case- and surgical step-specific OPIs to case complexity, surgical experience and console utilization, and post-operative clinical complications across 87 robotic cholecystectomy (RC) cases. METHODS Videos of RCs performed by a principal surgeon with and without fellows were segmented into eight surgical steps and linked to patients' clinical data. Data for OPI calculations were extracted from an Intuitive Data Recorder and the da Vinci ® robotic system. RC cases were each assigned a Nassar and Parkland Grading score and categorized as standard or complex. OPIs were compared across complexity groups, console attributions, and post-surgical complication severities to determine objective relationships across variables. RESULTS Across cases, differences in camera control and head positioning metrics of the principal surgeon were observed when comparing standard and complex cases. Further, OPI differences across the principal surgeon and the fellow(s) were observed in standard cases and include differences in arm swapping, camera control, and clutching behaviors. Monopolar coagulation energy usage differences were also observed. Select surgical step duration differences were observed across complexities and console attributions, and additional surgical task analyses determine the adhesion removal and liver bed hemostasis steps to be the most impactful steps for case complexity and post-surgical complications, respectively. CONCLUSION This is the first study to establish the association between OPIs, case complexities, and clinical complications in RC. We identified OPI differences in intra-operative behaviors and post-surgical complications dependent on surgeon expertise and case complexity, opening the door for more standardized assessments of teaching cases, surgical behaviors and case complexities.
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Affiliation(s)
| | - Fahri Gokcal
- Good Samaritan Medical Center, Brockton, MA, USA
| | - Abeselom Fanta
- Applied Research, Intuitive Surgical Inc., Peachtree City, GA, USA
| | - Xi Liu
- Applied Research, Intuitive Surgical Inc., Peachtree City, GA, USA
| | - Mallory Shields
- Applied Research, Intuitive Surgical Inc., Peachtree City, GA, USA
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16
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Bodla AS, Rashid MU, Hassan M, Rehman S, Kirby G. The Short- and Long-Term Safety and Efficacy Profile of Subtotal Cholecystectomy: A Single-Centre, Long-Term, Follow-Up Study. Cureus 2023; 15:e44334. [PMID: 37779801 PMCID: PMC10538861 DOI: 10.7759/cureus.44334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Background Subtotal cholecystectomy (STC) has been reported as an effective method to remove the gallbladder if the hepatocystic triangle anatomy is unfavourable. However, the evidence regarding its long-term outcomes from the United Kingdom (UK) is lacking. This study aimed to assess its short and long-term outcomes with a minimum of one-year follow-up. Methodology We retrospectively analysed all elective and emergency STCs performed in a single UK NHS Trust between 2014 and 2020. Relevant data were collected using electronic patient records and questionnaire-based, long-term, telephonic follow-up (median follow-up of 3.7 years). Outcomes examined were immediate/short-term complications (biliary injury, bile leak, return-to-theatre) and long-term problems (recurrent symptoms, choledocholithiasis, cholangitis/pancreatitis). Results There were a total of 50 STC cases (58% females) out of 4,341 cholecystectomies performed (1.15%), with the median age, body mass index, and length of stay being 69.5 years, 29 kg/m2 and eight days, respectively. Twenty-eight (56%) were emergency. No patient endured bile duct injury. Seven (14%) patients had postoperative bile leak which was significantly more common when Hartmann's pouch was left open (33% vs. 8%; p = 0.03). No bile duct injury was reported. Most were managed conservatively (endoscopic retrograde cholangiopancreatography + stent: four; radiological drainage: one; no intervention: one). Only one patient required laparoscopic lavage and drainage. The true incidence of developing choledocholithiasis over the long term was 4/50 (8%) in our study. The median interval between STC and the diagnosis of postoperative choledocholithiasis was 15.9 months. All four patients had undergone type 1 STC (where the remnant of Hartmann's pouch was closed with sutures); however, subsequent cross-sectional imaging (magnetic resonance cholangiopancreatography or computed tomography) showed that the gallbladder remnant was visible in only two of these four patients. Conclusions STC is a safe option in difficult situations and prevents bile duct injury. Although the risk of bile leak can be reduced by closing Hartmann's pouch remnant, this may slightly increase the risk of subsequent stone formation. Infrequent occurrence of recurrent gallstone-related symptoms or complications favours its use.
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Affiliation(s)
- Ahmed Salman Bodla
- General Surgery, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, GBR
| | | | - Maleeha Hassan
- General Surgery, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, GBR
| | - Saad Rehman
- General Surgery, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, GBR
| | - George Kirby
- General Surgery, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, GBR
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17
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Ramírez-Giraldo C, Isaza-Restrepo A, Rico-Rivera EX, Vallejo-Soto JC, Van-Londoño I. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute calculous cholecystitis in patients over 90 years of age. Langenbecks Arch Surg 2023; 408:194. [PMID: 37178184 PMCID: PMC10182932 DOI: 10.1007/s00423-023-02903-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the standard of care for acute calculous cholecystitis; however, in patients at high risk for surgery, particularly in the elderly, insertion of a percutaneous catheter drainage (PCD) at gallbladder is recommended. Current evidence suggests that PCD may have less favorable outcomes than LC, but also that LC-associated complications increase in direct relation to patient age. There is no recommendation supported by robust evidence to decide between one or the other procedure in super elderly patients. METHODS A retrospective observational cohort study was designed to analyze the surgical outcomes of super elderly patients with cholecystitis who underwent LC versus PCD for treatment. The surgical outcomes of a subgroup of high-risk patients were also analyzed. RESULTS A total of 96 patients who met the inclusion criteria between 2014 and 2021 were included. The median age of patients were 92 years (IQR: 4.00) with a female predominance (58.33%). The overall morbidity rate in the series was 36.45% and mortality rate was 7.29%. There was no statistically significant difference when compared to the associated morbidity and mortality among patients who underwent LC versus those who underwent PCD, neither in the analysis of the complete series or in the subgroup of high-risk patients. CONCLUSIONS The morbidity and mortality associated with the two most frequently recommended therapeutic options for operating super elderly patients with acute cholecystitis are high. We found no evidence of superiority in outcomes for either of the two procedures in this age group.
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Affiliation(s)
- Camilo Ramírez-Giraldo
- Hospital Universitario Mayor - Méderi, Bogotá, Colombia.
- Universidad del Rosario, Bogotá, Colombia.
| | - Andrés Isaza-Restrepo
- Hospital Universitario Mayor - Méderi, Bogotá, Colombia
- Universidad del Rosario, Bogotá, Colombia
| | - Enid Ximena Rico-Rivera
- Hospital Universitario Mayor - Méderi, Bogotá, Colombia
- Universidad del Rosario, Bogotá, Colombia
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Ramírez-Giraldo C, Rosas-Morales C, Vásquez F, Isaza-Restrepo A, Ibáñez-Pinilla M, Vargas-Rubiano S, Vargas-Barato F. Laparoscopic cholecystectomy in super elderly (> 90 years of age): safety and outcomes. Surg Endosc 2023:10.1007/s00464-023-10048-3. [PMID: 37093280 PMCID: PMC10338395 DOI: 10.1007/s00464-023-10048-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 03/26/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Nonagenarian patients are an age group in progressive growth. In this age group, indications for surgical procedures, including cholecystectomy, will be increasingly frequent, as biliary pathology and its complications are frequent in this population group. The main objective of this study was to analyze the safety and outcomes of laparoscopic cholecystectomy in patients older than 90 years. METHODS A retrospective observational cohort study was designed. This study involved 600 patients that were classified in 4 age groups for analysis (under 50 years, 50-69 years, 70-89 years, and over 90 years). Demographic, clinical, paraclinics, surgical, and outcome variables were compared according to age group. A multivariate analysis, which included variables considered clinically relevant, was performed to identify factors associated with mortality and complications classified with the Clavien-Dindo scale. RESULTS The patients evaluated had a median age of 65.0 (IQR 34.0) years and there was a female predominance (61.8%). A higher complication rate, conversion rate, subtotal cholecystectomy rate, and prolonged hospital stay were found in nonagenarians. The overall mortality rate was 1.6%. Mortality in the age group over 90 years was 6.8%. Regression models showed that age over 90 years (RR 4.6 CI95% 1.07-20.13), presence of cholecystitis (RR 8.2 CI95% 1.29-51.81), and time from admission to cholecystectomy (RR 1.2 CI95% 1.10-1.40) were the variables that presented statistically significant differences as risk factors for mortality. CONCLUSION Cholecystectomy in nonagenarian patients has a higher rate of complications, conversion rate, subtotal cholecystectomy rate, and mortality. Therefore, an adequate perioperative assessment is necessary to optimize comorbidities and improve outcomes. Also, it is important to know the greatest risk for informed consent and choose the surgical equipment and schedule of the procedure.
