Drain After Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis. A Pilot Randomized Study

Critical view of safety approach vs. infundibular technique in laparoscopic cholecystectomy, which one is safer? A systematic review and meta-analysis

Laparoscopic cholecystectomy (LC) remains the gold standard procedure for the management of benign gallbladder disease. Recognizing the need to mitigate complications, mainly bile duct injury (BDI), various techniques for ductal identification during LC have emerged, including the "Critical View of Safety" (CVS) and the infundibular technique (IT). In this systematic review and meta-analysis, we assess and compare the outcomes of both techniques, with a primary focus on evaluating their impact on BDIs. A comprehensive search was conducted using PubMed and Scopus databases. The search focused on the surgical technique, incidences of minor and major BDIs, operative time, conversion rate, and length of stay, among patients undergoing LC for benign gallbladder disease. Our initial search retrieved 264 studies. After screening the unique studies against our predefined inclusion/exclusion criteria, only five met our criteria and were included. Additionally, a manual search identified eight more relevant studies, bringing the total number of included studies to 13. The total number of included patients was 4,837. Approximately two-thirds underwent LC using the CVS approach (61.1%), and 66.3% were female, with a mean age of 44.4 ± 11.2 years. The CVS approach was associated with a significant reduction in overall BDIs (RR = 0.36; 95% CI 0.18-0.71) and major BDIs (RR = 0.28; 95% CI 0.13-0.63). However, there were no significant differences in terms of minor BDIs, operative time, conversion rates, or length of stay. Our study demonstrated the superiority of the CVS approach in terms of reducing the incidence of overall and major BDIs compared to IT. However, our study revealed no other significant differences between the two techniques. Further research, including multicentric randomized controlled trials, will be necessary to further evaluate the efficacy of these techniques.

Optimal drain management following complicated laparoscopic cholecystectomy for acute cholecystitis: a propensity-matched comparative study

PURPOSE

This study was performed to investigate the effect of drain placement on complicated laparoscopic cholecystectomy (cLC) for acute cholecystitis (AC).

METHODS

This single-center retrospective study reviewed patients with AC who underwent cLC between January 2010 and December 2020. cLC was defined as open conversion, subtotal cholecystectomy, adjacent organ injury during surgery, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL. One-to-one propensity score matching was performed to compare the surgical outcomes between patients with and without drain on cLC.

RESULTS

A total of 216 patients (mean age, 65.8 years; 75 female patients [34.7%]) underwent cLC, and 126 (58.3%) underwent intraoperative abdominal drainage. In the propensity score-matched cohort (61 patients in each group), early drain removal (≤postoperative day 3) was performed in 42 patients (68.9%). The overall rate of surgical site infection (SSI) was 10.7%. Late drain removal demonstrated significantly worse surgical outcomes than no drain placement and early drain removal for overall complications (13.1% vs. 21.4% vs. 47.4%, p = 0.006), postoperative hospital stay (3.8 days vs. 4.4 days vs. 12.7 days, p < 0.001), and SSI (4.9% vs. 11.9% vs. 31.6%, p = 0.006). In the multivariate analysis, late drain removal was the most significant risk factor for organ space SSI.

CONCLUSION

This study demonstrated that drain placement is not routinely recommended, even after cLC for AC. When placing a drain, early drain removal is recommended because late drain removal is associated with a higher risk of organ space SSI.

Effect of routine abdominal drainage on postoperative pain after uncomplicated laparoscopic cholecystectomy for cholelithiasis: A randomised controlled trial

This is a prospective randomized controlled trial to investigate the effect of routine abdominal drainage on postoperative pain after uncomplicated laparoscopic cholecystectomy for cholelithiasis. This study was a single-center randomized controlled trial performed at the general surgery ward of Taleghani hospital, in Tehran, Iran, from July 2018 to October 2018. Patients were randomly divided into two parallel groups, one receiving routine abdominal drainage and the other receiving no treatment. Postoperative pain was measured by the Universal Pain Assessment Tool (UPAT) 0, 2, 4, 6, 12, and 24 h postoperatively. A total of 60 patients (30 patients in the study and control groups) were included. GLM repeated measure analysis showed a significant time*treatment effect for routine abdominal drainage in decreasing UPAT scores from baseline to 24 h after surgery (F = 4.59, df = 3.98, P-value = 0.001). Our findings demonstrated that abdominal drainage significantly reduces postoperative pain 0, 2, 4, 6, and 12 h after surgery (P-value<0.05). We also showed that abdominal drainage increases the time to first morphine sulfate administration and decreases the total dose of morphine sulfate administration (P-value<0.001). Moreover, we demonstrated that abdominal drainage decreases the average postoperative pain (P-value<0.001) and does not lead to any considerable side effects. However, 24 h after surgery, no significant pain-relieving effect was evident for abdominal drainage. In conclusion, insertion of abdominal drainage leads to decreased postoperative pain. Future studies need to investigate the optimal time for removal of the abdominal drain.

This trial was prospectively registered in the Iranian Registry of Clinical Trials with a registration ID of IRCT20130706013875N2.

Safety of Laparoscopic Cholecystectomy for Acute Cholecystitis in the Elderly: A Multivariate Analysis of Risk Factors for Intra and Postoperative Complications

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.

The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018

BACKGROUND

The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide.

METHODS

We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies.

RESULTS

There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese.

CONCLUSIONS

The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.

Routine drain or no drain after laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Laparoscopic cholecystectomy (LC) is considered to be the gold standard in the early management of acute cholecystitis however, recommendations for routine drain insertion in the acute setting are unavailable.

STUDY DESIGN

A systematic review of literature review and metanalysis was conducted. All studies comparing drain versus no drain after LC for acute cholecystitis were included.

