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Ho VP, Towe CW, Bensken WP, Pfoh E, Dalton J, Connors AF, Claridge JA, Perzynski AT. Mortality burden from variation in provision of surgical care in emergency general surgery: a cohort study using the National Inpatient Sample. Trauma Surg Acute Care Open 2024; 9:e001288. [PMID: 38933602 PMCID: PMC11202721 DOI: 10.1136/tsaco-2023-001288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/15/2024] [Indexed: 06/28/2024] Open
Abstract
Background The decision to undertake a surgical intervention for an emergency general surgery (EGS) condition (appendicitis, diverticulitis, cholecystitis, hernia, peptic ulcer, bowel obstruction, ischemic bowel) involves a complex consideration of factors, particularly in older adults. We hypothesized that identifying variability in the application of operative management could highlight a potential pathway to improve patient survival and outcomes. Methods We included adults aged 65+ years with an EGS condition from the 2016-2017 National Inpatient Sample. Operative management was determined from procedure codes. Each patient was assigned a propensity score (PS) for the likelihood of undergoing an operation, modeled from patient and hospital factors: EGS diagnosis, age, gender, race, presence of shock, comorbidities, and hospital EGS volumes. Low and high probability for surgery was defined using a PS cut-off of 0.5. We identified two model-concordant groups (no surgery-low probability, surgery-high probability) and two model-discordant groups (no surgery-high probability, surgery-low probability). Logistic regression estimated the adjusted OR (AOR) of in-hospital mortality for each group. Results Of 375 546 admissions, 21.2% underwent surgery. Model-discordant care occurred in 14.6%; 5.9% had no surgery despite a high PS and 8.7% received surgery with low PS. In the adjusted regression, model-discordant care was associated with significantly increased mortality: no surgery-high probability AOR 2.06 (1.86 to 2.27), surgery-low probability AOR 1.57 (1.49 to 1.65). Model-concordant care showed a protective effect against mortality (AOR 0.83, 0.74 to 0.92). Conclusions Nearly one in seven EGS patients received model-discordant care, which was associated with higher mortality. Our study suggests that streamlined treatment protocols can be applied in EGS patients as a means to save lives. Level of evidence III.
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Affiliation(s)
- Vanessa P Ho
- Surgery, The MetroHealth System, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
- Population Health and Equity Research Institute, The MetroHealth System, Cleveland, Ohio, USA
| | - Christopher W Towe
- Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Elizabeth Pfoh
- Department of Internal Medicine and Geriatrics, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jarrod Dalton
- Center for Populations Health Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Alfred F Connors
- The MetroHealth System, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Adam T Perzynski
- Population Health and Equity Research Institute, The MetroHealth System, Cleveland, Ohio, USA
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Repo A, Eskelinen M, Saimanen I, Selander T, Kärkkäinen J, Juvonen P, Aspinen S, Pulkkinen J, Eskelinen M. Patient-reported Outcome Measure (PROM) Rand-36-item Health Survey for Gallstone Disease Patients Five Years Following Surgery: A Prospective Randomized Study. In Vivo 2024; 38:1213-1219. [PMID: 38688655 PMCID: PMC11059901 DOI: 10.21873/invivo.13557] [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: 12/20/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND/AIM There are no studies assessing the long-term quality of life (QoL) following three-dimensional laparoscopy cholecystectomy (3D-LC) in patients with cholelithiasis (Chole). PATIENTS AND METHODS A cohort of 200 patients with Chole were randomized into 3D-LC or minilaparotomy cholecystectomy (MC) groups. RAND-36 survey was performed before randomization, four weeks and five years postoperatively. RESULTS Similar postoperative five years RAND-36 scores were reported in the 3D-LC and MC groups. The MC and 3D-LC groups combined analysis, social functioning (SF, p=0.007), mental health (MH, p=0.001), role physical (RP, p<0.001) and bodily pain (BP, p<0.001) domains increased significantly. In comparison to the Finnish reference RAND-36 (FRR) scores, the scores at five years increased significantly in the MH domain, while four RAND-36 domains; Physical functioning (PF), general health (GH), RP, BP remained significantly lower in comparison to the FRR scores. CONCLUSION A relatively similar long-term outcome in the 3D-LC and MC patients is shown. Interestingly, five RAND-36 domains increased during five years follow-up, while four RAND-36 domains remained lower than FRR scores, which may indicate onset of possible new symptoms following cholecystectomy in long-term follow-up.
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Affiliation(s)
- Anni Repo
- Department of Surgery, and Science Service Center, Kuopio University Hospital (KUH) and University of Eastern Finland (UEF), Kuopio, Finland
| | - Maaret Eskelinen
- Department of Surgery, and Science Service Center, Kuopio University Hospital (KUH) and University of Eastern Finland (UEF), Kuopio, Finland
| | - Iina Saimanen
- Department of Surgery, and Science Service Center, Kuopio University Hospital (KUH) and University of Eastern Finland (UEF), Kuopio, Finland
| | - Tuomas Selander
- Science Service Center, Kuopio University Hospital (KUH) and University of Eastern Finland (UEF), Kuopio, Finland
| | - Jari Kärkkäinen
- Department of Surgery, and Science Service Center, Kuopio University Hospital (KUH) and University of Eastern Finland (UEF), Kuopio, Finland
| | - Petri Juvonen
- Department of Surgery, and Science Service Center, Kuopio University Hospital (KUH) and University of Eastern Finland (UEF), Kuopio, Finland
| | - Samuli Aspinen
- Department of Surgery, and Science Service Center, Kuopio University Hospital (KUH) and University of Eastern Finland (UEF), Kuopio, Finland
| | - Jukka Pulkkinen
- Department of Surgery, and Science Service Center, Kuopio University Hospital (KUH) and University of Eastern Finland (UEF), Kuopio, Finland
| | - Matti Eskelinen
- Department of Surgery, and Science Service Center, Kuopio University Hospital (KUH) and University of Eastern Finland (UEF), Kuopio, Finland
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Ramírez-Giraldo C, Venegas-Sanabria LC, Rojas-López S, Avendaño-Morales V. Outcomes after laparoscopic cholecystectomy in patients older than 80 years: two-years follow-up. BMC Surg 2024; 24:87. [PMID: 38475792 DOI: 10.1186/s12893-024-02383-6] [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: 01/31/2024] [Accepted: 03/06/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND The laparoscopic cholecystectomy is the treatment of choice for patients with benign biliary disease. It is necessary to evaluate survival after laparoscopic cholecystectomy in patients over 80 years old to determine whether the long-term mortality rate is higher than the reported recurrence rate. If so, this age group could benefit from a more conservative approach, such as antibiotic treatment or cholecystostomy. Therefore, the aim of this study was to evaluate the factors associated with 2 years survival after laparoscopic cholecystectomy in patients over 80 years old. METHODS We conducted a retrospective observational cohort study. We included all patients over 80 years old who underwent laparoscopic cholecystectomy. Survival analysis was conducted using the Kaplan‒Meier method. Cox regression analysis was implemented to determine potential factors associated with mortality at 24 months. RESULTS A total of 144 patients were included in the study, of whom 37 (25.69%) died at the two-year follow-up. Survival curves were compared for different ASA groups, showing a higher proportion of survivors at two years among patients classified as ASA 1-2 at 87.50% compared to ASA 3-4 at 63.75% (p = 0.001). An ASA score of 3-4 was identified as a statistically significant factor associated with mortality, indicating a higher risk (HR: 2.71, CI95%:1.20-6.14). CONCLUSIONS ASA 3-4 patients may benefit from conservative management due to their higher risk of mortality at 2 years and a lower probability of disease recurrence.
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Affiliation(s)
- Camilo Ramírez-Giraldo
- Surgery Department, Hospital Universitario Mayor - Méderi, Bogotá, Colombia.
- Universidad del Rosario, Bogotá, Colombia.
- Grupo de Investigación Clínica, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia.
| | - Luis Carlos Venegas-Sanabria
- Research Department, Hospital Universitario Mayor - Méderi, Bogotá, Colombia
- Universidad del Rosario, Bogotá, Colombia
| | - Susana Rojas-López
- Surgery Department, Hospital Universitario Mayor - Méderi, Bogotá, Colombia
- Universidad del Rosario, Bogotá, Colombia
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Matsui Y, Yao S, Ishikawa K, Homma S, Hosokawa S, Murakami T, Kan T, Nakajima S, Harada T, Arii S. Simplified risk stratification in early cholecystectomy for acute cholecystitis based on age: A report from an institution with zero mortality. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024; 31:89-98. [PMID: 37767887 DOI: 10.1002/jhbp.1378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND/PURPOSE The existing risk stratification for early cholecystectomy in patients with acute cholecystitis (AC) is complex. This study aims to establish a simpler risk assessment for surgical complications after cholecystectomy based on age group. METHODS This single-center retrospective observational study enrolled 350 patients diagnosed with AC who underwent early cholecystectomy within 72 h of diagnosis from 2013 to 2021. Patients were divided into three subgroups based on age: young (<65 years), elderly (65-79 years), and very elderly (≥80 years). Since no mortality was observed, risk factors for the Clavien-Dindo (CD) grade ≥ II complications were identified within the entire cohort and in each subgroup. RESULTS There were 120 young, 130 elderly, and 100 very elderly patients. The overall prevalence of complications with CD grade ≥ II was 11.1%. Age and Tokyo Guidelines 18 (TG18) severity were independent risk factors for surgical complications in the whole cohort. Subgroup analysis revealed that there was no independent risk factor in the young group. Meanwhile, age and poor physical status were independent risk factors in the elderly group, and TG18 severity in the very elderly group. CONCLUSION Evaluation of only age, physical status, and TG18 severity may be sufficient for risk stratification of surgical complications of AC.
