Surgical outcomes of laparoscopic cholecystectomy for severe acute cholecystitis

Does Operative Time Affect Complication Rate in Laparoscopic Cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is the most common laparoscopic procedure performed in the United States. Our aim was to determine if increased operative time (OT) is associated with increased morbidity following laparoscopic cholecystectomy.

METHODS

Using ACS NSQIP from 2006 to 2015, we identified all adult (≥18 years) patients that underwent laparoscopic cholecystectomy for cholecystitis performed within 3 days of admission. Our analysis was limited to cases with OT ≥15 minutes and ≤360 minutes. Outcome variables included postoperative surgical site infections (SSI), dehiscence, pneumonia, reintubation, failure to wean from ventilator, pulmonary embolism, renal failure, urinary tract infection, cardiac arrest, myocardial infarct, bleeding, deep vein thrombosis, sepsis, septic shock, return to the operating room, and death.

RESULTS

7,031 cases met inclusion criteria. Median OT was 63 minutes, first quartile was 46 minutes and third quartile was 87 minutes. Logistic regression analysis showed that increased OT (third vs first quartile) was an independent risk factor for superficial SSI (OR 1.75, 95% CI 1.36-2.25, P < .0001), organ-space SSI (OR 1.77, 95% CI 1.33-2.35, P < .0001), dehiscence (OR 2.03, 95% CI 1.01-4.07, P = 0.0470), and septic shock (OR 1.81, 95% CI 1.06-3.09, P = 0.0286). Increased OT was independently associated with increased LOS (fourth vs 1st quartile: IRR 1.53, P < 0.0001; third vs 1st quartile: IRR 1.29, P < .0001; 2nd vs 1st quartile: IRR 1.16, P < 0.0001).

CONCLUSION

Increased OT is independently associated with morbidity and increased LOS following laparoscopic cholecystectomy for cholecystitis. Prospective studies are warranted to determine which factors contribute to increased OT and why.

Percutaneous cholecystostomy as bridge to surgery vs surgery in unfit patients with acute calculous cholecystitis: A systematic review and meta-analysis

BACKGROUND

Acute cholecystitis is one of the most common causes of acute abdomen. Early laparoscopic cholecystectomy is the gold standard treatment, still burdened by a risk of intraoperative biliary duct injury. An alternative strategy to manage patients with severe acute cholecystitis is the percutaneous gallbladder drainage (PGBD).

METHODS

The Italian Society of Emergency Surgery and Trauma performed a systematic review and meta-analysis with the aim to clarify controversies about the preoperative use of PGBD. We extracted 32 studies: 9 Randomized Control Trial Studies (RCTs) and 23 no RCTs.

RESULTS OF CRITICAL OUTCOMES

The incidence of post-operative complications was lower in the PGBD associated at LC than in the LC alone (RCTs: RR 0.28, 95% CI 0.14 to 0.56, I2 = 63%). The incidence of the post-operative biliary leakage was higher in late PGBD' group (RCTs: RR 0.18, 95% CI 0.04 to 0.80).

RESULTS OF OTHER OUTCOMES

The incidence of intraabdominal abscess, blood loss, conversion to open, subtotal cholecystectomy, operative time and wound infection was lower in PGBD' group. The total hospital stay was the same.

CONCLUSION

A strong recommendation is performed to the use of the PGBD + LC than upfront LC to reduce biliary leakage (recommendation "strong positive") in high risk acute cholecystitis especially in patients with higher perioperative risks or longstanding acute cholecystitis. For post-operative complications a recommendation "positive weak" suggests that PGBD + LC could be used than upfront LC to reduce the rate of post-operative complications.

Systematic review and meta-analysis of early vs late interval laparoscopic cholecystectomy following percutaneous cholecystostomy

BACKGROUND

High risk surgical patients with acute cholecystitis are commonly treated with percutaneous cholecystostomy (PTC) drainage. The optimal timing of subsequent interval laparoscopic cholecystectomy (LC) remains unclear.

METHODS

Medline, EMBASE, and Scopus were searched to identify studies published between 01/01/2000 and 31/12/2020, reporting on interval LC outcomes in patients initially treated by PTC. Early and late interval LC were defined as <30 and ≥ 30 days respectively. The Methodological Index for Nonrandomized Studies was used for quality assessment. Meta-analysis of proportions was conducted using a random-effects model.