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Affiliation(s)
- Camilo Ramírez-Giraldo
- Hospital Universitario Mayor - Méderi, Bogotá, Colombia.
- Universidad del Rosario, Bogotá, Colombia.
| | | | | | - Andrés Isaza-Restrepo
- Hospital Universitario Mayor - Méderi, Bogotá, Colombia
- Universidad del Rosario, Bogotá, Colombia
| | | | - Saul Vargas-Rubiano
- Hospital Universitario Mayor - Méderi, Bogotá, Colombia
- Universidad del Rosario, Bogotá, Colombia
| | - Felipe Vargas-Barato
- Hospital Universitario Mayor - Méderi, Bogotá, Colombia
- Universidad del Rosario, Bogotá, Colombia
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19
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Gupta R, Khanduri A, Singh A, Tyagi H, Varshney R, Rawal N, Daspal U, Singh SK, Morey P, Pokharia P. Defining Critical View of Safety During Laparoscopic Cholecystectomy: The Preoperative Predictors of Failure. Cureus 2023; 15:e37464. [PMID: 37187662 PMCID: PMC10181886 DOI: 10.7759/cureus.37464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Background Defining critical view of safety (CVS) is one of the most crucial steps during laparoscopic cholecystectomy (LC). This study aimed to determine the preoperative predictors of failure to achieve CVS during LC. Methods All patients undergoing LC from December 2020 to July 2022 were prospectively included. Results There were 180 females and 93 males. CVS was achieved during LC in 238 (87.2%) patients. Conversion to open surgery was performed for 11 patients. Bile leak occurred in three patients which resolved spontaneously. No patient developed bile duct injury. On univariate analysis, age, male sex, American Society of Anaesthesiologists (ASA) grading, Murphy's sign, emergency surgery, neutrophil percentage, lymphocyte percentage, gallbladder wall thickness > 3mm, and impacted gallstone on abdominal ultrasound were predictors of failure to achieve CVS. On multivariate analysis, neutrophil and lymphocyte percentages were independent predictors of failure to achieve CVS. Patients in whom CVS could not be achieved had significantly longer operative time, higher blood loss, complications, and hospital stays. Discussion Inability to achieve CVS during LC can be predicted preoperatively using various parameters including neutrophil and lymphocyte percentages. Such cases must be operated by senior surgeons or referred to experienced general or hepatobiliary surgeons for cholecystectomy to avoid bile duct injury. The proposed algorithm can help in intraoperative decision-making in difficult cases.
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Affiliation(s)
- Rahul Gupta
- Gastrointestinal Surgery, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Archana Khanduri
- Gastrointestinal Surgery, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Arvind Singh
- Gastroenterology, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Harshdeep Tyagi
- Anaesthesiology, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Rahul Varshney
- Anesthesia and Critical Care, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Nagendra Rawal
- Anaesthesiology, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Ujjwal Daspal
- Anaesthesiology, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Sudhir K Singh
- Anaesthesiology, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Parikshit Morey
- Radiology, Synergy Institute of Medical Sciences, Dehradun, IND
| | - Pradip Pokharia
- Radiology, Synergy Institute of Medical Sciences, Dehradun, IND
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20
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Pal A, Ahluwalia PS, Sachdeva K, Kashyap R. Intraoperative Scoring System to Assess the Difficult Laparoscopic Cholecystectomy: A Prospective Study From a Tertiary Care Centre. Cureus 2023; 15:e35767. [PMID: 37025744 PMCID: PMC10072186 DOI: 10.7759/cureus.35767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 03/07/2023] Open
Abstract
Background In comparison to a traditional cholecystectomy (open), the laparoscopic cholecystectomy approach provides a number of benefits and has been demonstrated in some studies to have a greater complication rate. The conversion rate from laparoscopic to open surgery ranged between 2% and 15%. A preoperative scoring or grading system (based on age, sex, history, clinical examination, laboratory, and sonographic results) was developed by Nassar et al., to anticipate the challenge of laparoscopic cholecystectomy. So, we conducted this study to assess the degree of difficulty in faced during laparoscopic cholecystectomy using an intraoperative scoring system and validate the same using the preoperative scoring system. Methods We conducted this study in the department of General Surgery among 105 patients who underwent laparoscopic cholecystectomy during the defined study period of one year. We performed the preoperative workup for all patients. A preoperative scoring or grading system developed by Nassar et al., in 2020 was used. In our study, laparoscopic cholecystectomy was performed by surgeons having a minimum of eight years of hands-on experience in laparoscopic surgeries. An intraoperative scoring or grading system for the degree of difficulty during laparoscopic cholecystectomy, developed by Sugrue et al., in 2015 was used. The Chi-square test was applied to assess the association between preoperative variables and the intraoperative score grading. We have also performed the receiver operating characteristic (ROC) curve analysis to validate the preoperative score in predicting the intraoperative findings. All tests were considered statically significant if the p-value was < 0.05. Results In our study, a total of 105 patients were included in the study and the mean age of patients was 57.6±16.4 years. The male patients were 58.1% and the remaining 41.9% were females. The primary diagnosis was cholecystitis among 44.8% of patients and 2.9% of patients were diagnosed with pancreatitis. Among enrolled patients, laparoscopic cholecystectomy was done on an emergency basis among 2.9% of subjects. During the laparoscopic cholecystectomy, among 21.0% and 30.5% of patients, there was a severe and extreme degree of difficulty respectively. In our study, the conversion rate from laparoscopic to open cholecystectomy was 8.6%. In our study, we found that at a preoperative score of 6, the sensitivity and specificity for predicting easy cases were 88.2% and 73.8%, respectively, and had an accuracy of 88.6% for easy cases and 68.5% for difficult cases. Conclusion When grading the difficulties of doing a laparoscopic cholecystectomy and determining the severity of cholecystitis, this intraoperative scoring system is effective and accurate. Additionally, it signifies the need for conversion from laparoscopic to open cholecystectomy in cases of severe cholecystitis.
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21
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Tongyoo A, Liwattanakun A, Sriussadaporn E, Limpavitayaporn P, Mingmalairak C. The Modification of a Preoperative Scoring System to Predict Difficult Elective Laparoscopic Cholecystectomy. J Laparoendosc Adv Surg Tech A 2023; 33:269-275. [PMID: 36445743 PMCID: PMC9997034 DOI: 10.1089/lap.2022.0407] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Laparoscopic cholecystectomy (LC) is one of the most common abdominal operations. The difficult cases are still challenging for surgeons. There had been many studies providing several preoperative models to predict difficult LC or conversion. Randhawa's scoring system was a simple and practical predictive model for clinicians. The modification was reported to be more preferable for delayed LC. This study aimed to confirm the advantage of modified predictive model in larger sample size. Materials and Methods: This retrospective cohort study reviewed medical records of patients who underwent LC since January 2017 to December 2021. The difficulty of operation was categorized into three groups: easy, difficult, and very difficult. Multivariate analysis was performed to define significant factors of very difficult and converted cases. The predictive scores were calculated by using the original Randhawa's model and the modification, then compared with actual outcome. Results: There were 567 cases of delayed LC in this study, with 44 cases (7.8%) converted to open cholecystectomy. Four factors (previous cholecystitis, previous endoscopic retrograde cholangiopancreatography, higher ALP, and gallbladder wall thickening) for very difficult group and five factors (previous cholecystitis, previous cholangitis, higher white blood cell count, gallbladder wall thickening, and contracted gallbladder) for conversion were significant. The modification provided the better correlation and higher area of receiver operating characteristic (ROC) curve comparing with the original model. Conclusion: The modification of Randhawa's model was supposed to be more preferable for predicting the difficulty in elective LC. Thai Clinical Trials Registry No. 20220712006.