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Affiliation(s)
- Yugo Matsui
- Department of Surgery, Kobe City Medical Center West Hospital, Hyogo, Japan
| | - Siyuan Yao
- Department of Surgery, Kobe City Medical Center West Hospital, Hyogo, Japan
| | - Kana Ishikawa
- Department of Surgery, Kobe City Medical Center West Hospital, Hyogo, Japan
| | - Shusaku Homma
- Department of Surgery, Kobe City Medical Center West Hospital, Hyogo, Japan
| | - Shinichi Hosokawa
- Department of Surgery, Kobe City Medical Center West Hospital, Hyogo, Japan
| | - Teppei Murakami
- Department of Surgery, Kobe City Medical Center West Hospital, Hyogo, Japan
| | - Takatsugu Kan
- Department of Surgery, Kobe City Medical Center West Hospital, Hyogo, Japan
| | - Sanae Nakajima
- Department of Surgery, Kobe City Medical Center West Hospital, Hyogo, Japan
| | - Takehisa Harada
- Department of Surgery, Kobe City Medical Center West Hospital, Hyogo, Japan
| | - Shigeki Arii
- Department of Surgery, Kobe City Medical Center West Hospital, Hyogo, Japan
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Ostergar A, Alkazemi MH, Hill H, Awad MM, Ushinsky A, Darcy M, Desai AC, Figenshau RS. Successful Percutaneous Ultrasonic Lithotripsy of Gallstones. Ochsner J 2024; 24:84-86. [PMID: 38510219 PMCID: PMC10949052 DOI: 10.31486/toj.23.0071] [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] [Indexed: 03/22/2024] Open
Abstract
Background: Acute calculous cholecystitis is the obstruction of the cystic duct by a gallstone that leads to inflammation of the gallbladder necessitating cholecystectomy. Case Series: We present the cases of 2 patients with acute calculous cholecystitis who were deemed ineligible candidates for cholecystectomy because of their complicating medical histories. Both patients initially underwent cholecystostomy and drain placement with interventional radiology for management of acute calculous cholecystitis. Their large gallstones remained refractory to attempts at removal by electrohydraulic lithotripsy via the cholecystostomy access. The patients' gallstones were successfully removed via percutaneous ultrasonic lithotripsy during a collaborative procedure with interventional radiology and urology. Conclusion: An interdisciplinary approach using percutaneous cholecystolithotomy with rigid ultrasonic lithotripsy is an effective method for removing challenging gallstones in patients for whom traditional approaches fail.
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Affiliation(s)
- Adam Ostergar
- Division of Urologic Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Muhammad Hassan Alkazemi
- Division of Urologic Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Hayden Hill
- Division of Urologic Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Michael M. Awad
- Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Alexander Ushinsky
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Michael Darcy
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Alana C. Desai
- Division of Urologic Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
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6
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Kubat M, Şengül S, Şahin S. Efficacy of blood parameters as indicators of the need for overdue urgent cholecystectomy in elderly patients with acute cholecystitis. ULUS TRAVMA ACIL CER 2023; 29:1248-1254. [PMID: 37889024 PMCID: PMC10771242 DOI: 10.14744/tjtes.2023.75670] [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: 04/10/2023] [Revised: 08/20/2023] [Accepted: 09/14/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Although early cholecystectomy is recommended for patients with acute cholecystitis, conservative treatment followed by delayed cholecystectomy (DC) is a highly preferred modality, especially in older adult patients. However, some severe cases require overdue urgent cholecystectomy (OC). This study aimed to evaluate the ability of laboratory findings and Tokyo severity classification (TokyoSC) to differentiate those with the need for OC among elderly patients. METHODS Laboratory/radiological/clinical findings of geriatric patients with acute cholecystitis on admission and TokyoSC were retrospectively analyzed. The DC and OC groups were compared. RESULTS The mean age of the 164 patients was 72.3±6.4 years. White blood cell, neutrophil (NEU), immature granulocyte (IG), C-reactive protein, neutrophil-to-lymphocyte ratio (NLR), and TokyoSC parameters were all significant at P<0.001 in differentiation. NLR had a specificity of 98%, and TokyoSC had a sensitivity of 98%. CONCLUSION NLR, NEU, IG, and TokyoSC were effective in differentiating patients who needed OC while planning conservative treatment + DC for older adult patients who were followed up due to acute cholecystitis. If the NLR is >9.9 and TokyoSC is moderate/high, early cholecystectomy should be preferred instead of conservative treatment + DC in aged patients.
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Affiliation(s)
- Mehmet Kubat
- Department of General Surgery, Alanya Training and Research Hospital, Antalya-Türkiye
| | - Serkan Şengül
- Department of General Surgery, Alaaddin Keykubat University, Antalya-Türkiye
| | - Serdar Şahin
- Department of General Surgery, Ahi Evran University, Kırşehir-Türkiye
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7
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Mc Geehan G, Melly C, O' Connor N, Bass G, Mohseni S, Bucholc M, Johnston A, Sugrue M. Prophylactic cholecystectomy offers best outcomes following ERCP clearance of common bile duct stones: a meta-analysis. Eur J Trauma Emerg Surg 2023; 49:2257-2267. [PMID: 36053288 PMCID: PMC10520076 DOI: 10.1007/s00068-022-02070-2] [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: 05/04/2022] [Accepted: 08/05/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Symptomatic calculus biliary disease is common with associated morbidity and occasional mortality, further confounded when there is concomitant common bile duct (CBD) stones. Choledocholithiasis and clearance of the duct reduces recurrent cholangitis, but the question is whether after clearance of the CBD if there is a need to perform a cholecystectomy. This meta-analysis evaluated outcomes in patients undergoing ERCP with or without sphincterotomy to determine if cholecystectomy post-ERCP clearance offers optimal outcomes over a wait-and-see approach. METHODS A Prospero registered meta-analysis of the literature using PRISMA guidelines incorporating articles related to ERCP, choledocholithiasis, cholangitis and cholecystectomy was undertaken for papers published between 1st January 1991 and 31st May 2021. Existing research that demonstrates outcomes of ERCP with no cholecystectomy versus ERCP and cholecystectomy was reviewed to determine the related key events, complications and mortality of leaving the gallbladder in situ and removing it. Odds ratios (OR) were calculated using Review Manager Version 5.4 and meta-analyses performed using OR using fixed-effect (or random-effect) models, depending on the heterogeneity of studies. RESULTS 13 studies (n = 2598), published between 2002 and 2019, were included in this meta-analysis, 6 retrospective, 2 propensity score-matched retrospective studies, 3 prospective studies and 2 randomised control trials from a total of 11 countries. There were 1433 in the no cholecystectomy cohort (55.2%) and 1165 in the prophylactic cholecystectomy (44.8%) cohort. Cholecystectomy resulted in a decreased risk of cholecystitis (OR = 0.15; CI 0.07-0.36; p < 0.0001), cholangitis (OR = 0.51; CI 0.26-1.00; p = 0.05) and mortality (OR = 0.38; CI 0.16-0.9; p = 0.03). In addition, prophylactic cholecystectomy resulted in a significant reduction in biliary events, biliary pain and pancreatitis. CONCLUSIONS In patients undergoing CBD clearance, consideration should be given to performing prophylactic cholecystectomy to optimise outcomes.
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Affiliation(s)
- Gearóid Mc Geehan
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland.