RESULTS

A total of 512 studies were screened, 41 met the inclusion criteria. There were 22 studies in both early and late interval LC groups, with 3 included studies reporting both early and late groups. Following quality assessment, 29 studies were included in the meta-analysis. There were no significant differences between early and late interval LC in terms of conversion rates (7.2% vs 8.3%, p = 0.854), 90-day morbidity (12.8% vs 15.9%, p = 0.496), and 90-day mortality (0.25% vs 0.32%, p = 0.704). Heterogeneity was significant (I²>50%) in all groups.

CONCLUSION

Current evidence of interval LC within or beyond 30 days demonstrates no significant impact on outcomes. Patient factors, clinical experience, and hospital facilities may prove more important predictors.

Comparison of emergency cholecystectomy and delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in patients with acute cholecystitis: a systematic review and meta-analysis

Laparoscopic cholecystectomy and percutaneous transhepatic gallbladder drainage (PTGBD) are common treatments for patients with acute cholecystitis. However, the safety and efficacy of emergency laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC) after PTGBD in patients with acute cholecystitis remain unclear. The PubMed, EMBASE, and Cochrane Library databases were searched through October 2019. The quality of the included nonrandomized studies was assessed using the Methodological Index for Nonrandomized Studies (MINORS). The meta-analysis was performed using STATA version 14.2. A random-effects model was used to calculate the outcomes. A total of fifteen studies involving 1780 patients with acute cholecystitis were included in the meta-analysis. DLC after PTGBD was associated with a shorter operative time (SMD − 0.51; 95% CI − 0.89 to − 0.13; P = 0.008), a lower conversion rate (RR 0.43; 95% CI 0.26 to 0.69; P = 0.001), less intraoperative blood loss (SMD − 0.59; 95% CI − 0.96 to − 0.22; P = 0.002) and longer time of total hospital stay compared to ELC (SMD 0.91; 95% CI 0.57–1.24; P < 0.001). There was no difference in the postoperative complications (RR 0.68; 95% CI 0.48–0.97; P = 0.035), biliary leakage (RR 0.65; 95% CI 0.34–1.22; P = 0.175) or mortality (RR 1.04; 95% CI 0.39–2.80; P = 0.933). Compared to ELC, DLC after PTGBD had the advantages of a shorter operative time, a lower conversion rate and less intraoperative blood loss.

Surgical outcomes of percutaneous transhepatic gallbladder drainage in acute cholecystitis grade II patients according to time of surgery

BACKGROUND

The objective of this study was to determine the appropriate timing for surgical intervention for Grade II acute cholecystitis patients. The study compares the clinical outcomes of patients in Group A, who were treated with early laparoscopic cholecystectomy (ELC) within the first two weeks of hospitalization, and Group B, treated with delayed laparoscopic cholecystectomy (DLC) after recovering from symptoms and that received conservative treatment and were discharged for more than two weeks.

METHODS

From November 2011 to June 2019, from a total of 196 acute cholecystitis patients that received percutaneous transhepatic gallbladder drainage (PTGBD) insertion, we conducted a retrospective review of the group that received early laparoscopic cholecystectomy within 2 weeks and the group that received delayed laparoscopic cholecystectomy. The clinical characteristics and post-treatment outcomes were evaluated.

RESULTS

In all patients treated with PTGBD insertion, Group A, the patients who were treated with ELC, showed a significantly longer mean operative time than Group B, the patients who were treated with DLC (72.46 ± 46.396 vs. 54.08 ± 27.12, P = 0.001). Similarly, Group A showed a significantly longer postoperative hospital stay compared to Group B (5.71 ± 5.062 vs. 4.27 ± 2.931, P = 0.014).

CONCLUSION

In patients with Grade II acute cholecystitis with PTGBD insertion, DLC produces better outcomes with shorter hospital stay and operative time than ELC. These results suggest that DLC may lead to a better outcome than ELC, specifically when deciding the timing for laparoscopic cholecystectomy in patients diagnosed with acute Grade II cholecystitis.