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Affiliation(s)
- Assanee Tongyoo
- Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | | | - Ekkapak Sriussadaporn
- Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Palin Limpavitayaporn
- Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Chatchai Mingmalairak
- Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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22
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Alotaibi AM. Gallbladder wall thickness adversely impacts the surgical outcome. Ann Hepatobiliary Pancreat Surg 2023; 27:63-69. [PMID: 36536504 PMCID: PMC9947375 DOI: 10.14701/ahbps.22-067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/17/2022] [Accepted: 10/12/2022] [Indexed: 12/24/2022] Open
Abstract
Backgrounds/Aims To evaluate surgical outcomes of patients with gallbladder wall thickness (GBWT) > 5 mm. Methods Patients who underwent cholecystectomy were classified into two groups according to their GBWT status (GBWT+ vs. GBWT-). Results Among 1,211 patients who underwent cholecystectomy, GBWT+ was seen in 177 (14.6%). The GBWT+ group was significantly older with more males, higher ASA score, higher alkaline phosphatase level, higher international normalized ratio, and lower albumin level than the GBWT- group. On ultrasound, GBWT+ patients had larger stone size, more pericholecystic fluid, more common bile duct stone, and more biliary pancreatitis. Compared with the GBWT- group, the GBWT+ group had more urgent surgeries (12.4% vs. 3.2%, p = 0.001), higher conversion rate (4.5% vs. 0.3%, p = 0.001), prolonged operative time (67 ± 38 vs. 54 ± 29 min; p = 0.001), more bleeding (3.4% vs. 0.5%, p = 0.002), and more need of drain (21.5% vs. 10.5%, p = 0.001). By multivariate analysis, factors associated with increased length of hospital stay were GBWT+ (HR: 1.97, 95% CI: 1.19-3.25, p = 0.008), urgent surgery (HR: 10.2, 95% CI: 4.07-25.92, p = 0.001), prolonged surgery (HR: 1.01, 95% CI: 1.0-1.02, p = 0.001), and postoperative drain (HR: 11.3, 95% CI: 6.40-20.0, p = 0.001). Conclusions Variables such as GBWT ≥ 5 mm, urgent prolonged operation, and postoperative drains are independent predictors of extended hospital stay. GBWT+ patients are twice likely to stay in hospital for more than 72 hours and more prone to develop complications than GBWT- patients.
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Affiliation(s)
- Abdulrahman Muaod Alotaibi
- Department of Surgery, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia,Department of Surgery, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia,Corresponding author: Abdulrahman Muaod Alotaibi, MD Department of Surgery, Faculty of Medicine, University of Jeddah, Al Madinah Street, Alsharafiah District, Jeddah 21959, Saudi Arabia Tel: +966-504707351, Fax: +966-126951044, E-mail: ORCID: https://orcid.org/0000-0001-8444-7229
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23
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Ramírez-Giraldo C, Torres-Cuellar A, Van-Londoño I. State of the art in subtotal cholecystectomy: An overview. Front Surg 2023; 10:1142579. [PMID: 37151864 PMCID: PMC10162495 DOI: 10.3389/fsurg.2023.1142579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/31/2023] [Indexed: 05/09/2023] Open
Abstract
Introduction Subtotal cholecystectomy is a type of surgical bail-out procedure indicated when facing difficult laparoscopic cholecystectomy due to not reaching the critical view of safety, inadequate identification of the anatomical structures involved and/or risk of injury. Materials and methods A comprehensive search on PubMed were performed using the following Mesh terms: Subtotal cholecystectomy and Partial cholecystectomy. The PubMed databases were used to search for English-language reports related to Subtotal cholecystectomy between January 1, 1987, the date of the first published laparoscopic cholecystectomy, through January 2023. 41 studies were included. Results Subtotal cholecystectomy's incidence oscillates between 4.00% and 9.38%. Strasberg et al., divided subtotal cholecystectomies in "fenestrating" and "reconstituting" types based on if the remaining portion of the gallbladder was left open or closed. Subtotal cholecystectomy can sometimes be a challenging procedure and is associated to a high rate of complications such as biliary fistula, retained gallstones, subhepatic or subphrenic collections, among others. Conslusion Subtotal cholecystectomy is a safe alternative when facing difficult cholecystectomy in which the critical view of safety is not reached in order to avoid complications. A classification system should be implemented in surgical descriptions to compare the different surgical techniques employed. In order to avoid bile leakage and cholecystitis of the remnant gallbladder, the surgical technique must be performed skillfully. There is still a current lack of information on alternative techniques such as omental plugging or falciform patch in order to judge their utility. There needs to be further research on long-term complications such as malignancy of the remnant gallbladder.
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Affiliation(s)
- Camilo Ramírez-Giraldo
- General Surgery Department, Hospital Universitario Mayor – Méderi, Bogotá, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
- Correspondence: Camilo Ramírez-Giraldo
| | - Andrés Torres-Cuellar
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Isabella Van-Londoño
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
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Abe T, Oshita A, Fujikuni N, Hattori M, Kobayashi T, Hanada K, Noriyuki T, Ohdan H, Nakahara M. Efficacy of bailout surgery for preventing intraoperative biliary injury in acute cholecystitis. Surg Endosc 2022; 37:2595-2603. [PMID: 36348169 DOI: 10.1007/s00464-022-09755-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/29/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Bailout surgery (BOS; partial cholecystectomy, open conversion, and fundus-first approach) has been recommended for difficult cases to ensure safe performance of cholecystectomy. However, the efficacy of BOS for preventing intraoperative massive bleeding and bile duct injury (BDI) remains unclear, especially in the context of acute cholecystitis (AC). This study aimed to retrospectively validate the feasibility of BOS for AC. METHODS We enrolled 479 patients who underwent emergency cholecystectomies for AC between 2011 and 2021. Univariate and multivariate analyses were performed to detect the risk factors for BOS in patients with AC. Perioperative variables were compared between patients who underwent total cholecystectomy (TC) and those who underwent BOS. Propensity score matching analysis was performed to compare the two groups. RESULTS Significant differences in American Society of Anesthesiologists physical status and Charlson Comorbidity Index scores, TG18 severity grading, white blood cell count, and albumin and C-reactive protein (CRP) levels were found between the TC and BOS groups. Preoperative CT imaging demonstrated severe inflammation evidenced by gallbladder wall thickness, enhancement of the liver bed, and duodenal edema in the BOS group compared to the TC group. Postoperative complications were significantly higher in the BOS group than in the TC group. Further, BDI was completely prevented by BOS. Multivariate analysis identified TG18 grade ≥ II, CRP ≥ 7.7, and duodenal edema as independent risk factors for BOS. After PSM analysis, postoperative complications were not worse in patients who underwent BOS rather than TC. Among BOS procedures, laparoscopic BOS (lap-BOS) was the most efficacious in preventing intraoperative blood loss and postoperative bile leakage. CONCLUSION Severity grading > II, elevated CRP levels, or duodenum edema revealed by CT were determined to be risk factors impeding total cholecystectomy. BOS is a safe, feasible, and efficacious procedure for preventing BDI. Among BOS procedures, lap-BOS showed better postoperative outcomes.
