Laparoscopic cholecystectomy in adults with sickle cell disease

NMR spectroscopy-based analysis of gallstones of cancerous and benign gallbladders from different geographical regions of the Indian subcontinent

Analysis of the chemical composition of gallstones is vital for the etiopathogenesis of gallstone diseases that can ultimately help in the prevention of its formation. In the present study, gallstones from seven different regions of India were analyzed to highlight the major difference in their composition. Also, gallstones of different pathological conditions i.e., benign (chronic cholecystitis, CC) and malignant gallbladder disease (gallbladder cancer GBC) were characterized. The type of polymorphs of cholesterol molecules was also studied to provide insight into the structure of gallstones. 1H solution state NMR spectroscopy 1D experiments were performed on a total of 94 gallstone (GS) samples collected from seven different geographical regions of India. Solid-State NMR spectroscopy 13C cross-polarization magic angle spinning (CPMAS) experiments were done on the 20 CC GS samples and 20 GBC GS samples of two regions. 1H NMR spectra from the solution state NMR of all the stones reveal that cholesterol was a major component of the maximum stones of the north India region while in south Indian regions, GS had very less cholesterol. 13C CPMAS experiments reveal that the quantity of cholesterol was significantly more in the GS of CC in the Lucknow region compared with GBC stones of Lucknow and Chandigarh. Our study also revealed that GS of the Lucknow region of both malignant and benign gallbladder diseases belong to the monohydrate crystalline form of cholesterol while GS of Chandigarh region of both malignant and benign gallbladder diseases exists in both monohydrate crystalline form with the amorphous type and anhydrous form. Gallstones have a complicated and poorly understood etiology. Therefore, it is important to understand the composition of gallstones, which can be found in various forms and clinical conditions. Variations in dietary practices, environmental conditions, and genetic factors may influence and contribute to the formation of GS. Prevention of gallstone formation may help in decreasing the cases of gallbladder cancer.

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

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

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

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

[Management of Gallstone]

Gallstones are one of the most common diseases worldwide. Recently, the incidence of gallstones has increased and the pattern of gallstones has changed in Korea. Laparoscopic cholecystectomy is the standard treatment for symptomatic gallstones. Expectant management is considered the most appropriate choice in patients with asymptomatic gallstones. The dissolution of cholesterol gallstones by oral bile acid, such as ursodeoxycholic acid, can be considered in selected patients with gallstones. Although the advent of laparoscopic cholecystectomy has moved interest away from the pharmacologic treatment of gallstones, several promising agents related to various mechanisms are under investigation.

Laparoscopic cholecystectomy for cholelithiasis in children with sickle cell disease

Patients with sickle cell disease (SCD) suffer from an increased incidence of gallstone formation due to hemolysis of sickled red blood cells; this leads to an increased level of bilirubin in secreted bile that becomes a nidus for pigment stone formation. Laparoscopic cholecystectomy (LC) is considered a standard operative procedure for gallstone disease mainly due to lower postoperative wound complaints, faster recovery, better postoperative cosmetic results, shorter hospital stay, and earlier return to work. Although numerous studies have been published addressing both the advantages and complications of LC in acute calcular cholecystitis, there is still limited evidence concerning the safety and efficacy of LC for the management of cholelithiasis in pediatric patients with SCD, and controversies remain unresolved. In this review, we aim to comprehensively study the available literature and propose evidence-based practice recommendations for the optimal management of gallstones in pediatric SCD patients. The current practice differs greatly depending on the prevalence of SCD in a particular geographic area. We acknowledge the limited number of patients reported, the lack of randomized control trials addressing the practice of specific recommendations, and the need for further evidence-based studies.

Management of gallstones and its related complications

The majority of gallstone patients remain asymptomatic; however, interest toward the gallstone disease is continuing because of the high worldwide prevalence and management costs and the development of gallstone symptoms and complications. For cholesterol gallstone disease, moreover, a strong link exists between this disease and highly prevalent metabolic disorders such as obesity, dyslipidemia, type 2 diabetes, hyperinsulinemia, hypertriglyceridemia and the metabolic syndrome. Information on the natural history as well as the diagnostic, surgical (mainly laparoscopic cholecystectomy) and medical tools available to facilitate adequate management of cholelithiasis and its complications are, therefore, crucial to prevent the negative outcomes of gallstone disease. Moreover, some risk factors for gallstone disease are modifiable and some preventive strategies have become necessary to reduce the onset and the severity of complications.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

Laparoscopic cholecystectomy in adult patients with sickle cell disease

SUMMARY BACKGROUND DATA

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Epidemiology of gallbladder disease: cholelithiasis and cancer