Efficacy of preoperative percutaneous cholecystostomy in the management of acute cholecystitis according to severity grades

BACKGROUND/AIMS

The aim of this retrospective study was to assess the efficacy of percutaneous cholecystostomy (PC) for patients with acute cholecystitis (AC) according to severity.

METHODS

A total of 325 patients who underwent cholecystectomy between January 2008 and October 2010 were enrolled. Patients were classified into three groups based on severity grade according to the Tokyo guidelines for AC: grade I (mild), grade II (moderate), and grade III (severe). These groups were further classified into two subgroups based on whether or not they underwent preoperative PC.

RESULTS

A total of 184 patients were classified into the grade I group (57%), 135 patients were classified into the grade II group (42%), and five patients were classified into the grade III group (1%). In the grade I and II groups, the mean length of hospital stay was significantly shorter in the patients who did not undergo PC than in those who received PC (10.7 ± 4.4 vs. 13.7 ± 5.8, p < 0.001; 11.8 ± 6.5 vs. 16.9 ± 12.5, p = 0.003, respectively). The mean length of preoperative hospital stay was significantly shorter in the patients without PC than in those with PC in the grade I and II groups (5.8 ± 3.3 vs. 8.2 ± 4.6, p = 0.001; 6.0 ± 4.4 vs. 8.8 ± 5.2, p = 0.002). In addition, the operative time was shorter in patients without PC, especially in the grade I group (94.6 ± 36.4 vs. 107.3 ± 33.5, p = 0.034).

CONCLUSIONS

Preoperative PC should be reserved for only selected patients with mild or moderate AC. No significant benefit of preoperative PC was identified with respect to clinical outcome or complications.

Impact of scheduled laparoscopic cholecystectomy in patients with acute cholecystitis, following percutaneous transhepatic gallbladder drainage

Backgrounds/Aims

Frequently encountered in practice, the first-line treatment for acute cholecystitis is early or urgent cholecystectomy, with laparoscopic cholecystectomy (LC) being the preferred method. Percutaneous transhepatic gallbladder drainage (PTGBD) is considered as a safe alternative therapeutic option for resolving acute cholecystitis in surgically high-risk patients. We evaluated the surgical outcomes of acute cholecystitis, focusing on the differences between emergent LC without PTGBD, and scheduled LC following PTGBD.

Methods

Between March 2010 and December 2014, 294 patients with acute cholecystitis who had undergone LC, were retrospectively studied. Group I included 166 patients who underwent emergency LC without PTGBD. Group II included 128 patients who underwent scheduled LC after PTGBD. Clinical outcomes were analyzed according to each group.

Results

On admission, Group II had a higher mean level of c-reactive protein than Group I. According to the classification of the American Society of Anesthesiologists (ASA), group II had a greater number of high-risk patients than group I. There was no significant difference on perioperative outcomes between the two groups, including open conversion rate and complications. Analysis as per the ASA classes revealed no statistically remarkable finding between the groups.

Conclusions

There are no significant differences in the surgical outcomes of emergency LC group without PTGBD, and scheduled LC group following PTGBD. Comparison between two groups according to ASA classification reflecting the comorbidity and severity of condition of the patients also revealed no significant differences. However, scheduled LC following PTGBD is important for patients having acute cholecystitis with concurrent comorbidity.

Emergency Versus Delayed Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage in Grade II Acute Cholecystitis Patients

INTRODUCTION

In grade II acute cholecystitis patients presenting more than 72 h after onset of symptoms, we prospectively compared treatment with emergency (ELC) to delayed laparoscopic cholecystectomy performed 6 weeks after percutaneous transhepatic gallbladder drainage (PTGBD).

METHODS

Four hundred ninety-five patients with acute cholecystitis were assessed for eligibility; 345 were excluded or declined to participate. One hundred fifty patients were treated after consent with either ELC or PTGBD.

RESULTS

Both PTGBD and ELC were able to resolve quickly cholecystitis sepsis. ELC patients had a significantly higher conversion rate (24 vs. 2.7 %, P < 0.001), longer mean operative time (87.8 ± 33.06 vs. 38.09 ± 8.23 min, P < 0.001), higher intraoperative blood loss (41.73 ± 51.09 vs. 26.33 ± 23.86, P = 0.008), and longer duration of postoperative hospital stay (51.71 ± 49.39 vs. 10.76 ± 5.75 h, P < 0.001) than those in the PTGBD group. Postoperative complications were significantly more frequent in the ELC group (26.7 vs. 2.7 %, P < 0.001) with a significant increase in incidence (10.7 %) of bile leak (P = 0.006) compared to those in the PTGBD group.