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Affiliation(s)
- Tomoyuki Abe
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara, Onomichi, Hiroshima, Japan.
| | - Akihiko Oshita
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara, Onomichi, Hiroshima, Japan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuaki Fujikuni
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara, Onomichi, Hiroshima, Japan
| | - Minoru Hattori
- Center for Medical Education Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, 1-10-23 Hirahara, Onomichi, Hiroshima, Japan
| | - Toshio Noriyuki
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara, Onomichi, Hiroshima, Japan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masahiro Nakahara
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara, Onomichi, Hiroshima, Japan
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Room H, Wood A, Ji C, Nightingale H, Toh SKC. Performance of ultrasound in the diagnosis of cholecystitis: not so (ultra)sound? Ann R Coll Surg Engl 2022; 104:655-660. [PMID: 35175883 PMCID: PMC9685908 DOI: 10.1308/rcsann.2021.0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/03/2023] Open
Abstract
INTRODUCTION Ultrasound has long been the radiological investigation of choice for right upper quadrant pain in the detection of gallstones and cholecystitis. However, previously reported sensitivity, specificity and other diagnostic metrics have varied widely and the underlying patient numbers have been small. We present robust and exhaustive diagnostic metrics based on a large series of 795 patients. METHODS All laparoscopic cholecystectomies at Portsmouth Hospitals University were prospectively logged between 2017 and 2020. Ultrasound findings, Nassar operative difficulty and histopathological findings were all collected in addition to patient biometrics. RESULTS In our large patient series, the sensitivity of ultrasound for cholecystitis was lower than previously reported at 75.7% for acute cholecystitis, 34.6% for chronic cholecystitis and 42.7% overall. Moreover, we show that sensitivity degrades with the time between ultrasound and cholecystectomy, falling below 50% at 140 days. Finally, we show that ultrasound strongly predicts the Nassar difficulty grade of cholecystectomy and that its ability to do so is greatest when the interval between ultrasound and cholecystectomy is less than 27 days. CONCLUSIONS We present robust diagnostic metrics for ultrasound in the diagnosis of cholecystitis. These should caution the clinician that ultrasound may miss a quarter of cases of acute cholecystitis and over half of all cases of cholecystitis. Conversely, the finding of a thickened gallbladder wall on ultrasound can predict a 'difficult cholecystectomy' and highlight the need for appropriate expertise and resources. Both this prediction and the diagnostic sensitivity are best if the ultrasound is done less than 27 days before cholecystectomy.
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Affiliation(s)
- H Room
- Portsmouth Hospitals University NHS Trust, UK
| | - A Wood
- Portsmouth Hospitals University NHS Trust, UK
| | - C Ji
- Portsmouth Hospitals University NHS Trust, UK
| | | | - SKC Toh
- Portsmouth Hospitals University NHS Trust, UK
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Khanna S, Barua A. Robotic assisted cholecystectomy – A retrospective cohort study of experience of 106 first robotic cholecystectomies in versius robotic platform. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Kohga A, Suzuki K, Okumura T, Yamashita K, Isogaki J, Kawabe A, Muramatsu K, Kimura T. Presence of cystic duct stone is a risk for postoperative retained stones in patients with acute cholecystitis. Clin Imaging 2022; 89:55-60. [PMID: 35704962 DOI: 10.1016/j.clinimag.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/06/2022] [Accepted: 06/03/2022] [Indexed: 12/07/2022]
Abstract
PURPOSE Retained stones (RS) in the common bile duct (CBD) are one of the major problems after laparoscopic cholecystectomy and usually require endoscopic treatment. However, few reports have investigated risk factors for the development of RS in the CBD. METHODS A total of 325 patients with acute cholecystitis underwent laparoscopic cholecystectomy at our hospital between January 2013 and Jury 2021. Patient characteristics, including radiographic factors and perioperative outcomes, were reviewed, and perioperative factors predicting RS in the CBD were investigated. RESULTS RS in the CBD were developed in 34 patients. All 34 patients were treated endoscopically. ASA-PS class 3 or more (p = 0.029, odds ratio = 2.601), subtotal cholecystectomy performance (p = 0.004, odds ratio = 3.783) and the presence of cystic duct stones (p < 0.001, odds ratio = 11.759) were found by logistic regression analysis to be independent risk factors for developing RS in the CBD. Cystic duct stones were preoperatively detected in 60 patients. Of these, 21 cases were not detected on magnetic resonance cholangiopancreatography (MRCP) but on CT, while 15 cases were not detected on CT but on MRCP. CONCLUSIONS The presence of cystic duct stones on preoperative CT or MRCP is a crucial risk factor for developing RS in the CBD. Both CT and MRCP are useful to avoid overlooking cystic duct stones.
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Affiliation(s)
- Atsushi Kohga
- Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan.
| | - Kenji Suzuki
- Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Takuya Okumura
- Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | | | - Jun Isogaki
- Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Akihiro Kawabe
- Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Katsuaki Muramatsu
- Division of Radiology, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Taizo Kimura
- Division of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
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Manuel-Vázquez A, Latorre-Fragua R, Alcázar C, Requena PM, de la Plaza R, Blanco Fernández G, Serradilla-Martín M, Ramia JM. Reaching a consensus on the definition of "difficult" cholecystectomy among Spanish experts. A Delphi project. A qualitative study. Int J Surg 2022; 102:106649. [PMID: 35525412 DOI: 10.1016/j.ijsu.2022.106649] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Being able to predict preoperatively the difficulty of a cholecystectomy can increase safety and improve results. However, there is a need to reach a consensus on the definition of a cholecystectomy as "difficult". The aim of this study is to achieve a national expert consensus on this issue. METHODS A two-round Delphi study was performed. Based on the previous literature, history of biliary pathology, preoperative clinical, analytical, and radiological data, and intraoperative findings were selected as variables of interest and rated on a Likert scale. Inter-rater agreement was defined as "unanimous" when 100% of the participants gave an item the same rating on the Likert scale; as "consensus" when ≥80% agreed; as "majority" when the agreement was ≥70%. The delta of change between the two rounds was calculated. RESULTS After the two rounds, the criteria that reached "consensus" were bile duct injury (96.77%), non-evident anatomy (93.55%), Mirizzi syndrome (93.55%), severe inflammation of Calot's triangle (90.32%), conversion to laparotomy (87.10%), time since last acute cholecystitis (83.87%), scleroatrophic gallbladder (80.65%) and pericholecystic abscess (80.65%). CONCLUSION The ability to predict difficulty in cholecystectomy offers important advantages in terms of surgical safety. As a preliminary step, the items that define a surgical procedure as difficult should be established. Standardization of the criteria can provide scores to predict difficulty both preoperatively and intraoperatively, and thus allow the comparison of groups of similar difficulty.