- School of Medicine, University of Limerick, Limerick, Ireland.
| | - Conor Melly
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Niall O' Connor
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
| | - Gary Bass
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, USA
| | - Shahin Mohseni
- Department of Trauma and Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Magda Bucholc
- Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University (European Union Interreg VA Funded), Magee Campus, Northern Ireland, UK
| | - Alison Johnston
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Michael Sugrue
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Co Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
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Kaoukabani G, Friedman A, Bahadir J, Gokcal F, Kudsi OY. Do the outcomes of robotic cholecystectomy in elderly worsen with age? J Robot Surg 2023; 17:2053-2057. [PMID: 37178344 DOI: 10.1007/s11701-023-01613-y] [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: 04/12/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
The elderly population are at an increased risk of perioperative morbidity and mortality due to their disease profile. Minimally invasive surgery and in particular the robotic approach may improve the outcomes of cholecystectomy in the elderly. Patients who underwent robotic cholecystectomy (RC) and were older than 65 at the time of the procedure were included in this retrospective study. Pre-, intra-, and postoperative variables of the whole cohort were initially reported and then compared between three different age ranges. In total, 358 elder patients were included. Mean age ± Standard deviation was 74.5 ± 6.9 years. Males constituted 43% of the cohort. American Society of Anesthesiologists (ASA) scores were mostly ASA-3 (64%). One hundred and fifty-seven (43.9%) were emergent procedures. Conversion to open surgery rate was 2.2%. Median hospital length of stay was 2 days. With a mean follow-up of 28 months, overall complication rate was 12.3%. After subdividing into three age groups (A:65-69; B:70-79; C:80 +), we noticed significantly higher comorbidities in group C. Same-day discharge was lower in the older patients. However, overall complications and conversion to open remained comparable between the three groups. This is the first study to investigate the outcomes of RC in patients older than 65. RC provided low conversion and complication rates, that are also comparable between the different age ranges, despite the higher comorbidities in patients older than 80.
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Affiliation(s)
- Georges Kaoukabani
- Department of Surgery, Good Samaritan Medical Center, One Pearl Street, Brockton, MA, 02301, USA
| | | | - Jenna Bahadir
- Department of Surgery, Good Samaritan Medical Center, One Pearl Street, Brockton, MA, 02301, USA
| | - Fahri Gokcal
- Department of Surgery, Good Samaritan Medical Center, One Pearl Street, Brockton, MA, 02301, USA
| | - Omar Yusef Kudsi
- Department of Surgery, Good Samaritan Medical Center, One Pearl Street, Brockton, MA, 02301, USA.
- Tufts University School of Medicine, Boston, MA, USA.
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Porras Fimbres DC, Nussbaum DP, Mosca PJ. Racial disparities in time to laparoscopic cholecystectomy for acute cholecystitis. Am J Surg 2023; 226:261-270. [PMID: 37149406 DOI: 10.1016/j.amjsurg.2023.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/25/2023] [Accepted: 05/02/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Disparities in healthcare exist, yet few data are available on racial differences in time from admission to surgery. This study aimed to compare time from admission to laparoscopic cholecystectomy for acute cholecystitis between non-Hispanic Black and non-Hispanic White patients. METHODS Patients who underwent laparoscopic cholecystectomy for acute cholecystitis from 2010 to 2020 were identified using NSQIP. Time to surgery and additional preoperative, operative, and postoperative variables were analyzed. RESULTS In the univariate analysis, 19.4% of Black patients experienced a time to surgery >1 day compared with 13.4% of White patients (p < 0.0001). In the multivariable analysis, controlling for potential confounding factors, Black patients were found to be more likely than White patients to experience a time to surgery >1 day (OR 1.23, 95% CI 1.17-1.30, p < 0.0001). CONCLUSIONS Further investigation is indicated to better define the nature and significance of gender, race, and other biases in surgical care. Surgeons should be aware that biases may adversely impact patient care and should strive to identify and proactively address them to promote health equity in surgery.
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Affiliation(s)
| | - Daniel P Nussbaum
- Duke University School of Medicine, Duke University Health System, Durham, NC, USA; Department of Surgery, Duke University School of Medicine, Duke University Health System, Durham, NC, USA; Duke Network Services, Duke University Health System, Durham, NC, USA
| | - Paul J Mosca
- Duke University School of Medicine, Duke University Health System, Durham, NC, USA; Department of Surgery, Duke University School of Medicine, Duke University Health System, Durham, NC, USA; Duke Network Services, Duke University Health System, Durham, NC, USA.
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10
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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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12
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Umemoto KK, Ananth S, Ma A, Ullal A, Ramdass PVAK, Lo PC, Vyas D. Novel Application of Hydrodissection in Laparoscopic Cholecystectomy for Gangrenous Gallbladders. J Surg Res 2023; 283:1124-1132. [PMID: 36915004 DOI: 10.1016/j.jss.2022.11.060] [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: 03/02/2022] [Revised: 11/12/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Laparoscopic cholecystectomy (LC) for gangrenous gallbladders (GGBs) can be challenging and represent a significant number of LC cases, necessitating more efficacious surgical techniques. Currently, the standard treatment for GGBs is blunt dissection which can have high iatrogenic complication rates. To our knowledge, this is the first large retrospective study conducted on the novel application of hydrodissection (HD) in LCs for GGBs. METHODS In this retrospective study of 386 LCs, data were collected for patient demographics, medical comorbidities, operating time (OT), anesthesia time (AT), length of stay (LOS), estimated blood loss, conversion to open procedures, 30-day readmissions, and mortality. Patients were categorized into four groups: (1) Vyas employing HD for GGBs (VHG), (2) non-Vyas group of five surgeons not employing HD for GGBs (NVG), (3) Vyas treating non-GGBs, and (4) non-Vyas group of five surgeons treating non-GGBs. Control groups were age-matched and sex-matched. Statistical analysis used descriptive statistics, Mann-Whitney U testing, and chi-squared testing (α = 0.05). RESULTS This study demonstrated significantly decreased (P < 0.05) OT (P = 0.001), AT (P < 0.001), LOS (P = 0.015), and conversion to open procedures (P = 0.047) between the VHG and NVG groups, with HD reducing OT by 35.5% compared to blunt dissection. This study did not demonstrate significantly decreased (P > 0.05) estimated blood loss (P = 0.185) and 30-day readmissions (P = 0.531) between the VHG and NVG groups, but they were trending toward significant. There were no mortalities in this study. CONCLUSIONS HD is associated with improved surgical outcomes of LCs for GGBs demonstrated by reduced OT, AT, LOS, and conversion to open procedures. Further multi-institutional studies are needed to validate HD implementation and further dissemination.
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Affiliation(s)
- Kayla K Umemoto
- California Northstate University College of Medicine, Elk Grove, California
| | - Shahini Ananth
- California Northstate University College of Medicine, Elk Grove, California
| | - Anthony Ma
- California Northstate University College of Medicine, Elk Grove, California
| | - Anvay Ullal
- California Northstate University College of Medicine, Elk Grove, California
| | - Prakash V A K Ramdass
- St. George's University School of Medicine, Department of Public Health and Preventative Medicine, St. George's, Grenada
| | - Peter C Lo
- San Joaquin General Hospital, Department of Surgery, French Camp, California
| | - Dinesh Vyas
- California Northstate University College of Medicine, Elk Grove, California; San Joaquin General Hospital, Department of Surgery, French Camp, California; Adventist Health Dameron Hospital, Department of Surgery, Stockton, California.
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13
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Wait-and-see strategy is justified after ERCP and endoscopic sphincterotomy in elderly patients with common biliary duct stones. J Trauma Acute Care Surg 2023; 94:443-447. [PMID: 36524923 DOI: 10.1097/ta.0000000000003852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Older patients with simultaneous main bile duct and gallbladder stones, especially those with high-surgical risks, create a common clinical dilemma. After successful endoscopic removal of main bile duct stones, should these patients undergo laparoscopic cholecystectomy to reduce risk of recurrent biliary events? In this population-based cohort study, we report long-term outcomes of a wait-and-see strategy after successful endoscopic extraction of main bile duct stones. METHODS Consecutive patients 75 years or older undergoing endoscopic stone extraction without subsequent cholecystectomy in two tertiary academic centers between January 2010 and December 2018 were included. Primary outcome measure was recurrence of biliary events. Secondary outcome measures were operation-related morbidity and mortality. RESULTS A total of 450 patients (median age, 85 years; 61% female) were included, with a median follow-up time of 36 months (0-120 months). Recurrent biliary events occurred in 51 patients (11%), with a median time from index hospital admission to recurrence of 307 days (12-1993 days). The most common biliary event was acute cholecystitis (7.1%). Twelve patients had cholangitis (2.7%) and two biliary pancreatitis (0.4%). Only one patient (0.4%) underwent surgery due to later gallstone-related symptoms. Eighteen patients (4.0%) required endoscopic intervention and 16 (3.5%) underwent surgery. There were no operation-associated deaths or morbidity among those undergoing later surgical or endoscopic interventions. CONCLUSION In elderly patients, it is relatively safe to leave gallbladder in situ after successful sphincterotomy and endoscopic common bile duct stone removal. In elderly and frail patients, a wait-and-see strategy without routine cholecystectomy rarely leads to clinically significant consequences. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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14
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Yu T, Zhao L, Zhao H, Fu H, Li J, Yu A. The enhanced recovery after surgery (ERAS) protocol in elderly patients with acute cholecystitis: A retrospective study. Medicine (Baltimore) 2023; 102:e32942. [PMID: 36820555 PMCID: PMC9907967 DOI: 10.1097/md.0000000000032942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) protocol is a perioperative management theory aimed at reducing the injury of surgical patients and accelerating postoperative recovery. It has been widely recognized and applied in elective surgery. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. We collected medical data from 126 elderly patients with acute cholecystitis from October 2018 to August 2021. Among the 126 patients, 70 were included in the ERAS group and 56 in the traditional group. We analyzed the clinical data and postoperative indicators of the 2 groups. No significant differences were observed regarding the general characteristics of the 2 groups (P > .05). The ERAS group had significantly earlier time to first flatus, time to first ambulation, and time to solid intake, compared with the traditional group (P < .001); additionally, the ERAS group had significantly shorter stay and gentler feeling of postoperative pain (P < .001). Furthermore, the ERAS group had significant incidences of lower postoperative lung (P = .029) and abdominal cavity infection (P = .025) compared to the traditional group. No significant difference was observed regarding the incidences of other postoperative complications between the 2 groups (P > .05). The ERAS protocol helps reduce elderly patients' stress reactions and accelerate postoperative recovery. Thus, it is effective and beneficial to implement the ERAS protocol during the perioperative period of elderly patients with acute cholecystitis.