CONCLUSION(S)

PTGBD and ELC are highly efficient in resolving cholecystitis sepsis. Delayed cholecystectomy after PTGBD produces better outcomes with a lower conversion rate, fewer procedure-related complications, and a shorter hospital stay than emergency cholecystectomy.

The Efficacy of Percutaneous Transhepatic Gallbladder Drainage on Acute Cholecystitis in High-Risk Elderly Patients Based on the Tokyo Guidelines: A Retrospective Case-Control Study

To evaluate the efficacy of percutaneous transhepatic gallbladder drainage (PTGD) for high-risk elderly patients with acute cholecystitis.Retrospective analysis of 159 acute cholecystitis patients who were admitted to General Surgery Division III of the First Affiliated Hospital of Dalian Medical University between January 2005 and November 2012. A total of 123 patients underwent laparoscopic cholecystectomy (LC), and 36 received only PTGD treatment. The LC patients were divided into 3 groups based on their preoperative treatment: group A, emergency patients (33 patients); group B (26 patients), patients who were treated with PTGD prior to LC; and group C (64 patients), patients who received nonsurgical treatment prior to LC. General conditions, LC surgery duration, intraoperative blood loss, rate of conversion to open surgery, incidence of postoperative complications, total fasting time, and total hospitalization time were analyzed and compared among the 3 groups.The remission rates of patients in the PTGD treatment groups (including group B and PTGD treatment only group) were significantly higher within 24 and 48 hours than those of patients who received nonsurgical treatment prior to LC (P < 0.05). Among the patients in the 3 surgery groups, the operation conversion rate (19.2%) of group B was significantly higher than that of group A (3.0%) and group C (1.6%) (P < 0.05). The total hospitalization time of the patients in group B (18.5 ± 4.5 days) was longer than that of the patients in group A (8.2 ± 3.9 days) and group C (10.5 ± 6.4 days). The total fasting time of the patients in group A (2.4 ± 1.2 days) was significantly shorter than that of those in group B (4.1 ± 1.7 days) and group C (3.4 ± 2.7 days) (P < 0.05).For high-risk elderly patients, if there is any emergency surgery contraindication, PTGD therapy may be safe and effective and can relieve the symptoms within a short time. For acute cholecystitis patients without surgery contraindications, emergency surgery should be performed as soon as possible after diagnosis.

Efficacy and safety of B-mode ultrasound-guided percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy for acute cholecystitis in elderly and high-risk patients

Background

Standards in treatment of acute cholecystitis (AC) in the elderly and high-risk patients has not been established. Our study evaluated the efficacy and safety of B-mode ultrasound-guided percutaneous transhepatic gallbladder drainage (PTGD) in combination with laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) in elderly and high-risk patients.

Methods

Our study enrolled 35 elderly and high-risk AC patients, hospitalized between January 2010 and April 2014 at the Wenzhou People's Hospital. The patients underwent B-mode ultrasound-guided PTGD and LC (PTGD + LC group). As controls, a separate group of 35 elderly and high-risk AC patients who underwent LC alone (LC group) during the same period at the same hospital were randomly selected from a pool of 186 such cases. The volume of bleeding, surgery time, postoperative length of stay, conversion rate to laparotomy and complication rates (bile leakage, bleeding, incisional hernia, incision infection, pulmonary infarction and respiratory failure) were recorded for each patient in the two groups.