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Affiliation(s)
| | | | | | | | | | | | | | - J M Ramia
- Hospital General Universitario de Alicante, Spain
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O'Connor N, Sugrue M, Melly C, McGeehan G, Bucholc M, Crawford A, O'Connor P, Abu-Zidan F, Wani I, Balogh ZJ, Shelat VG, Tebala GD, De Simone B, Eid HO, Chirica M, Fraga GP, Di Saverio S, Picetti E, Bonavina L, Ceresoli M, Fette A, Sakakushe B, Pikoulis E, Coimbra R, Ten Broek R, Hecker A, Leppäniemi A, Litvin A, Stahel P, Tan E, Koike K, Catena F, Pisano M, Coccolini F, Johnston A. It's time for a minimum synoptic operation template in patients undergoing laparoscopic cholecystectomy: a systematic review. World J Emerg Surg 2022; 17:15. [PMID: 35296354 PMCID: PMC8928637 DOI: 10.1186/s13017-022-00411-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/07/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Despite the call to enhance accuracy and value of operation records few international recommended minimal standards for operative notes documentation have been described. This study undertook a systematic review of existing operative reporting systems for laparoscopic cholecystectomy (LC) to fashion a comprehensive, synoptic operative reporting template for the future. METHODS A search for all relevant articles was conducted using PubMed version of Medline, Scopus and Web of Science databases in June 2021, for publications from January 1st 2011 to October 25th 2021, using the keywords: laparoscopic cholecystectomy AND operation notes OR operative notes OR proforma OR documentation OR report OR narrative OR audio-visual OR synoptic OR digital. Two reviewers (NOC, GMC) independently assessed each published study using a MINORS score of ≥ 16 for comparative and ≥ 10 for non-comparative for inclusion. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Synoptic operative templates from published data were assimilated into one "ideal" laparoscopic operative report template following international input from the World Society of Emergency Surgery board. RESULTS A total of 3567 articles were reviewed. Following MINORS grading 25 studies were selected spanning 14 countries and 4 continents. Twenty-two studies were prospective. A holistic overview of the operative procedure documentation was reported in 6/25 studies and a further 19 papers dealt with selective surgical aspects of LC. A unique synoptic LC operative reporting template was developed and translated into Chinese/Mandarin, French and Arabic. CONCLUSION This systematic review identified a paucity of publications dealing with operative reporting of LC. The proposed new template may be integrated digitally with hospitals' medical systems and include additional narrative text and audio-visual data. The template may help define new OR (operating room) recording standards and impact on care for patients undergoing LC.
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Affiliation(s)
- Niall O'Connor
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland.
| | - Conor Melly
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - Gearoid McGeehan
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - Magda Bucholc
- EU INTERREG Centre for Personalized Medicine, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Magee Campus, Derry-Londonderry, Northern Ireland
| | - Aileen Crawford
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - Paul O'Connor
- Department of Anaesthesia, Letterkenny University Hospital, Donegal, Ireland
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Zsolt J Balogh
- John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | | | - Giovanni D Tebala
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital. Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Belinda De Simone
- Poissy/Saint Germain en Laye Hospitals, Poissy-Ile de France, France
| | - Hani O Eid
- Abu Dhabi Police Aviation, HEMS, Abu Dhabi, UAE
| | - Mircea Chirica
- Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | | | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Luigi Bonavina
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, Department of Biomedical Sciences for Health, University of Milano, Milan, Italy
| | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, University of MIlano-Bicocca, Monza, Italy
| | | | - Boris Sakakushe
- RIMU/Research Institute at Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Emmanouil Pikoulis
- Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Raul Coimbra
- Riverside University Health System Medical CA and Loma Linda University School of Medicine CA, Riverside, USA
| | - Richard Ten Broek
- Department of Surgery. Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Ari Leppäniemi
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | - Philip Stahel
- Department of Specialty Medicine, College of Osteopathic Medicine, Rocky Vista University, Parker, CO, 80134, USA
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | | | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Alison Johnston
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
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The Need for Standardizing Diagnosis, Treatment and Clinical Care of Cholecystitis and Biliary Colic in Gallbladder Disease. Medicina (B Aires) 2022; 58:medicina58030388. [PMID: 35334564 PMCID: PMC8949253 DOI: 10.3390/medicina58030388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
Gallstones affect 20% of the Western population and will grow in clinical significance as obesity and metabolic diseases become more prevalent. Gallbladder removal (cholecystectomy) is a common treatment for diseases caused by gallstones, with 1.2 million surgeries in the US each year, each costing USD 10,000. Gallbladder disease has a significant impact on the logistics and economics of healthcare. We discuss the two most common presentations of gallbladder disease (biliary colic and cholecystitis) and their pathophysiology, risk factors, signs and symptoms. We discuss the factors that affect clinical care, including diagnosis, treatment outcomes, surgical risk factors, quality of life and cost-efficacy. We highlight the importance of standardised guidelines and objective scoring systems in improving quality, consistency and compatibility across healthcare providers and in improving patient outcomes, collaborative opportunities and the cost-effectiveness of treatment. Guidelines and scoring only exist in select areas of the care pathway. Opportunities exist elsewhere in the care pathway.
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Predicting the difficult laparoscopic cholecystectomy based on a preoperative scale. Updates Surg 2022; 74:969-977. [PMID: 35122205 PMCID: PMC9213361 DOI: 10.1007/s13304-021-01216-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 12/03/2021] [Indexed: 12/17/2022]
Abstract
It is important to establish the difficulty of a cholecystectomy preoperatively to improve the outcomes. There are multiple risk factors for a difficult cholecystectomy that may depend on the patient, the disease, or extrinsic factors. The aim of this study is to evaluate the predictive capacity of a difficult cholecystectomy with a preoperative scale. A diagnostic trial study was designed to evaluate the performance of a scale to predict the difficulty of laparoscopic cholecystectomy, considering as a reference standard the intraoperative findings evaluated according to an intraoperative difficulty scale. A ROC curve was performed and used to estimate predictive value of the preoperative score to predict the difficulty of a cholecystectomy preoperatively. The ROC curve shows an area of 0.88 under the curve. The calculated ideal cutoff was 8, with a sensitivity, specificity, positive predictive value and negative predictive value of 75.15%, 88.31%, 87.32 and 76.83%, respectively. It was demonstrated that, as the difficulty predicted by the preoperative scale increases, the rate of conversion to open procedure, the rate of subtotal cholecystectomies, the rate of complication and the rate of a critical view of safety failed increase. We suggest implementing the preoperative scale in all patients who are planning laparoscopic cholecystectomy, considering it a simple and easy tool to perform. This to inform the patient, organize the surgery schedule, select personnel, request support and have adequate pre-operative planning.
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Shakir T, Matwala K, Vasan A, Karamanakos S. Percutaneous Cholecystostomy for Acute Cholecystitis: A Three-Year Single-Centre Experience Including During COVID-19. Cureus 2022; 13:e20385. [PMID: 35036216 PMCID: PMC8752374 DOI: 10.7759/cureus.20385] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Percutaneous cholecystostomy is a recognised treatment modality for acute cholecystitis. Traditionally, its use was reserved for patients deemed unfit for surgery. However, the coronavirus disease 2019 (COVID-19) pandemic had a detrimental effect on both elective and emergency surgery. The utilisation of cholecystostomy thus increased. Unanswered questions remain over timing with respect to interval cholecystectomy. We evaluated our local practice over the preceding three years. Methods A retrospective analysis was performed of all patients who had a percutaneous cholecystostomy inserted over a three-year period (1 January 2018-1 January 2021). The primary outcome was time to cholecystectomy. Secondary outcomes were cholecystostomy-related complications, 30-day mortality, cholecystectomy-related complications and length of postoperative hospital stay. Results A total of 31 patients were identified during the period. Thirteen (42%) patients went on to have a laparoscopic cholecystectomy. The median time interval from cholecystostomy to cholecystectomy was 97 days (interquartile range [IQR]: 81-140, minimum: 47 and maximum: 791). One case was complicated by small bowel perforation; this occurred after an interval of 106 days. The median length of postoperative stay was one day (IQR: 1-1, minimum: 0 and maximum: 4). Cholecystostomy-related complications were observed in four (13%) patients, whereby three became displaced and one developed blockage. Thirty-day mortality following cholecystostomy insertion was zero. Conclusions Percutaneous cholecystostomy is a safe and effective intervention for the management of acute cholecystitis. Interval cholecystectomy should be carefully considered; it may be safer to perform prior to 90 days.