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Affiliation(s)
- Tianyang Yu
- The First Department of General Surgery, Affiliated Hospital of Chengde Medical University, Chengde, Hebei Province, PR China
| | - Luwen Zhao
- The First Department of Gynecology, Affiliated Hospital of Chengde Medical University, Chengde, Hebei Province, PR China
| | - Hongtao Zhao
- Surgical Operation Department, Affiliated Hospital of Chengde Medical University, Chengde, Hebei Province, PR China
| | - Hua Fu
- The First Department of General Surgery, Affiliated Hospital of Chengde Medical University, Chengde, Hebei Province, PR China
| | - Jian Li
- The First Department of General Surgery, Affiliated Hospital of Chengde Medical University, Chengde, Hebei Province, PR China
| | - Aijun Yu
- The First Department of General Surgery, Affiliated Hospital of Chengde Medical University, Chengde, Hebei Province, PR China
- * Correspondence: Aijun Yu, The First Department of General Surgery, Affiliated Hospital of Chengde Medical University, Chengde, Hebei Province 067000, PR China (e-mail: )
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15
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Ahmed SH, Usmani SUR, Mushtaq R, Samad S, Abid M, Moeed A, Atif AR, Farhan SA, Saif A. Role of laparoscopic surgery in the management of gallbladder cancer: Systematic review & meta-analysis. Am J Surg 2023; 225:975-987. [PMID: 36693774 DOI: 10.1016/j.amjsurg.2023.01.008] [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: 11/15/2022] [Revised: 12/26/2022] [Accepted: 01/08/2023] [Indexed: 01/12/2023]
Abstract
BACKGROUND This meta-analysis evaluates the safety and short-term oncological outcomes of laparoscopic vs. open surgery for gallbladder carcinoma(GBC). METHODS Meta-analysis was performed on laparoscopic(LG) and open group(OG) studies. Data for survival outcomes were extracted from Kaplan-Meier curves and combined with Tierney's method to estimate hazard ratios(HRs) and 95% CIs. RESULTS There was no significant difference in overall survival(HR: 1.01), disease-free survival(HR: 0.84), 30-day mortality(RR:1.10), overall recurrence(RR:0.93), intraoperative gallbladder violation(RR:1.17), operative time(WMD:8.32), number of patients receiving adjuvant chemotherapy(RR:1.06) and blood transfusion(RR: 0.81). A significant difference was seen in survival of T3 subgroup(HR:0.77) and number of lymph node dissections (LND)(WMD: 0.63) favoring OG, along with a decrease in postoperative complications(RR:0.65), greater incidence of R0 resections(RR:1.04), lower volume of intraoperative blood loss(WMD: 128.62), lower time in removing drainage tube(WMD: 1.35), shorter diet recovery time(WMD: 1.88), shorter hospital stay(WMD: 3.51), lower incidence of 90-day mortality(RR:0.49) favoring LG. A higher incidence of port-site recurrence(RR:1.99) was reported in LG. CONCLUSION Laparoscopic surgery is non-inferior to the open approach in terms of oncological outcomes and has an improved rate of postoperative complications.
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Affiliation(s)
- Syeda Hoorulain Ahmed
- Department of Surgery, Dow University of Health Sciences, Baba-e-Urdu Rd, Karachi, 74200, Pakistan.
| | - Shajie Ur Rehman Usmani
- Department of Surgery, Dow University of Health Sciences, Baba-e-Urdu Rd, Karachi, 74200, Pakistan
| | - Rabeea Mushtaq
- Department of Surgery, Dow University of Health Sciences, Baba-e-Urdu Rd, Karachi, 74200, Pakistan
| | - Saba Samad
- Department of Surgery, Dow University of Health Sciences, Baba-e-Urdu Rd, Karachi, 74200, Pakistan
| | - Minaam Abid
- Department of Surgery, Dow University of Health Sciences, Baba-e-Urdu Rd, Karachi, 74200, Pakistan
| | - Abdul Moeed
- Department of Surgery, Dow University of Health Sciences, Baba-e-Urdu Rd, Karachi, 74200, Pakistan
| | - Abdul Raafe Atif
- Department of Surgery, Dow University of Health Sciences, Baba-e-Urdu Rd, Karachi, 74200, Pakistan
| | - Syed Ali Farhan
- Department of Surgery, Virginia Commonwealth University Health, 1200 E Marshall St, Richmond, VA, 23219, United States
| | - Areeba Saif
- Department of Surgery, University of Texas Health Science Center at Houston, 7000 Fannin St, Houston, TX, 77030, United States
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Vanella G, Bronswijk M, Arcidiacono PG, Larghi A, Wanrooij RLJV, de Boer YS, Rimbas M, Khashab M, van der Merwe SW. Current landscape of therapeutic EUS: Changing paradigms in gastroenterology practice. Endosc Ultrasound 2023; 12:16-28. [PMID: 36124531 PMCID: PMC10134933 DOI: 10.4103/eus-d-21-00177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Therapeutic EUS has witnessed exponential growth in the last decade, but it has been considered investigational until recently. An increasing body of good-quality evidence is now demonstrating clear advantages over established alternatives, adding therapeutic EUS to management algorithms of complex hepato-pancreato-biliary (HPB) and gastrointestinal (GI) conditions. In this review, the available evidence and clinical role of therapeutic EUS in established and evolving applications will be discussed. A Graphical Summary for each scenario will provide (1) technical steps, (2) anatomical sketch, (3) best-supporting evidence, and (4) role in changing current and future GI practice. Therapeutic EUS has accepted well-established applications such as drainage of symptomatic peripancreatic fluid collections, biliary drainage in failed endoscopic retrograde cholangiopancreatography, and treatment of acute cholecystitis in unfit-for-surgery patients. In addition, good-quality evidence on several emerging indications (e.g., treatment of gastric outlet obstruction, local ablation of pancreatic solid lesions, etc.) is promising. Specific emphasis will be given to how these technical innovations have changed management paradigms and algorithms and expanded the possibilities of gastroenterologists to provide therapeutic solutions to old and emerging clinical needs. Therapeutic EUS is cementing its role in everyday practice, radically changing the treatment of different HPB diseases and other conditions (e.g., GI obstruction). The development of dedicated accessories and increased training opportunities will expand the ability of gastroenterologists to deliver highly effective yet minimally invasive therapies, potentially translating into a better quality of life, especially for oncological and fragile patients.
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Affiliation(s)
- Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven; Department of Gastroenterology and Hepatology, Imelda General Hospital, Bonheiden, Belgium
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS; Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, AGEM Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ynto S de Boer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, AGEM Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mihai Rimbas
- Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Schalk W van der Merwe
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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17
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Han M, Wu X, Li J, Han S, Rong J. Effects of Remote Ischemic Preconditioning on Postoperative Cognitive Dysfunction in Elderly Patients with Laparoscopic Cholecystectomy. Int J Gen Med 2023; 16:961-971. [PMID: 36959973 PMCID: PMC10027852 DOI: 10.2147/ijgm.s401902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/03/2023] [Indexed: 03/17/2023] Open
Abstract
Purpose We hypothesized that remote ischemic preconditioning (RIPC) could improve postoperative cognitive dysfunction (POCD) in elderly patients following laparoscopic cholecystectomy (LC). Patients and Methods Eighty-eight patients were randomly assigned to either the control or the RIPC group. The RIPC was applied on the right upper limb using a blood pressure cuff inflating 200 mmHg, consisting of 3 cycles of 5 min ischemia and 5 min reperfusion. Serum concentrations of Neuron-specific Enolase (NSE) and Brain-Derived Neurotrophic Factor (BDNF) were collected at one-day preoperative (T0), at the end of the operation (T4) and one-day postoperative (T5). Z score was tested at T0 and 3 days after the operation (T6). POCD was determined if there were two Z scores ≥1.96 at the same time or an average Z score ≥1.96. Results There was no significant difference in the Z score of each test between the two groups at T0 (P > 0.05). Notably, the duration of Stroop test C was significantly shorter in the RIPC group than that in the Control group at T6 (P = 0.01). POCD occurred in 1/44 (2.3%) patients in the RIPC group and 8/44 (18.2%) patients in the control group at T6 (P=0.035). In addition, serum NSE concentration was significantly decreased, but serum BDNF concentration was increased compared with the control group at T4 and T5 (P<0.001). Conclusion RIPC could reduce the incidence of POCD in elderly patients after laparoscopic cholecystectomy.