Results

All patients in the PTGD + LC group successfully underwent PTGD. In the PTGD + LC group, abdominal pain in patients was relieved and leukocyte count, alkaline phosphatase level, total bilirubin and carbohydrate antigen 19-9 (CA19-9) decreased to normal range, and alanine aminotransferase and aspartate aminotransferase levels improved significantly within 72 h after treatment. All patients in the PTGD + LC group underwent LC within 6–10 weeks after PTGD. Our study revealed that PTGD + LC showed a significantly higher efficacy and safety compared to LC alone in AC treatment, as measured by the following parameters: duration of operation, postoperative length of hospital stay, volume of bleeding, conversion rate to laparotomy and complication rate (operation time of LC: 55.6 ± 23.3 min vs. 91.35 ± 25.1 min; hospitalized period after LC: 3.0 ± 1.3 d vs. 7.0 ± 1.7 d; intraoperative bleeding: 28.7 ± 15.2 ml vs. 60.38 ± 16.4 ml; conversion to laparotomy: 3 cases vs. 10 cases; complication: 3 cases vs. 8 cases; all P < 0.05 ).

Conclusion

Our results suggest that B-mode ultrasound-guided PTGD in combination with LC is superior to LC alone for treatment of AC in elderly and high-risk patients, showing multiple advantages of minimal wounding, accelerated recovery, higher safety and efficacy, and fewer complications.

Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis

BACKGROUND

In low-risk patients with acute cholecystitis who did not respond to nonoperative treatment, we prospectively compared treatment with emergency laparoscopic cholecystectomy or percutaneous transhepatic cholecystostomy followed by delayed cholecystectomy.

METHODS

In 91 patients (American Society of Anesthesiologists class I or II) who had symptoms of acute cholecystitis ≥72 hours at hospital admission and who did not respond to nonoperative treatment (48 hours), 48 patients were treated with emergency laparoscopic cholecystectomy and 43 patients were treated with delayed cholecystectomy at ≥4 weeks after insertion of a percutaneous transhepatic cholecystostomy catheter. After initial treatment, the patients were followed up for 23 months on average (range 7-29).

RESULT

Compared with the patients who had emergency laparoscopic cholecystectomy, the patients who were treated with percutaneous transhepatic cholecystostomy and delayed cholecystectomy had a lower frequency of conversion to open surgery [19 (40%) vs 8 (19%); P=0.029], a frequency of intraoperative bleeding ≥100 mL [16 (33%) vs 4 (9%); P=0.006], a mean postoperative hospital stay (5.3+/-3.3 vs 3.0+/-2.4 days; P=0.001), and a frequency of complications [17 (35%) vs 4 (9%); P=0.003].

CONCLUSION

In patients with acute cholecystitis who presented to the hospital ≥72 hours after symptom onset and did not respond to nonoperative treatment for 48 hours, percutaneous transhepatic cholecystostomy with delayed laparoscopic cholecystectomy produced better outcomes and fewer complications than emergency laparoscopic cholecystectomy.

Is a drain necessary routinely after laparoscopic cholecystectomy for an acutely inflamed gallbladder? A retrospective analysis of 457 cases

BACKGROUND

During laparoscopic surgery for an acutely inflamed gallbladder, most surgeons routinely insert a drain. However, no consensus has been reached regarding the need for drainage in these cases, and the use of a drain remains controversial.

METHODS

This retrospective study divided 457 cases into two groups according to whether or not a drain was inserted and reviewed the surgical outcomes and perioperative morbidity.

RESULTS

In this study, 231 patients had no drains and 226 had drains. Both groups were comparable in terms of pathology, demographics, and operative details. There was no statistical difference in operating time, visual analog scale for pain, or postoperative hospital stay. Morbidity occurred in 49 cases (10.7%) and did not differ significantly between the two groups. No mortality occurred in this study.

CONCLUSIONS

The routine use of a drain after laparoscopic cholecystectomy for an acutely inflamed gallbladder had no effect on the postoperative morbidity. Therefore, this retrospective study supports that it is feasible not to insert a drain routinely in laparoscopic cholecystectomy for patients who have an acutely inflamed gallbladder.

Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy in patients with moderate acute cholecystitis under antithrombotic therapy

BACKGROUND

Standard treatment for acute cholecystitis (AC) in patients receiving antithrombotic drugs has not been established. We evaluated the safety of percutaneous transhepatic gallbladder drainage (PTGBD) followed by elective laparoscopic cholecystectomy (LC) in patients with moderate AC who were receiving antithrombotics.

METHODS

Seventy-five patients received PTGBD from January 2006 to March 2013 followed by elective LC for moderate AC. Patients were divided into Group A, which consisted of patients receiving antithrombotic therapy (n = 23), and Group B, which included the remaining patients (n = 52). We analyzed clinical outcomes and perioperative complications between groups.