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Affiliation(s)
- Taner Shakir
- General Surgery, Mid and South Essex NHS Foundation Trust, Basildon, GBR
| | - Kabir Matwala
- General and Colorectal Surgery, Mid and South Essex NHS Foundation Trust, Basildon, GBR
| | - Abhilash Vasan
- General Surgery, Mid and South Essex NHS Foundation Trust, Basildon, GBR
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Patient and surgeon factors contributing to bailout cholecystectomies: a single-institutional retrospective analysis. Surg Endosc 2022; 36:6696-6704. [PMID: 34981223 DOI: 10.1007/s00464-021-08942-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/06/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomies continue to pose trouble for surgeons in the face of severe inflammation. In the advent of inability to perform an adequate dissection, a "bailout cholecystectomy" is advocated. Conversion to open or subtotal cholecystectomy is among the standard bailout procedures in such instances. METHODS We performed a retrospective single institution review from January 2016 to August 2019. All patients who underwent a cholecystectomy were included, while those with a concurrent operation, malignancy, planned as an open cholecystectomy, or performed by a low volume surgeon were excluded. Patient characteristics, operative reports, and outcomes were collected, as were surgeon characteristics such as years of experience, case volume, and bailout rate. Univariable and multivariable analysis were performed. RESULTS 2458 (92.6%) underwent laparoscopic total cholecystectomy (LTC) and 196 (7.4%) underwent a bailout cholecystectomy (BOC). BOC patients tended to be older (p < 0.001), male (p < 0.001), have a longer duration of symptoms (p < 0.001), and higher ASA class (p < 0.001). They also had more signs of biliary inflammation, as evidenced by increased leukocytosis (p < 0.001), tachycardia (p < 0.001), bilirubinemia (p = 0.003), common bile duct dilation (p < 0.001), and gallbladder wall thickening (p < 0.001). The BOC cohort also had increased rates of complications, including bile leak (16%, p < 0.001), retained stone (5.1%, p = 0.005), operative time (114 min vs 79 min, p < 0.001), and secondary interventions (22.7%, p < 0.001). Male gender (aOR = 2.8, p < 0.001), preoperative diagnosis of acute cholecystitis (aOR = 2.2, p = 0.032), right upper quadrant tenderness (aOR = 3.0, p = 0.008), Asian race (aOR = 2.7, p = 0.014), and intraoperative adhesions (aOR = 13.0, p < 0.001) were found to carry independent risk for BOC. Surgeon bailout rate ≥ 7% was also found to be an independent risk factor for conversion to BOC. CONCLUSIONS Male gender, signs of biliary inflammation (tachycardia, leukocytosis, dilated CBD, and diagnosis of acute cholecystitis), as well as surgeon bailout rate of 7% were independent risk factors for BOC.
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Vannucci M, Laracca GG, Mercantini P, Perretta S, Padoy N, Dallemagne B, Mascagni P. Statistical models to preoperatively predict operative difficulty in laparoscopic cholecystectomy: A systematic review. Surgery 2021; 171:1158-1167. [PMID: 34776259 DOI: 10.1016/j.surg.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/01/2021] [Accepted: 10/03/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy operative difficulty is highly variable and influences outcomes. This systematic review analyzes the performance and clinical value of statistical models to preoperatively predict laparoscopic cholecystectomy operative difficulty. METHODS PRISMA guidelines were followed. PubMed, Embase, and the Cochrane Library were searched until June 2020. Primary studies developing or validating preoperative models predicting laparoscopic cholecystectomy operative difficulty in cohorts of >100 patients were included. Studies not reporting performance metrics or enough information for clinical implementation were excluded. Data were extracted according to CHARMS, and study quality was assessed using the PROBAST tool. RESULTS In total, 2,654 articles were identified, and 22 met eligibility criteria. Eighteen were model development, whereas 4 were validation studies. Eighteen studies were at high risk of bias. However, 11 studies showed low concern for applicability. Identified models predict 9 definitions of laparoscopic cholecystectomy operative difficulty, the most common being conversion to open surgery and operating time. The most validated models predict an intraoperative difficulty scale and procedures >90 minutes with an area under the curve of >0.70 and >0.76, respectively. Commonly used predictors include demographic variables such as age and gender (9/18 models) and ultrasound findings such as gallbladder wall thickness (11/18). Clinical implementation was never studied. CONCLUSION There is a longstanding interest in estimating laparoscopic cholecystectomy operative difficulty. Models to preoperatively predict laparoscopic cholecystectomy operative difficulty have generally good performance and seem applicable. However, an unambiguous definition of operative difficulty, validations, and clinical studies are needed to implement patients' stratification in laparoscopic cholecystectomy.
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Affiliation(s)
- Maria Vannucci
- University of Tor Vergata, Rome, Italy; Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France
| | - Giovanni Guglielmo Laracca
- Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France; Department of Medical Surgical Science and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Italy
| | - Paolo Mercantini
- Department of Medical Surgical Science and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Italy
| | - Silvana Perretta
- Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France; Institute of Image-Guided Surgery, Institut Hospitalo-Universitaire (IHU), Strasbourg, France; Department of Digestive and Endocrine Surgery, University of Strasbourg, France
| | - Nicolas Padoy
- Institute of Image-Guided Surgery, Institut Hospitalo-Universitaire (IHU), Strasbourg, France; ICube, University of Strasbourg, CNRS, Illkirch, France
| | - Bernard Dallemagne
- Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France; Department of Digestive and Endocrine Surgery, University of Strasbourg, France
| | - Pietro Mascagni
- Institute of Image-Guided Surgery, Institut Hospitalo-Universitaire (IHU), Strasbourg, France; Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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Alberici L, Paganini AM, Ricci C, Balla A, Ballarini Z, Ortenzi M, Casole G, Quaresima S, Di Dalmazi G, Ursi P, Alfano MS, Selva S, Casadei R, Ingaldi C, Lezoche G, Guerrieri M, Minni F, Tiberio GAM. Development and validation of a preoperative "difficulty score" for laparoscopic transabdominal adrenalectomy: a multicenter retrospective study. Surg Endosc 2021; 36:3549-3557. [PMID: 34402981 PMCID: PMC9001553 DOI: 10.1007/s00464-021-08678-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/07/2021] [Indexed: 12/14/2022]
Abstract
Background A difficulty score for laparoscopic adrenalectomy (LA) is lacking in the literature. A retrospective cohort study was designed to develop a preoperative “difficulty score” for LA. Methods A multicenter study was conducted involving four Italian tertiary centers for adrenal disease. The population was randomly divided into two subsets: training group and validation one. A multicenter study was undertaken, including 964 patients. Patient, adrenal lesion, surgeon’s characteristics, and the type of procedure were studied as potential predictors of target events. The operative time (pOT), conversion rate (cLA), or both were used as indicators of the difficulty in three multivariate models. All models were developed in a training cohort (70% of the sample) and validated using 30% of patients. For all models, the ability to predict complicated postoperative course was reported describing the area under the curve (AUCs). Logistic regression, reporting odds ratio (OR) with p-value, was used. Results In model A, gender (OR 2.04, p = 0.001), BMI (OR 1.07, p = 0.002), previous surgery (OR 1.29, p = 0.048), site (OR 21.8, p < 0.001) and size of the lesion (OR 1.16, p = 0.002), cumulative sum of procedures (OR 0.99, p < 0.001), extended (OR 26.72, p < 0.001) or associated procedures (OR 4.32, p = 0.015) increased the pOT. In model B, ASA (OR 2.86, p = 0.001), lesion size (OR 1.20, p = 0.005), and extended resection (OR 8.85, p = 0.007) increased the cLA risk. Model C had similar results to model A. All scores obtained predicted the target events in validation cohort (OR 1.99, p < 0.001; OR 1.37, p = 0.007; OR 1.70, p < 0.001, score A, B, and C, respectively). The AUCs in predicting complications were 0.740, 0.686, and 0.763 for model A, B, and C, respectively. Conclusion A difficulty score based on both pOT and cLA (Model C) was developed using 70% of the sample. The score was validated using a second cohort. Finally, the score was tested, and its results are able to predict a complicated postoperative course. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08678-6.