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Affiliation(s)
- Mengnan Han
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
- Graduate Faculty, Hebei North University, Zhangjiakou, People’s Republic of China
| | - Xiaoqian Wu
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
| | - Jianli Li
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
- Correspondence: Jianli Li, Department of Anesthesiology, Hebei General Hospital, No. 348 West Heping Road, Shijiazhuang, 050051, People’s Republic of China, Tel +86 13785118676, Email
| | - Shuang Han
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
| | - Junfang Rong
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, People’s Republic of China
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18
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Fair L, Squiers JJ, Jacinto K, Perryman M, Misenhimer J, Blair S, Rodriguez C. Fast-Track Nonelective Laparoscopic Cholecystectomy is Safe and Feasible. J Surg Res 2023; 281:256-263. [PMID: 36219937 DOI: 10.1016/j.jss.2022.09.003] [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: 03/22/2022] [Revised: 08/11/2022] [Accepted: 09/12/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Ample evidence exists to support the safety of fast-track discharge after elective laparoscopic cholecystectomy (LC), but there is currently no data available to support the safety of fast-tracking patients undergoing nonelective LC. We sought to determine whether fast-tracking patients undergoing nonelective LC is safe and feasible. METHODS We performed a retrospective cohort review of 661 consecutive patients undergoing LC at a single teaching institution from April 2018 to January 2020. Subjects were divided into two groups: elective LC (ELC) and fast-track nonelective LC (FTLC). FTLC was defined as nonelective LC with total length of stay <36 h. Patients undergoing nonelective LC with length of stay exceeding 36 h were excluded. The primary outcome of interest was readmission within 30 d. The secondary outcomes included incidences of return to emergency department within 30 d, retained stone, bile leak, and wound infection. RESULTS Of 661 LC, 185 (27%) were ELC and 476 (72%) were nonelective. FTLC included 121 (25%) of the nonelective LC. Preoperative characteristics were similar among the groups. On final pathology, chronic cholecystitis was predominant in both groups, but FTLC exhibited higher rates of acute cholecystitis (P < 0.0001). There was no significant difference in the primary outcome among groups: readmission within 30 d occurred in 6 (3%) ELC patients and 4 (3%) FTLC patients (P = 1.0). There were no significant differences in rates of return to emergency department within 30 d, retained stone, bile leak, or wound infection. CONCLUSIONS With comparable postoperative complication rates to ELC, FTLC can be safely used in select patients. Additional studies are needed to determine preoperative predictors of FTLC suitability to prospectively identify appropriate patients.
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Affiliation(s)
- Lucas Fair
- Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas; Department of Surgery, Baylor University Medical Center, Dallas, Texas.
| | - John J Squiers
- Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas; Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Kimberly Jacinto
- Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas; Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Matthew Perryman
- Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas; Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Jennifer Misenhimer
- Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas; Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Somer Blair
- Office of Clinical Research, John Peter Smith Hospital, Fort Worth, Texas
| | - Carlos Rodriguez
- Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas; Department of Surgery, Texas Health Harris Methodist Hospital, Fort Worth, Texas
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Song J, Chen J, Zheng S. Lateral dorsal infundibular approach: an alternative option for the safe completion of difficult laparoscopic cholecystectomy. BMC Surg 2022; 22:439. [PMID: 36567315 PMCID: PMC9790120 DOI: 10.1186/s12893-022-01894-4] [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: 07/07/2022] [Accepted: 12/22/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Difficult laparoscopic cholecystectomy (LC) due to acute cholecystitis (AC) increases the risk of bile duct injuries and postoperative complications. Here, we added the lateral dorsal infundibular approach as an initial surgical maneuver during LC to improve outcomes. METHODS We describe the detailed technical procedure of the lateral dorsal infundibular approach in patients with AC resulting in difficult LC. This technique was developed after nearly 10 years of experience in laparoscopic surgery, and has been routinely used in the past 5 years. We also retrospectively analyzed the perioperative data for 469 patients with difficult LC. RESULTS A total of 469 patients with AC received difficult LC between July 2016 and June 2021, of which 438 (93.4%) performed a lateral dorsal infundibular approach. Sixty-four patients (13.6%) had variations of the hepatic bile duct and cystic duct according to preoperative magnetic resonance cholangiopancreatography, 438 patients (93.4%) received elective surgery, 31 (6.6%) received emergency surgery, and 10 (2.1%) underwent conversion. There was no postoperative bile leaks and no bile duct injuries in the described technique. CONCLUSION During difficult LC, the critical view of safety can be gradually achieved by changing the surgical approach to achieve cholecystectomy.
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Affiliation(s)
- Juxian Song
- Department of Hepatobiliary Surgery, The 925Th Hospital of the Chinese People’s Liberation Army, Guiyang, 550009 China
| | - Jian Chen
- Institute of Hepatobiliary Surgery, First Affiliated Hospital, Army Military Medical University, Shapingba District, Gaotanyan Main Street 29, Chongqing, 400038 China
| | - Shuguo Zheng
- Institute of Hepatobiliary Surgery, First Affiliated Hospital, Army Military Medical University, Shapingba District, Gaotanyan Main Street 29, Chongqing, 400038 China
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Montenegro DM, Chukwu M, Ehsan P, Aburumman RN, Muthanna SI, Menon SR, Vithani V, Sutariya B, Yu AK. The Safety of Minimally Invasive and Open Cholecystectomy in Elderly Patients With Acute Cholecystitis: A Systematic Review. Cureus 2022; 14:e31170. [DOI: 10.7759/cureus.31170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 11/01/2022] [Indexed: 11/07/2022] Open
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D'Acapito F, Solaini L, Di Pietrantonio D, Tauceri F, Mirarchi MT, Antelmi E, Flamini F, Amato A, Framarini M, Ercolani G. Which octogenarian patients are at higher risk after cholecystectomy for symptomatic gallstone disease? A single center cohort study. World J Clin Cases 2022; 10:8556-8567. [PMID: 36157828 PMCID: PMC9453367 DOI: 10.12998/wjcc.v10.i24.8556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/13/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Incidence of gallstones in those aged ≥ 80 years is as high as 38%-53%. The decision-making process to select those oldest old patients who could benefit from cholecystectomy is challenging.
AIM To assess the risk of morbidity of the “oldest-old” patients treated with cholecystectomy in order to provide useful data that could help surgeons in the decision-making process leading to surgery in this population.
METHODS A retrospective study was conducted between 2010 and 2019. Perioperative variables were collected and compared between patients who had postoperative complications. A model was created and tested to predict severe postoperative morbidity.
RESULTS The 269 patients were included in the study (193 complicated). The 9.7% of complications were grade 3 or 4 according to the Clavien-Dindo classification. Bilirubin levels were lower in patients who did not have any postoperative complications. American Society of Anesthesiologists scale 4 patients, performing a choledocholithotomy and bilirubin levels were associated with Clavien-Dindo > 2 complications (P < 0.001). The decision curve analysis showed that the proposed model had a higher net benefit than the treating all/none options between threshold probabilities of 11% and 32% of developing a severe complication.
CONCLUSION Patients with American Society of Anesthesiologists scale 4, higher level of bilirubin and need of choledocholithotomy are at the highest risk of a severely complicated postoperative course. Alternative endoscopic or percutaneous treatments should be considered in this subgroup of octogenarians.