RESULTS

No hemorrhagic events occurred during PTGBD insertion regardless of antithrombotic treatment. The open conversion rate was not significantly different between the two groups. Postoperative complications were found in 10 patients (13.3%). The rate of postoperative complications in Group A was slightly higher than that in Group B, but the difference was not significant (21.7% vs. 9.6%; P = 0.15). Complications associated with PTGBD occurred in six patients (8%). There were no significant differences in the incidence of these complications, operation time, intraoperative blood loss, or length of postoperative hospital stay.

CONCLUSIONS

Percutaneous transhepatic gallbladder drainage followed by elective LC may be an effective therapeutic strategy for moderate AC in patients receiving antithrombotic therapy.

Operative timing of laparoscopic cholecystectomy for acute cholecystitis in a Japanese institute

These authors suggest that the best timing of laparoscopic cholecystectomy for acute cholecystitis in Japan may be within 24 hours of the onset of the disease.

Background and Objectives:

In patients with acute cholecystitis who cannot undergo early laparoscopic cholecystectomy (within 72 hours), 6 weeks to 12 weeks after onset is widely considered the optimal timing for delayed laparoscopic cholecystectomy. However, there has been no clear consensus about it. We aimed to determine optimal timing for delayed laparoscopic cholecystectomy for acute cholecystitis.

Methods:

Medical records of 100 patients who underwent standard laparoscopic cholecystectomy were reviewed retrospectively. Patients were divided into group 1, patients undergoing laparoscopic cholecystectomy within 72 hours of onset; group 2, between 4 days to 14 days; group 3, between 3 weeks to 6 weeks; group 4, >6 weeks.

Results:

No significant differences existed between groups in conversion rate to open surgery, operation time, blood loss, or postoperative morbidity, and hospital stay. However, total hospital stay in groups 1 and 2 was significantly shorter than that in groups 3 and 4 (P<.01). In addition, the total hospital stay in group 3 was also significantly shorter than that in group 4 (P<.01).

Conclusions:

Best timing of laparoscopic cholecystectomy for acute cholecystitis may be within 72 hours, and the delayed timing of laparoscopic cholecystectomy in patients who cannot undergo early laparoscopic cholecystectomy is probably as soon as possible after they can tolerate laparoscopic cholecystectomy.

Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis

Many surgeons have found it difficult to decide whether to apply percutaneous transhepatic gallbladder drainage (PTGBD) in patients with acute cholecystitis that is not responsive to initial medical management (IMMx), because the indications of PTGBD are ambiguous. The aim of this study was to evaluate the appropriate treatment for acute cholecystitis that is not responsive to IMMx. Specifically, we focused on differences in surgical outcomes between elective and emergency laparoscopic surgeries. Between March 2006 and February 2009, 738 patients with acute cholecystitis who had undergone laparoscopic cholecystectomy (LC) at our institution were retrospectively studied. We divided them into 3 groups. Group I included 494 patients who underwent elective LC without pre-operative PTGBD, group II included 97 patients who intended to undergo elective LC after preoperative PTGBD, and group III included 147 patients who underwent emergency LC without preoperative PTGBD. We compared age, sex, symptom duration, body temperature, leukocyte counts, and American Society of Anesthesiologists (ASA) class on admission as clinical characteristics. We compared the time interval from symptom development and admission to surgery, operative time, the conversion rate to open surgery, postoperative complications, the total length of stay, and the postoperative length of stay as perioperative surgical outcomes. For patients with ASA 2 and 3, the conversion rate to open surgery in group II was significantly less than that in group III (P<.05, P<.01, respectively). We recommend PTGBD as the first choice for acute cholecystitis in patients who show no improvement after IMMx, to allow the patient to undergo an elective LC rather than emergency surgery for patients with ASA 2 and 3.

Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium

BACKGROUND

Laparoscopic cholecystectomy is considered nowadays as the standard management of acute cholecystitis (AC). However, results from multicentric studies in the general surgical community are still lacking.