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Affiliation(s)
- Laura Alberici
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Alessandro M Paganini
- Bariatric Surgery Unit, Department of General Surgery and Surgical Specialties "Paride Stefanini", AOU Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Claudio Ricci
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy.
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy.
- Policlinico S.Orsola-Malpighi, Alma Mater Studiorum-Università di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.
| | - Andrea Balla
- Bariatric Surgery Unit, Department of General Surgery and Surgical Specialties "Paride Stefanini", AOU Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Zeno Ballarini
- Surgical Clinic, Department of Clinical and Experimental Sciences, The University of Brescia at ASST Spedali Civili di Brescia, Brescia, Italy
| | - Monica Ortenzi
- Clinica Chirurgica Generale e d'Urgenza, AOU Umberto I-Lancisi-Salesi, Ancona, Italy
| | - Giovanni Casole
- Surgical Clinic, Department of Clinical and Experimental Sciences, The University of Brescia at ASST Spedali Civili di Brescia, Brescia, Italy
| | - Silvia Quaresima
- Bariatric Surgery Unit, Department of General Surgery and Surgical Specialties "Paride Stefanini", AOU Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Guido Di Dalmazi
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Unit of Endocrinology and Diabetes Prevention and Care, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Pietro Ursi
- Bariatric Surgery Unit, Department of General Surgery and Surgical Specialties "Paride Stefanini", AOU Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Marie Sophie Alfano
- Surgical Clinic, Department of Clinical and Experimental Sciences, The University of Brescia at ASST Spedali Civili di Brescia, Brescia, Italy
| | - Saverio Selva
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Riccardo Casadei
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Carlo Ingaldi
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Giovanni Lezoche
- Clinica Chirurgica Generale e d'Urgenza, AOU Umberto I-Lancisi-Salesi, Ancona, Italy
| | - Mario Guerrieri
- Clinica Chirurgica Generale e d'Urgenza, AOU Umberto I-Lancisi-Salesi, Ancona, Italy
| | - Francesco Minni
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Guido Alberto Massimo Tiberio
- Surgical Clinic, Department of Clinical and Experimental Sciences, The University of Brescia at ASST Spedali Civili di Brescia, Brescia, Italy
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Orabi A, Di Mauro D, Njere I, Ratano M, Thavakumar S, Reece-Smith A, Wajed S, Manzelli A. Can Preoperative Characteristics Predict the Outcomes of Laparoscopic Cholecystectomy? J Laparoendosc Adv Surg Tech A 2021; 32:532-537. [PMID: 34357804 DOI: 10.1089/lap.2021.0398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Intraoperative findings during laparoscopic cholecystectomy (LC) are highly unpredictable and operative difficulty varies from straightforward to very challenging procedures. Several studies described predictors of technical difficulty and graded intraoperative findings of LC; however, none specifically reported on the effect of such factors on clinical outcomes. This study aims to evaluate if preoperative characteristics of patients undergoing LC predict how likely they are to fail to be day case (DC). Methods: Data of patients who underwent LC from 2015 to 2017 were retrospectively analyzed. Subjects were divided into four groups, according to Nassar's classification of intraoperative difficulty. Differences in frequencies were evaluated with the the chi square and post hoc chi square tests or Fisher's exact test; logistic regression analysis was used to identify independent variables that were predictors of intraoperative complexity, postoperative morbidity, and length of stay. Results: A total of 1043 patient were included with male to female ratio of 1:2.5. Older age, male gender, and comorbidities were associated with higher Nassar score (P < .0001); Nassar 3 and 4 were predictors of postoperative morbidity (P < .05). The DC rate was 74.2% (Nassar 1), 75.8% (Nassar 2), 61.1% (Nassar 3), and 26.2% (Nassar 4), respectively. Age ≥60 years (P < .05), body mass index ≥35 (P < .05), and Nassar 3 and 4 (P < .05) were predictors of increased conversion from DC to inpatient (IP) stay. Conclusion: LC can be safely performed on a DC basis even when surgery is technically challenging. The need of IP stay can be predicted in comorbid old adult men with anticipated higher Nassar's score.
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Affiliation(s)
- Amira Orabi
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Davide Di Mauro
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Ikechukwu Njere
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Marco Ratano
- Department of Surgery, San Liberatore di Atri Hospital, Teramo, Italy
| | - Sankavi Thavakumar
- Department of Surgery, Nottingham Univeristy Hospital, Nottingham, United Kingdom
| | - Alex Reece-Smith
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Shahjehan Wajed
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Antonio Manzelli
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
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OR black box and surgical control tower: Recording and streaming data and analytics to improve surgical care. J Visc Surg 2021; 158:S18-S25. [PMID: 33712411 DOI: 10.1016/j.jviscsurg.2021.01.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Effective and safe surgery results from a complex sociotechnical process prone to human error. Acquiring large amount of data on surgical care and modelling the process of surgery with artificial intelligence's computational methods could shed lights on system strengths and limitations and enable computer-based smart assistance. With this vision in mind, surgeons and computer scientists have joined forces in a novel discipline called Surgical Data Science. In this regard, operating room (OR) black boxes and surgical control towers are being developed to systematically capture comprehensive data on surgical procedures and to oversee and assist during operating rooms activities, respectively. Most of the early Surgical Data Science works have focused on understanding risks and resilience factors affecting surgical safety, the context and workflow of procedures, and team behaviors. These pioneering efforts in sensing and analyzing surgical activities, together with the advent of precise robotic actuators, bring surgery on the verge of a fourth revolution characterized by smart assistance in perceptual, cognitive and physical tasks. Barriers to implement this vision exist, but the surgical-technical partnerships set by ambitious efforts such as the OR black box and the surgical control tower are working to overcome these roadblocks and translate the vision and early works described in the manuscript into value for patients, surgeons and health systems.
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Mahmood F, Akingboye A, Malam Y, Thakkar M, Jambulingam P. Complicated Acute Cholecystitis: The Role of C-Reactive Protein and Neutrophil-Lymphocyte Ratio as Predictive Markers of Severity. Cureus 2021; 13:e13592. [PMID: 33796428 PMCID: PMC8006862 DOI: 10.7759/cureus.13592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objectives The clinical diagnosis of complicated acute cholecystitis (CAC) remains difficult with several pathological or ultrasonography criteria used to differentiate it from uncomplicated acute cholecystitis (UAC). This study aims to evaluate the use of combined inflammatory markers C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR) as surrogate markers to differentiate between UAC and CAC. Methods We identified 600 consecutive patients admitted with biliary symptoms during an acute surgical take from our electronic prospectively maintained database over a period of 55 months. Only patients undergoing emergency cholecystectomy performed during the index admission were included. The primary outcome was the finding of CAC versus UAC. Results A total of 176 patients underwent emergency laparoscopic cholecystectomy (ELC) during the index admission, including 118 (67%) females with a median age of 51 years (range: 21-97 years). The proportion of UAC (130 [74%]) and CAC (46 [26%]) was determined along with demographic data. Multivariate regression analysis showed that patient's age (OR=1.047; p=0.003), higher CRP (OR=1.005; p=0.012) and NLR (OR=1.094; p=0.047) were significant independent factors associated with severity of cholecystitis. Receiver operating characteristic (ROC) analysis for CRP showed an AUC (area under the curve) of 0.773 (95% CI: 0.698- 0.849). Using a cut-off value of 55 mg/L for CRP, the sensitivity of CAC was 73.9% and specificity was 73.1% in predicting CAC. The median post-operative length of stay was four days. The conversion rate from laparoscopic cholecystectomy to open surgery was 2% (4/176), and 5% (9/176) patients suffered post-operative complications with no mortality at 30 days. Conclusion CRP, NLR and age were independent factors associated with the severity of acute cholecystitis. NLR and CRP can be used as surrogate markers to predict patients at risk of CAC during emergency admission, which can inform future guidelines. Moreover, ELC for CAC can be safely performed under the supervision of dedicated upper GI surgeons.