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Affiliation(s)
- Fabrizio D'Acapito
- Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì 47121, Italy
| | - Leonardo Solaini
- Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì 47121, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40126, Italy
| | - Daniela Di Pietrantonio
- Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì 47121, Italy
| | - Francesca Tauceri
- Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì 47121, Italy
| | - Maria Teresa Mirarchi
- Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì 47121, Italy
| | - Elena Antelmi
- Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì 47121, Italy
| | - Francesca Flamini
- Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì 47121, Italy
| | - Alessio Amato
- Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì 47121, Italy
| | - Massimo Framarini
- Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì 47121, Italy
| | - Giorgio Ercolani
- Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì 47121, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40126, Italy
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22
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Forecasting outcomes after cholecystectomy in octogenarian patients. Surg Endosc 2022; 36:4479-4485. [PMID: 34697679 DOI: 10.1007/s00464-021-08801-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 10/17/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Although gallstone disease increases with aging, elderly patients are less likely to undergo cholecystectomy. This is because age itself is a negative predictor after cholecystectomy. The ACS-NSQIP risk calculator can therefore help surgeons decide whether to operate or not. However, little is known about the accuracy of this model outside the ACS National Surgical Quality Improvement Program. The aim of the present study is to evaluate the ability of the ACS-NSQIP model to predict the clinical outcomes of patients aged 80 years or older undergoing elective or emergency cholecystectomy. STUDY DESIGN The study focused on 263 patients over 80 years of age operated on between 2010 and 2019: 174 were treated as emergencies because of acute cholecystitis (66.2%). Outcomes evaluated are those predicted by the ACS-NSQIP calculator within 30 days of surgery. The ACS-NSQIP model was tested for both discrimination and calibration. Differences among observed and expected outcomes were evaluated. RESULTS When considering all patients, the discrimination of mortality was very high, as it was that of severe complications. Considering only the elective cholecystectomies, the discrimination capacity of ACS-NSQIP risk calculator has consistently worsened in each outcome while it remains high considering the emergency cholecystectomies. In the evaluation of the emergency cholecystectomy, the model showed a very high discriminatory ability and, more importantly, it showed an excellent calibration. Comparisons between main outcomes showed small or even negligible differences between observed and expected values. CONCLUSION The results of the present study suggest that clinical decisions on cholecystectomy in a patient aged 80 years or older should be assisted through the ACS-NSQIP model.
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23
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Melly C, McGeehan G, O’Connor N, Johnston A, Bass G, Mohseni S, Donohoe C, Bucholc M, Sugrue M. OUP accepted manuscript. BJS Open 2022; 6:6603491. [PMID: 35668711 PMCID: PMC9171002 DOI: 10.1093/bjsopen/zrac062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/24/2022] [Accepted: 04/06/2022] [Indexed: 11/24/2022] Open
Abstract
Background Healthcare requires patient feedback to improve outcomes and experience. This study undertook a systematic review of the depth, variability, and digital suitability of current patient-reported outcome measures (PROMs) in patients undergoing laparoscopic cholecystectomy. Methods A PROSPERO-registered (registration number CRD42021261707) systematic review was undertaken for all relevant English language articles using PubMed version of MEDLINE, Scopus, and Web of Science electronic databases in June 2021. The search used Boolean operators and wildcards and included the keywords: laparoscopic cholecystectomy AND patient outcome OR patient-reported outcome OR patient-reported outcome measure OR PRO OR PROM. Medical Subjects Heading terms were used to search PubMed and Scopus. Articles published from 1 January 2011 to 2 June 2021 were included. Results A total of 4960 individual articles were reviewed in this study, of which 44 were found to evaluate PROMs in patients undergoing laparoscopic cholecystectomy and underwent methodological index for non-randomized studies (MINORS) grading. Twenty-one articles spanning 19 countries and four continents met all inclusion criteria and were included in the qualitative data synthesis. There was significant heterogeneity in PROMs identified with eight different comprehensive PROM tools used in the 21 studies. There was wide variation in the time points at which PROMs were recorded. Fourteen of 21 studies recorded PROMs before and after surgery, and 7 of 21 recorded PROMs only after surgery. Follow-up intervals ranged from 3 days to 2 years after surgery. Conclusions This study identified that while post-laparoscopic cholecystectomy PROMs are infrequently measured currently, tools are widely available to achieve this in clinical practice. PROMs may not capture all the outcomes but should be incorporated into future cholecystectomy outcome research. The EQ-5D™ (EuroQoL Group, Rotterdam, the Netherlands) provides a simple platform for the modern digital era.
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Affiliation(s)
| | - Gearoid McGeehan
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
- University of Limerick School of Medicine, University of Limerick, Limerick, Ireland
| | - Niall O’Connor
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - Alison Johnston
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - Gary Bass
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery Orebro University Hospital, & School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Claire Donohoe
- Department of Surgery, Trinity College Dublin, St James’ Hospital, Dublin, Ireland
| | - Magda Bucholc
- Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Magee Campus, Derry-Londonderry, UK
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
- EU INTERREG Centre for Personalized Medicine, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Magee Campus, Derry-Londonderry, UK
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24
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Edwards K, Johnson G, Bednarz J, Hardy K, McKay A, Vergis A. Long-Term Outcomes of Elderly Patients Managed Without Early Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography and Sphincterotomy for Choledocholithiasis. Cureus 2021; 13:e19074. [PMID: 34849308 PMCID: PMC8620330 DOI: 10.7759/cureus.19074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 12/16/2022] Open
Abstract
Background Prophylactic cholecystectomy following endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-S) remains the gold standard management of choledocholithiasis. Some clinicians propose ERCP-S alone as the definitive management in the elderly, given perioperative complication risks. This retrospective cohort study aimed to assess the long-term efficacy and safety of non-operative management of choledocholithiasis in adults aged ≥70. Methodology A total of 252 patients aged ≥70 underwent ERCP from 2004 to 2014 at a single institution. The rates of cholecystectomy, ERCP, complications, and mortality were gathered. Data were linked to a provincial health database to capture follow-up visits to alternate hospitals. Predictors of operation, recurrence, and mortality were analyzed using multivariable regression. Results Following ERCP, of the 252 patients, 33 (13.1%) underwent prophylactic cholecystectomy within three months, while 219 (86.9%) were initially managed conservatively. Of the 219 patients, 147 (67.1%) experienced no further choledocholithiasis after conservative management, while 23 (10.5%) patients underwent cholecystectomy. The mean follow-up was 2.9 years. Delayed operative patients were younger (mean age: 77.56 vs. 82.90; p < 0.001) and had lower Charlson Comorbidity Index (CCI) (1.04 vs. 1.84; p = 0.030). When adjusted for age, CCI score, and sex, cholecystectomy was associated with increased survival, with an odds ratio of 0.48 (95% confidence interval = 0.26-0.90; p = 0.021). Perioperative complications occurred in 7/56 (12.5%) patients. Conclusions Recurrent choledocholithiasis is common in elderly patients. Despite recurrent symptoms, these patients are unlikely to undergo cholecystectomy. Surgeons operate on patients with greater life expectancy and fewer comorbidities with high success despite advanced patient age. Future prospective studies should examine objective criteria for prophylactic cholecystectomy in this population, given purported safety and benefits.
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25
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Elective Laparoscopic Cholecystectomy Is Better than Conservative Treatment in Elderly Patients with Acute Cholecystitis After Percutaneous Transhepatic Gallbladder Drainage. J Gastrointest Surg 2021; 25:3170-3177. [PMID: 34173163 DOI: 10.1007/s11605-021-05067-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/07/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is unclear whether cholecystectomy is beneficial after percutaneous transhepatic gallbladder drainage (PTGBD) in elderly patients with acute cholecystitis (AC). METHODS This single-center, retrospective study included 202 patients aged >80 years with AC without common bile duct (CBD) stones who underwent PTGBD between January 2010 and December 2019. RESULTS One hundred and forty-two patients underwent elective laparoscopic cholecystectomy (ELC), and 60 underwent conservative treatment, specifically PTGBD removal (PTGBD-R) in 36 patients and PTGBD maintained (PTGBD-M) in 24 patients. The postoperative major complication (POMC) rate in the ELC group was 8.5%. The cumulative incidence for recurrence of biliary events (BE) in the PTGBD-R group was 22.2%. The cumulative incidence for PTGBD-related complication in the PTGBD-M group was 70.8%. Mortality after initial treatment was not significantly different between the three groups (2.8% vs. 2.8% vs. 8.3%, p=0.381). In multivariate analysis, a Charlson age comorbidity index ≥6 and body mass index ≤19 were significant risk factors for POMC after ELC, and a closed cystic duct was a significant risk factor for recurrent BE after PTGBD-R. CONCLUSION ELC is recommended in AC after PTGBD for selected patients aged >80 years without CBD stones due to the high recurrence rate of BE after PTGBD-R and the difficulty associated with PTGBD-M.