METHODS

A prospective multicenter survey of surgical management of AC patients was conducted over a 2-year period in Belgium. Operative features and patients' clinical outcome were recorded. The impact of independent predictive factors on the choice of surgical approach, the risk of conversion, and the occurrence of postoperative complications was studied by multivariate logistic regression analysis.

RESULTS

Fifty-three surgeons consecutively and anonymously included 1,089 patients in this prospective study. A primary open approach was chosen in 74 patients (6.8%), whereas a laparoscopic approach was the first option in 1,015 patients (93.2%). Independent predictive factors for a primary open approach were previous history of upper abdominal surgery [odds ratio (OR) 4.13, p < 0.001], patient age greater than 70 years (OR 2.41, p < 0.05), surgeon with more than 10 years' experience (OR 2.08, p = 0.005), and gangrenous cholecystitis (OR 1.71, p < 0.05). In the laparoscopy group, 116 patients (11.4%) required conversion to laparotomy. Overall, 38 patients (3.5%) presented biliary complications and 49 had other local complications (4.5%). Incidence of bile duct injury was 1.2% in the whole series, 2.7% in the open group, and 1.1% in the laparoscopy group. Sixty patients had general complications (5.5%). The overall mortality rate was 0.8%. All patients who died were in poor general condition [American Society of Anesthesiologists (ASA) III or IV].

CONCLUSIONS

Although laparoscopic cholecystectomy is currently considered as the standard treatment for acute cholecystitis, an open approach is still a valid option in more advanced disease. However, overall mortality and incidence of bile duct injury remain high.

Prolonged (Longer than 3 Hours) Laparoscopic Cholecystectomy: Reasons and Results

For the experienced surgeon, the average operative time for a laparoscopic cholecystectomy is less than 1 hour. There has been no study documenting the causes and results of prolonged (longer than 3 hours) surgery. A retrospective study was done of patients who underwent cholecystectomy between January 2003 and December 2007. A total of 3126 cholecystectomies were done. After excluding patients who had a planned open cholecystectomy and patients who had additional laparoscopic surgeries, we identified 70 patients who had a planned laparoscopic cholecystectomy with operative time exceeding 3 hours. Multivariate stepwise logistic regression was performed analyzing the various factors leading to prolonged surgery. Of the 70 patients, ranging in age from 21 to 92 years (mean, 57 years), most (n = 53) were female. Operative time ranged from 3 hours to 6 hours 40 minutes (mean, 3 hours 37 minutes). Emergency:elective admission ratio was 9:5 and acute cholecystitis (n = 40) was the most common indication. Common characteristics were obesity (n = 44, P = 0.031), intraabdominal adhesions (n = 43, P = 0.004), and previous abdominal surgeries (n = 40, P = 0.002). Intraoperative complications included spillage of stones (n = 6), bile duct injury (n = 3), and bleeding (n = 3). The possibility of prolonged laparoscopic cholecystectomy should be anticipated in patients with obesity and previous abdominal operations. Prolonged surgery increases the risk of complications (bile duct injury, bleeding) and prolongs the postoperative hospital stay.

Early Laparoscopic Cholecystectomy Is the Appropriate Management for Acute Gangrenous Cholecystitis

Treatment of severe acute cholecystitis by laparoscopic cholecystectomy remains controversial because of technical difficulties and high rates of complications. We determined whether early laparoscopic cholecystectomy is appropriate for acute gangrenous cholecystitis. The medical records of 116 patients with acute gangrenous cholecystitis admitted to the Korea University Guro Hospital between January 2005 and December 2009 were reviewed. The early operation group, those patients who had cholecystectomies within 4 days of the diagnosis, was compared with the delayed operation group, who had cholecystectomies 4 days after the diagnosis. Of the 116 patients, 57 were in the early operation group and 59 were in the delayed operation group. There were no statistical differences between the groups with respect to gender, age, body mass index, operative methods, major complications, duration of symptoms, mean operative time (98 vs 107 minutes), or postoperative hospital stay. However, the total hospital stay was significantly longer in the delayed operation group. More patients underwent preoperative percutaneous cholecystostomy in the delayed operation group (3.5 vs 15.3%). Early laparoscopic cholecystectomy for acute gangrenous cholecystitis is safe and feasible. There is no advantage to postponing an urgent operation in patients with acute gangrenous cholecystitis.