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Affiliation(s)
- Fahad Mahmood
- General Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
| | | | - Yogeshkumar Malam
- General Surgery, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, GBR
| | - Mehual Thakkar
- General Surgery, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, GBR
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Does preoperative MRCP imaging predict risk for conversion to subtotal cholecystectomy in patients with acute cholecystitis? Surg Endosc 2020; 35:6717-6723. [PMID: 33258035 DOI: 10.1007/s00464-020-08175-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/15/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Subtotal cholecystectomy (SC) is a useful procedure for avoiding bile duct injury in patients with difficult gallbladder. However, risk factors for conversion to SC, especially preoperative magnetic resonance cholangiopancreatography (MRCP) findings that predict conversion to SC, have not been investigated in detail. METHODS A total of 290 patients with acute cholecystitis who underwent laparoscopic cholecystectomy at our hospital between November 2011 and March 2020 were included. Patient characteristics and perioperative outcomes were reviewed, and preoperative clinical factors predicting conversion to SC were investigated. RESULTS Forty-three patients underwent SC, whereas the remaining 247 patients underwent total cholecystectomy. An American Society of Anesthesiologists (ASA) score of 3 or greater (p = 0.011), surgery on or after 9 days from symptom onset (p < 0.001), obscuration of the gallbladder wall around the neck on MRCP images (p = 0.010) and disruption of the common hepatic duct on MRCP images (p < 0.001) were significantly associated with conversion to SC. Logistic regression analyses revealed that an ASA score of 3 or greater (odds ratio = 2.667, p = 0.020), surgery on or after 9 days from symptom onset (odds ratio = 4.229, p < 0.001) and disruption of the common hepatic duct on MRCP images (odds ratio = 4.478, p = 0.002) were independent predictors for conversion to SC. CONCLUSIONS Early surgery yielded a lower risk for conversion to SC. Disruption of the common hepatic duct on preoperative MRCP images is associated with a risk for conversion to SC.
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Acar N, Acar T, Sür Y, Bağ H, Kar H, Yılmaz Bozok Y, Dilek ON. Is subtotal cholecystectomy safe and feasible? Short- and long-term results. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:263-271. [PMID: 33058478 DOI: 10.1002/jhbp.847] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/01/2020] [Accepted: 09/20/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cholecystectomy is one of the most commonly performed surgical procedures. However, it may result in some unpleasant conditions such as bile duct injury (BDI), bile leak, and vessel injury. Subtotal cholecystectomy (SC), which has been introduced as an alternative method for reducing the complication rates, has been reported to have lower risk of BDI when compared to total cholecystectomy. This study aimed to evaluate the indications for SC, its early and late complications and their management, and the risk factors affecting the bile leak. METHODS Fifty-seven patients who underwent SC were included in the study, and their medical records were retrospectively reviewed. RESULTS Thirty-three patients were male (57.9%) and the mean age was 64.84 ± 11.35 (range: 29-86). All patients had at least one episode of cholecystitis. Forty-seven (82.5%) patients underwent surgery under emergency conditions. Postoperative bile leak/fistula, surgical site infection, and fluid collection were developed in 12 (21.1%), eight (14%), and six (10.5%) patients, respectively. Leaving the remnant tissue pouch open, presence of comorbidity and emergency operative condition were found to increase the risk of leak development (P < .001). During the average follow-up of 49 months (range: 13-98), symptomatic choledocholithiasis, symptomatic gallstones in the remnant tissue, and incisional hernia were detected within the first year of surgery in three (5.3%), four (7%), and seven (12.3%) patients, respectively. CONCLUSIONS Although SC is not an equivalent to total cholecystectomy, its vital benefit of lowering the risk of BDI should be considered in difficult cases.
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Affiliation(s)
- Nihan Acar
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Turan Acar
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Yunus Sür
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Halis Bağ
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Haldun Kar
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Yeliz Yılmaz Bozok
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Osman Nuri Dilek
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
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Nassar AHM, Ng HJ, Ahmed Z, Wysocki AP, Wood C, Abdellatif A. Optimising the outcomes of index admission laparoscopic cholecystectomy and bile duct exploration for biliary emergencies: a service model. Surg Endosc 2020; 35:4192-4199. [PMID: 32860135 PMCID: PMC8263394 DOI: 10.1007/s00464-020-07900-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/17/2020] [Indexed: 01/12/2023]
Abstract
Aims The rate of acute laparoscopic cholecystectomy remains low due to operational constraints. The purpose of this study is to evaluate a service model of index admission cholecystectomy with referral protocols, refined logistics and targeted job planning. Methods A prospectively maintained dataset was evaluated to determine the processes of care and outcomes of patients undergoing emergency biliary surgery. The lead author has maintained a 28 years prospective database capturing standard demographic data, intraoperative details including the difficulty of cholecystectomy as well as postoperative outcome parameters and follow up data. Results Over five thousand (5555) consecutive laparoscopic cholecystectomies were performed. Only patients undergoing emergency procedures (2399,43.2% of entire group) were analysed for this study. The median age was 52 years with 70% being female. The majority were admitted with biliary pain (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgeons. 80% underwent surgery within 5 days (40% within 24 h). Cholecystectomies were performed on scheduled lists (44%) or dedicated emergency lists (29%). Two thirds had suspected bile duct stones and 38.1% underwent bile duct exploration. The median operating time was 75 min, median hospital stay 7 days, conversion rate 0.8%, morbidity 8.9% and mortality rate 0.2%. Conclusion Index admission cholecystectomy for biliary emergencies can have low rates of morbidity and mortality. Timely referral and flexible theatre lists facilitate the service, optimising clinical results, number of biliary episodes, hospital stay and presentation to resolution intervals. Cost benefits and reduced interval readmissions need to be weighed against the length of hospital stay per episode.
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Affiliation(s)
- Ahmad H M Nassar
- Laparoscopic Biliary Service, University Hospital Monklands, Airdrie, Scotland, UK.
| | - Hwei J Ng
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | | | - Colin Wood
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Ayman Abdellatif
- Laparoscopic Biliary Service, University Hospital Monklands, Airdrie, Scotland, UK
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One-session laparoscopic management of Mirizzi syndrome: feasible and safe in specialist units. Surg Endosc 2020; 35:3286-3295. [PMID: 32632481 PMCID: PMC8195921 DOI: 10.1007/s00464-020-07765-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/25/2020] [Indexed: 11/16/2022]
Abstract
Background To evaluate the laparoscopic management of Mirizzi syndrome, seldom diagnosed preoperatively causing difficulty when performing cholecystectomy and increasing complication risks. Methods Analysis of a prospective single-surgeon database of 5700 laparoscopic cholecystectomies found 58 Mirizzi syndrome cases. They were managed with an intention to treat during the index admission according to protocol of single-session management of bile duct stones. Results 38/58 patients were females (65.5%). The median age was 55 years. 53 cases were emergency admissions. 34 cases (58.6%) only had ultrasound scanning. Operative difficulty was Grade IV in 34 cases (58.6%) and Grade V in 20 (34.5%) (Nassar Scale). There were 33 Mirizzi Type IA, 7 Type IB, 16 Type II and one each of Type III and Type IV. Bile duct exploration was performed in 94.8% through choledochotomy/ transfistula in 58.6% or transcystic in 36.2%. Four cases required conversion to open. Postoperative morbidity occurred in 29%. Two 30-day mortalities occurred from pneumonia in two elderly patients who were late referrals. Conclusion Although the utilization of the laparoscopic approach in managing bile duct stones is not currently widely practiced it was safer in this series than in reported series of open surgery in Mirizzi Syndrome. The optimal approach to Mirizzi Type II is via cholecystocholedochal fistula to explore the bile duct then drain with T-tube through the fistula. It is unnecessary to perform bilioenteric bypass in majority of cases, reducing the morbidity and mortality.
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