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26
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Lei C, Lu T, Yang W, Yang M, Tian H, Song S, Gong S, Yang J, Jiang W, Yang K, Guo T. Comparison of intraoperative endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration combined with laparoscopic cholecystectomy for treating gallstones and common bile duct stones: a systematic review and meta-analysis. Surg Endosc 2021; 35:5918-5935. [PMID: 34312727 DOI: 10.1007/s00464-021-08648-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 07/16/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND This study aimed to compare the efficacy and safety of laparoscopic cholecystectomy combined with intraoperative endoscopic retrograde cholangiopancreatography (LC-IntraERCP) and laparoscopic cholecystectomy combined with laparoscopic common bile duct exploration (LC-LCBDE) to determine which one-stage therapeutic strategy provides better outcomes for patients with gallstones and common bile duct stones. METHODS Cochrane Library, EMBASE, PubMed, and Web of Science databases were searched to identify eligible articles from the database inception to September 2020. The revised Cochrane risk of bias tools for randomized trials (RoB-2) and non-randomized interventions (ROBINS-I) was used to assess the quality of the included studies. The overall quality of evidence was assessed through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. The primary outcomes consisted of surgical success, retained stones, and overall postoperative complications, while secondary outcomes included postoperative bleeding, postoperative pancreatitis, postoperative bile leakage, conversion to laparotomy, and operative time. RESULTS Eight studies (four RCTs and four Non-RCTs with high quality) with 2948 patients were included. No significant difference was seen between the two groups regarding surgical success, overall postoperative complications, conversion to laparotomy, and operative time. The meta-analysis demonstrated that in the LC-IntraERCP group, the rate of retained stones (OR 0.51, 95% CI 0.28-0.91) and postoperative bile leakage were lower (OR 0.25, 95% CI 0.09-0.69), while in the LC-LCBDE group, postoperative bleeding (OR 5.24, 95% CI 1.65-16.65) and postoperative pancreatitis (OR 4.80, 95% CI 2.35-9.78) decreased. CONCLUSIONS LC-IntraERCP and LC-LCBDE exhibited similar efficacies when surgical success rate, overall postoperative complications, conversion to laparotomy, and operative time were compared. However, LC-IntraERCP is probably to be more effective in terms of lowering the rate of retained stones.
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Affiliation(s)
- Caining Lei
- The First Clinical Medicine College, Gansu University of Chinese Medicine, Lanzhou, 730000, China.,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, 730000, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Tingting Lu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China.,Institution of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Lanzhou, 730000, China
| | - Wenwen Yang
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, 730000, China.,The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Man Yang
- The Affiliated Cancer Hosptial School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610000, China
| | - Hongwei Tian
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, 730000, China.,Key Laboratory of Surgical Tumor Molecular Diagnosis and Precision Therapy in Gansu Province, Lanzhou, 730000, China
| | - Shaoming Song
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, 730000, China.,The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Shiyi Gong
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, 730000, China
| | - Jia Yang
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, 730000, China
| | - Wenjie Jiang
- Affiliated Hospital of Gansu University of Chinese Medicine, Lanzhou, 730000, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China. .,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China.
| | - Tiankang Guo
- The First Clinical Medicine College, Gansu University of Chinese Medicine, Lanzhou, 730000, China. .,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, 730000, China. .,Key Laboratory of Surgical Tumor Molecular Diagnosis and Precision Therapy in Gansu Province, Lanzhou, 730000, China.
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27
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Fransvea P, Covino M, Rosa F, Puccioni C, Quero G, Cozza V, La Greca A, Franceschi F, Alfieri S, Sganga G. Role of serum procalcitonin in predicting the surgical outcomes of acute calculous cholecystitis. Langenbecks Arch Surg 2021; 406:2375-2382. [PMID: 34213583 DOI: 10.1007/s00423-021-02252-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/16/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND Acute calculous cholecystitis (AC) is a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation. In the preoperative planning, the severity of AC should be considered as well as time of onset of symptoms and patient comorbidities. The aim of the present study was to investigate the role of an early PCT assessment in the emergency department in predicting the outcomes of laparoscopic surgery for AC. STUDY DESIGN Retrospective, mono-centric study conducted in a teaching urban hospital. We evaluated all patients admitted to our ED from January 1st, 2015, to December 31st, 2019, underwent laparoscopic cholecystectomy for AC having a preoperative PCT determination in ED. RESULTS A total of 2285 patients in our ED were admitted for AC. Among them 822 patients were treated surgically, 174 had a PCT determination in ED. Median age was 63 [50-74]. Overall, 33 patients (19.0%) had major complications (MC): 32 needed an open surgery conversion, and 3 among them deceased. Multivariate analysis demonstrated that PCT, WBC, BUN, and CCI were significantly associated to MC in our cohort. When we calculated the area under the ROC curve with regard to MC, a procalcitonin value > 0.09 at admission had sensitivity = 84.8% [68.1-94.9] and specificity = 51.8% [43.2-60.3] for the occurrence of MC. CONCLUSION Our results, suggest that a PCT > 0.09 ng/mL at ED admission, could be associated to a poor surgical outcome in patients treated by laparoscopic surgery for AC.
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Affiliation(s)
- Pietro Fransvea
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario "A. Gemelli", IRCCS, 00168, Rome, Italy.
| | - Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fausto Rosa
- Università Cattolica del Sacro Cuore, Rome, Italy.,Digestive Surgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Caterina Puccioni
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario "A. Gemelli", IRCCS, 00168, Rome, Italy
| | - Giuseppe Quero
- Digestive Surgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Valerio Cozza
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario "A. Gemelli", IRCCS, 00168, Rome, Italy
| | - Antonio La Greca
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario "A. Gemelli", IRCCS, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sergio Alfieri
- Università Cattolica del Sacro Cuore, Rome, Italy.,Digestive Surgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario "A. Gemelli", IRCCS, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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28
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Kamarajah SK, Gujjuri RR, Elhadi M, Umar H, Bundred JR, Subramanya MS, Evans RP, Powell SL, Griffiths EA. Elderly patients have increased perioperative morbidity and mortality from oesophagectomy for oesophageal cancer: A systematic review and meta-analysis. Eur J Surg Oncol 2021; 47:1828-1835. [PMID: 33814241 DOI: 10.1016/j.ejso.2021.02.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/06/2021] [Accepted: 02/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although oesophagectomy remains technically challenging and associated with high morbidity and mortality, it is now increasingly performed in an ever-ageing population with improvement in perioperative care. However, the risks in the elderly population are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of oesophagectomy for cancer in the elderly population compared to younger patients. METHOD A systematic literature search of PubMed, EMBASE and the Cochrane Library databases was conducted including studies reporting oesophagectomy for cancer in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were pulmonary and cardiac complications, anastomotic leaks, overall and disease-free survival. RESULTS This review identified 37 studies incorporating 30,836 patients. Increasing age was significantly associated with increased rates of overall complications (OR 1.67, CI95%: 1.42-1.96), pulmonary complications (OR 1.87, CI95%: 1.48-2.35), and cardiac complications (OR: 2.22, CI95%: 1.95-2.53). However, there was no increased risk of anastomotic leak (OR: 0.98, CI95%: 0.85-1.18). Elderly patients were significantly more likely to have lower rates of 5-year overall survival (OR: 1.36, CI95%: 1.11-1.66) and 5-year disease-free survival (OR: 1.72, CI95%: 1.51-1.96). CONCLUSION Elderly patients undergoing oesophagectomy for cancer are at increased risk of overall, pulmonary and cardiac complications, irrespective of age subgroups, albeit no difference in anastomotic leaks. Therefore, they represent high-risk patients warranting implementation of preoperative pathways such as prehabilitation to improve cardiopulmonary fitness prior to surgery, although benefit of prehabilitation is yet to be proven. This information will also aid future pre-operative counselling and informed consent.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, United Kingdom; Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Rohan R Gujjuri
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | | | - Hamza Umar
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - James R Bundred
- Leeds Teaching Hospitals National Health Service Trust, Beckett Street, Leeds, United Kingdom
| | - Manjunath S Subramanya
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, United Kingdom
| | - Richard Pt Evans
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, United Kingdom; Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Susan L Powell
- Department of Geriatric Medicine, Worcestershire Acute Hospitals NHS Foundation Trust, Worcestershire, United Kingdom
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, United Kingdom; Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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29
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Serban D, Socea B, Balasescu SA, Badiu CD, Tudor C, Dascalu AM, Vancea G, Spataru RI, Sabau AD, Sabau D, Tanasescu C. Safety of Laparoscopic Cholecystectomy for Acute Cholecystitis in the Elderly: A Multivariate Analysis of Risk Factors for Intra and Postoperative Complications. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:230. [PMID: 33801408 PMCID: PMC8002041 DOI: 10.3390/medicina57030230] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 12/13/2022]
Abstract
Background and Objectives: This study investigates the impact of age upon the safety and outcomes of laparoscopic cholecystectomy performed for acute cholecystitis, by a multivariate approach. Materials and Methods: A 2-year retrospective study was performed on 333 patients admitted for acute cholecystitis who underwent emergency cholecystectomy. The patients included in the study group were divided into four age subgroups: A ≤49 years; B: 50-64 years; C: 65-79 years; D ≥80 years. Results: Surgery after 72 h from onset (p = 0.007), severe forms, and higher American Society of Anesthesiologists Physical Status Classification and Charlson comorbidity index scores (p < 0.001) are well correlated with older age. Both cardiovascular and surgical related complications were significantly higher in patients over 50 years (p = 0.045), which also proved to be a turning point for increasing the rate of conversion and open surgery. However, the comparative incidence did not differ significantly between patients aged from 50-64 years, 65-79 years and over 80 years (6.03%, 9.09% and 5.8%, respectively). Laparoscopic cholecystectomy (LC) was the most frequently used surgical approach in the treatment of acute cholecystitis in all age groups, with better outcomes than open cholecystectomy in terms of decreased overall and postoperative hospital stay, reduced surgery related complications, and the incidence of acute cardiovascular events in the early postoperative period (p < 0.001). Conclusions: The degree of systemic inflammation was the main factor that influenced the adverse outcome of LC in the elderly. Among comorbidities, diabetes was associated with increased surgical and systemic postoperative morbidity, while stroke and chronic renal insufficiency were correlated with a high risk of cardiovascular complications. With adequate perioperative care, the elderly has much to gain from the benefits of a minimally invasive approach, which allows a decreased rate of postoperative complications and a reduced hospital stay.