Diseases of the gallbladder are common and costly. The best epidemiological screening method to accurately determine point prevalence of gallstone disease is ultrasonography. Many risk factors for cholesterol gallstone formation are not modifiable such as ethnic background, increasing age, female gender and family history or genetics. Conversely, the modifiable risks for cholesterol gallstones are obesity, rapid weight loss and a sedentary lifestyle. The rising epidemic of obesity and the metabolic syndrome predicts an escalation of cholesterol gallstone frequency. Risk factors for biliary sludge include pregnancy, drugs like ceftiaxone, octreotide and thiazide diuretics, and total parenteral nutrition or fasting. Diseases like cirrhosis, chronic hemolysis and ileal Crohn's disease are risk factors for black pigment stones. Gallstone disease in childhood, once considered rare, has become increasingly recognized with similar risk factors as those in adults, particularly obesity. Gallbladder cancer is uncommon in developed countries. In the U.S., it accounts for only ~ 5,000 cases per year. Elsewhere, high incidence rates occur in North and South American Indians. Other than ethnicity and female gender, additional risk factors for gallbladder cancer include cholelithiasis, advancing age, chronic inflammatory conditions affecting the gallbladder, congenital biliary abnormalities, and diagnostic confusion over gallbladder polyps.

Therapy of gallstone disease: What it was, what it is, what it will be

Cholesterol gallstone disease is a common clinical condition influenced by genetic factors, increasing age, female gender, and metabolic factors. Although laparoscopic cholecystectomy is currently considered the gold standard in treating patients with symptomatic gallstones, new perspectives regarding medical therapy of cholelithiasis are currently under discussion, also taking into account the pathogenesis of gallstones, the natural history of the disease and the analysis of the overall costs of therapy. A careful selection of patients may lead to successful non-surgical therapy in symptomatic subjects with a functioning gallbladder harboring small radiolucent stones. The classical oral litholysis by ursodeoxycholic acid has been recently paralleled by new experimental observations, suggesting that cholesterol-lowering agents which inhibit cholesterol synthesis (statins) or intestinal cholesterol absorption (ezetimibe), or drugs acting on specific nuclear receptors involved in cholesterol and bile acid homeostasis, might be proposed as additional approaches for treating cholesterol gallstones. In this review we discuss old, recent and future perspectives on medical treatment of cholesterol cholelithiasis.

Targets for current pharmacologic therapy in cholesterol gallstone disease

Gallstone disease is a frequent condition throughout the world and, cholesterol stones are the most frequent form in Western countries. The standard treatment of symptomatic gallstone subjects is laparoscopic cholecystectomy. The selection of patients amenable for nonsurgical, medical therapy is of key importance; a careful analysis should consider the natural history of the disease and the overall costs of therapy. Only patients with mild symptoms and small, uncalcified cholesterol gallstones in a functioning gallbladder with a patent cystic duct are considered for oral litholysis by hydrophilic ursodeoxycholic acid, in the hope of achieving cholesterol desaturation of bile and progressive stone dissolution. Recent studies have raised the possibility that cholesterol-lowering agents that inhibit hepatic cholesterol synthesis (statins) or intestinal cholesterol absorption (ezetimibe), or drugs acting on specific nuclear receptors involved in cholesterol and bile acid homeostasis, may offer, alone or in combination, additional medical therapeutic tools for treating cholesterol gallstones. Recent perspectives on medical treatment of cholesterol gallstone disease are discussed in this article.

Cholecystectomy in sickle cell disease patients: is there more acute chest syndrome after laparoscopy? A case controlled study

Laparoscopy is increasingly being recommended in order to reduce postoperative complications among sickle cell disease patients undergoing cholecystectomy. Acute chest syndrome is the most deadly of these complications. The purpose of this study was to assess if laparoscopic approach reduces postoperative complications related to sickle cell disease after cholecystectomy. A retrospective study of records of sickle cell patients who underwent cholecystectomy for cholelithiasis, from January 1990 to December 2005 was conducted. 136 sickle cell patients underwent surgery: 47 (34.5%) by laparoscopy and 89 (63.5%) by laparotomy. The mean operative time was 71.4+/-18.9 min in the laparoscopy group and 61.2+/-15.3 min in the laparotomy group (non-significant difference). The mortality was not significantly different between the two groups: one patient died in the open cholecystectomy group but no death occurred in the laparoscopic one. The morbidity related to the sickle cell disease was significantly higher in the laparoscopy group [n=5 (10.5%)] than in the laparotomy group [n=4 (4.5%)] (p=0.04). This difference was associated with a higher rate of acute chest syndrome in the laparoscopy group [n=4 (8, 5%)] compared to that in the laparotomy group [n=1 (1.1%)] (p=0.01). There were more complications related to sickle cell disease in the laparoscopy group due to acute chest syndrome. Thus, these data should be confirmed in further randomized studies which must be undertaken.