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Affiliation(s)
- Dragos Serban
- 4th Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania;
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (B.S.); (C.D.B.); (A.M.D.); (G.V.); (R.I.S.)
| | - Bogdan Socea
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (B.S.); (C.D.B.); (A.M.D.); (G.V.); (R.I.S.)
- Department of Surgery, “Sf. Pantelimon” Emergency Hospital, 021659 Bucharest, Romania
| | | | - Cristinel Dumitru Badiu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (B.S.); (C.D.B.); (A.M.D.); (G.V.); (R.I.S.)
- Department of Surgery, “Bagdasar Arseni” Clinical Emergency Hospital, 041915 Bucharest, Romania
| | - Corneliu Tudor
- 4th Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania;
| | - Ana Maria Dascalu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (B.S.); (C.D.B.); (A.M.D.); (G.V.); (R.I.S.)
| | - Geta Vancea
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (B.S.); (C.D.B.); (A.M.D.); (G.V.); (R.I.S.)
| | - Radu Iulian Spataru
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (B.S.); (C.D.B.); (A.M.D.); (G.V.); (R.I.S.)
- Department of Pediatric Surgery, Emergency Clinic Hospital for Children “Maria S. Curie”, 41451 Bucharest, Romania
| | - Alexandru Dan Sabau
- 3rd Department Surgery, Faculty of Medicine, “Lucian Blaga” University Sibiu, 550169 Sibiu, Romania; (A.D.S.); (D.S.); (C.T.)
| | - Dan Sabau
- 3rd Department Surgery, Faculty of Medicine, “Lucian Blaga” University Sibiu, 550169 Sibiu, Romania; (A.D.S.); (D.S.); (C.T.)
| | - Ciprian Tanasescu
- 3rd Department Surgery, Faculty of Medicine, “Lucian Blaga” University Sibiu, 550169 Sibiu, Romania; (A.D.S.); (D.S.); (C.T.)
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30
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Zhao DQ, Qian GY, Jin J, Yao YP, Bian XM, Zhang WP. Acupuncture therapy strategy options in postoperative management after laparoscopic cholecystectomy: A protocol for systematic review and Bayesian meta-analysis. Medicine (Baltimore) 2021; 100:e24199. [PMID: 33429810 PMCID: PMC7793448 DOI: 10.1097/md.0000000000024199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is a common surgery accompanied by some unpleasant adverse effects. Clinical trials indicated that acupuncture therapy may help reduce complications in LC. However, no systematic reviews have been conducted on the topic. Therefore, we will evaluate the current evidence and provide a rank for the efficacy of acupuncture therapy in LC by performing Bayesian network meta-analysis. METHODS A total of 9 databases will be searched from inception to 10 December 2020. Randomized control trails met the criterion will be included. Quality evaluation of included studies will be performed using Cochrane risk-of-bias tool. STATA 14.0, Addis 1.16.8, R 3.6.3, and OpenBUGS 3.2.3 will be used to conduct pairwise meta-analysis and network meta-analysis. The evidence will be assessed by the Grades of Recommendations Assessment Development and Evaluation. RESULTS This review will be based on clinical evidence to choose the best choice of acupuncture treatment for LC. And the results will be submitted to a peer-reviewed journal for publication. CONCLUSION Through this systematic review, we will summarize the best available evidence of acupuncture therapy in LC and help to improve the clinical decision-making ability in LC domain. SYSTEMATIC REVIEW REGISTRATION The protocol has been registered on INPLASY2020120056.
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Affiliation(s)
- Dong-qin Zhao
- Zhuji People's Hospital of Zhejiang Province
- Zhuji Affiliated Hospital of Shaoxing University, Zhuji, 311800, China
| | - Guang-yu Qian
- Zhuji People's Hospital of Zhejiang Province
- Zhuji Affiliated Hospital of Shaoxing University, Zhuji, 311800, China
| | - Jing Jin
- Zhuji People's Hospital of Zhejiang Province
- Zhuji Affiliated Hospital of Shaoxing University, Zhuji, 311800, China
| | - Yin-ping Yao
- Zhuji People's Hospital of Zhejiang Province
- Zhuji Affiliated Hospital of Shaoxing University, Zhuji, 311800, China
| | - Xing-mao Bian
- Zhuji People's Hospital of Zhejiang Province
- Zhuji Affiliated Hospital of Shaoxing University, Zhuji, 311800, China
| | - Wei-ping Zhang
- Zhuji People's Hospital of Zhejiang Province
- Zhuji Affiliated Hospital of Shaoxing University, Zhuji, 311800, China
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Marziali I, Cicconi S, Marilungo F, Benedetti M, Ciano P, Pagano P, D'Emidio F, Guercioni G, Catarci M. Role of percutaneous cholecystostomy in all-comers with acute cholecystitis according to current guidelines in a general surgical unit. Updates Surg 2020; 73:473-480. [PMID: 33058055 DOI: 10.1007/s13304-020-00897-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/07/2020] [Indexed: 12/19/2022]
Abstract
Acute calculous cholecystitis (ACC) is a very common complication of gallstone-related disease. Its currently recommended management changes according to severity of disease and fitness for surgery. The aim of this observational study is to assess the short- and long-term outcomes in all-comers admitted with diagnosis of ACC, treated according to 2013 Tokyo Guidelines (TG13). A retrospective analysis was conducted on a prospectively maintained database of 125 patients with diagnosis of ACC consecutively admitted between January 2017 and September 2019, subdivided in three groups according to TG13: percutaneous cholecystostomy (PC group), cholecystectomy (CH group), and conservative medical treatment (MT group). The primary end point was a composite of morbidity and/or mortality rates; the secondary end points were ACC recurrence, readmission, need for cholecystectomy rates and overall length of hospital stay (LOS). After a median follow-up of 639 days, overall morbidity rate was 20.8% and mortality rate was 6.4%. Death was directly related to AC during the index admission in two out of eight cases. There were no significant differences in primary end point according to the treatment group. Concerning secondary end points, ACC recurrence rate was not significantly different after PC (10.0%) or MT (9.1%); the readmission rates were significantly higher (p < 0.0001) in the MT group (48.5%) and in the PC group (25.0%) than in the CH group (5.8%); need for cholecystectomy rates was significantly higher (p < 0.0001) in the MT group (42.4%) than in the PC group (20.0%); median overall LOS was significantly higher in the PC (16 days) than in the MT (9 days) and than in the CH group (5 days). PC is an effective and safe rescue procedure in high-risk patients with ACC, representing a definitive treatment in 80% of cases of this specific subgroup.
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Affiliation(s)
- Irene Marziali
- General Surgery, "C. e G. Mazzoni" Hospital, ASUR Marche AV5, Via degli Iris snc, 63100, Ascoli Piceno, Italy
| | - Simone Cicconi
- General Surgery, "C. e G. Mazzoni" Hospital, ASUR Marche AV5, Via degli Iris snc, 63100, Ascoli Piceno, Italy
| | - Fabio Marilungo
- General Surgery, "C. e G. Mazzoni" Hospital, ASUR Marche AV5, Via degli Iris snc, 63100, Ascoli Piceno, Italy
| | - Michele Benedetti
- General Surgery, "C. e G. Mazzoni" Hospital, ASUR Marche AV5, Via degli Iris snc, 63100, Ascoli Piceno, Italy
| | - Paolo Ciano
- General Surgery, "C. e G. Mazzoni" Hospital, ASUR Marche AV5, Via degli Iris snc, 63100, Ascoli Piceno, Italy
| | - Paolo Pagano
- Interventional Radiology Units, "C. e G. Mazzoni" Hospital, ASUR Marche AV5, Via degli Iris snc, 63100, Ascoli Piceno, Italy
| | - Fabio D'Emidio
- Interventional Radiology Units, "C. e G. Mazzoni" Hospital, ASUR Marche AV5, Via degli Iris snc, 63100, Ascoli Piceno, Italy
| | - Gianluca Guercioni
- General Surgery, "C. e G. Mazzoni" Hospital, ASUR Marche AV5, Via degli Iris snc, 63100, Ascoli Piceno, Italy
| | - Marco Catarci
- General Surgery, "C. e G. Mazzoni" Hospital, ASUR Marche AV5, Via degli Iris snc, 63100, Ascoli Piceno, Italy.
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