Hazard classification of chemicals inducing haemolytic anaemia: An EU regulatory perspective

Haemolytic anaemia is often induced following prolonged exposure to chemical substances. Currently, under EU Council Directive 67/548/EEC, substances which induce such effects are classified as dangerous and assigned the risk phrase R48 'Danger of serious damage to health by prolonged exposure.' Whilst the general classification criteria for this endpoint are outlined in Annex VI of this Directive, they do not provide specific information to assess haemolytic anaemia. This review produced by the EU Working Group on Haemolytic Anaemia provides a toxicological assessment of haemolytic anaemia and proposes criteria that can be used in the assessment for classification of substances which induce such effects. An overview of the primary and secondary effects of haemolytic anaemia which can occur in rodent repeated dose toxicity studies is given. A detailed analysis of the toxicological significance of such effects is then performed and correlated with the general classification criteria used for this endpoint. This review intends to give guidance when carrying out an assessment for classification for this endpoint and to allow for better transparency in the decision-making process on when to classify based on the presence of haemolytic anaemia in repeated dose toxicity studies. The extended classification criteria for haemolytic anaemia outlined in this review were accepted by the EU Commission Working Group on the Classification and Labelling of Dangerous Substances in September 2004.

Gallstone disease: Symptoms and diagnosis of gallbladder stones

The clinical aspects and the diagnostic features of gallstone disease are described. The natural history of silent gallstones is overviewed, and the risk of developing symptoms and complications is also discussed. The importance of colicky pain as a specific gallstone symptom is highlighted, and the role of both laboratory tests and diagnostic investigations for differential diagnosis is discussed. Finally, we describe the diagnostic features of gallbladder stone disease, including indications, sensitivity, specificity, and limitations of different test investigations under special circumstances.

Outcomes for children with gallbladder abnormalities and sickle cell disease

OBJECTIVE

To determine whether elective cholecystectomy is justifiable in children with sickle cell disease (SCD), gallbladder abnormalities, and minimal clinical symptoms.

STUDY DESIGN

A retrospective review comparing clinical presentations and abdominal ultrasound results with outcomes in 146 children with SCD.

RESULTS

Ultrasound examination showed sludge or stones in 83 of 146 children (57%). This was found during a diagnostic ultrasound in 59 patients (71%) and during a screening ultrasound in 24 asymptomatic patients (29%). Fifty-four (65%) children with a positive ultrasound underwent cholecystectomy; 13 of these were initially asymptomatic patients who had subsequent development of clinical symptoms. Of the patients with cholecystectomy, 93% had histopathologic evidence of cholecystitis. Perioperative complications were rare, and there were no episodes of postoperative acute chest syndrome. Children who underwent elective surgery had an average 12-days-shorter overall hospital stay than those who underwent emergent surgery (4 vs 16 days, P <.001).

CONCLUSIONS

Elective laparoscopic cholecystectomy may be safely performed in children with SCD. Surgery should be strongly considered at the time of gallstone diagnosis before symptoms or complications develop. Histopathologic chronic cholecystitis does not correlate with clinical symptoms.

[Laparoscopic cholecystectomy in sickle cell disease]

STUDY AIM

Sickle cell affection is a public health problem in Africa. The aims of this prospective study were to evaluate the early results of laparoscopic cholecystectomy in sickle cell patients in Senegal.

METHOD

From January 1998 to June 2002 all the sickle cell patients undergoing a laparoscopic cholecystectomy were included. Intra- and post-operative protocol (blood transfusion if Hb < 9 g/dl, rehydration, oxygenotherapy) was standardized.

RESULTS

Forty-two patients with sickle cell of types SS-33 and AS9 were operated upon by same surgeon. One case of conversion due to an effraction of biliary junction was reported. One homozygote patient died post-operatively because of peritonitis. Two acute thoracic syndromes, three vaso-occlusive crisis, and two cases of wound infection constituted the post-operative morbidity. No case of complication was noted in those who underwent pre-operative transfusion.

CONCLUSION

Laparoscopic cholecystectomy can be carried out in sickle cell patients with biliary lithiasis provided that general anaesthetic rules are respected.

The role of laparoscopic cholecystectomy in the management of acute cholecystitis in patients with sickle cell disease

BACKGROUND

As emergency surgery in sickle cell disease patients is associated with high morbidity, the aim of the study was to assess the safety of laparoscopic cholecystectomy in the acute state for these patients.

METHODS

Over a 5-year period, April 1994 till December 1998, 35 sickle cell patients with acute cholecystitis had laparoscopic cholecystectomy within the first 5 days of presentation. A retrospective study of these was undertaken.

RESULTS

Thirty-five patients were diagnosed as having acute cholecystitis with sickle cell disease. There were 26 female and 9 male patients; 5 patients needed preoperative and 1 patient needed postoperative endoscopic retrograde cholangiopancreatography. Twenty-seven patients needed simple transfusion and 8 needed partial exchange; conversion was necessary in two cases (5.7%). The mean hospital stay was 5.3 days and the complication rate was 17.5%.

CONCLUSIONS

Because of the lack of significant complications, we believe that laparoscopic cholecystectomy for acute cholecystitis is safe and recommended in experienced hands with adequate preoperative preparation for patients with sickle cell disease.