RESULTS

Seven studies, with 1274 patients, were included. Postoperative wound infection rates (relative risk (RR) 0.30, 95% confidence interval (CI) 0.10 to 0.88; I2 = 0%) and postoperative abdominal collection requiring drainage (RR 1.20, 95% CI 0.35 to 4.12; I 2 = 0%) were lower in the no-drain group, but this was only significant for wounded infections on subgroup analysis of RCTs. Length of stay hospital (mean difference (MD) -0.49, 95% CI -0.89 to -0.09; I 2 = 69%) and operative time (MD -8.13, 95% CI -13.87 to -2.38; I 2 = 92%) were significantly shorter in the no drain group however this was in the context of significant heterogeneity.

CONCLUSION

The available data suggests that acute cholecystitis is not an indication for routine drain placement after LC. However, these results must be interpreted with caution due to the limitations of the included studies. In effect, the main issue of this meta-analysis lies on the limitations of the included studies themselves, because of a considerable heterogeneity among the included works, particularly for the inclusion criteria of patients and reported severity of acute cholecystitis. Further work is required to produce evidence which will definitively alter clinical practice.

LEVEL OF EVIDENCE

Level 2a (systematic review of cohort studies). Oxford CEBM levels of evidence.

Comparison of laparoscopic cholecystectomy with and without abdominal drainage in patients with non-complicated benign gallbladder disease: A protocol for systematic review and meta analysis

OBJECTIVE

To evaluate whether conventional postoperative drainage is more effective than not providing drainage in patients with non-complicated benign gallbladder disease following laparoscopic cholecystectomy (LC).

METHODS

A search of the electronic databases MEDLINE, EMBASE, Web of science, Cochrane Library, and Chinese Biomedical Database (CBM) was conducted for randomized controlled trials (RCTs) reporting outcomes of LC surgery with and without an abdominal drain.

RESULTS

Twenty-one RCTs involving 3246 patients (1666 with drains vs 1580 without) were included in the meta-analysis. There were no statistically significant differences in the rates of incidence of intra-abdominal fluid (RR: 1.10; 95% CI: 0.81-1.49; P = .54) or post-surgical mortality (RR: 0.44; 95% CI: 0.04-4.72; P = .50) between the two groups. Abdominal drains did not reduce the overall incidence of nausea and vomiting (RR: 1.16; 95% CI: 0.95-1.42; P = .15) or shoulder tip pain (RR: 1.03; 95% CI: 0.76-1.38; P = .86). The abdominal drain group displayed significantly higher pain scores (MD: 1.07; 95% CI: 0.69-1.46; P < .001) than the non-drainage patients. Abdominal drains prolonged the duration of the surgical procedure (MD: 5.69 min; 95% CI: 2.51-8.87; P = .005) and postoperative hospital stay (MD: 0.47 day; 95% CI: 0.14-0.80; P = .005). Wound infection was found to be associated with the use of abdominal drains (RR: 1.97; 95% CI: 1.11-3.47; P = .02).

CONCLUSIONS

Currently, there is no evidence to support the use of routine drainage after LC in non-complicated benign gallbladder disease. Further well-designed randomized clinical trials are required to confirm this finding.

Drain in laparoscopic cholecystectomy in acute calculous cholecystitis: a randomised controlled study

BACKGROUND

There is paucity of evidence regarding the role of drain in laparoscopic cholecystectomy (LC) in acute calculous cholecystitis (ACC), and surgeons have placed the drains based on their experiences, not on evidence-based guidelines. This study aims to assess the value of drain in LC for ACC in a randomised controlled prospective study.

PATIENTS AND METHODS

All patients with mild and moderate ACC undergoing LC were assessed. Preoperatively, patients with choledocholithiasis, Mirizzi syndrome and biliary stent were excluded. Intraoperatively or postoperatively, patients with complications, partial cholecystectomies and malignancies were excluded. Patients were randomised using computer-generated random numbers into two groups at the end of cholecystectomy before closure. Requirement of radiologically guided (ultrasonography () or CT) percutaneous aspiration/drainage of symptomatic intra-abdominal collection or reoperation; continuation of parenteral antibiotics beyond 24 hours or change in antibiotics empirically or based on peritoneal fluid culture sensitivity; requirement of postoperative USG or CT scan based on postoperative clinical course; wound infection rates; postoperative pain using numeric rating scale at 6 and 24 hours; and the duration of hospital stay in both groups were noted.

RESULTS

Forty-two out of 50 consecutive patients were randomised into two equal groups. Pain score at 6 and 24 hours was less in patients without drain. All other complication rates and duration of stay were similar in both groups.

CONCLUSIONS

Drains should not be placed routinely after LC in ACC as it increases pain and does not help in detecting or decreasing complications.

The effect on morbidity of the use of prophylactic abdominal drain following elective laparoscopic cholecystectomy

Background and Objective

To evaluate the clinical role of the routine use of a drain in an elective laparoscopic cholecystectomy operation applied to patients with symptomatic cholelithiasis not showing acute inflammation.

Method

Following laparoscopic removal of the gallbladder, patients were separated into two groups of 30 each, either with subhepatic drain placement or without. The presence of subhepatic fluid collection was evaluated with transabdominal ultrasonography (USG) at 24 hours postoperatively and on the 7th day. The other parameters evaluated were postoperative morbidity, shoulder and abdominal pain.

Results

No statistically significant difference was found between the two groups in respect of demographic characteristics and operative details. The median pain score was determined to be statistically significantly higher in the group with a drain applied compared to the group without a drain (p=0.007). In the comparison between the groups of fluid collection on USG at 24 hours and shoulder pain persisting until the 7th day, although seen less in the group with no drain applied, no statistically significant difference was determined (p=0.065, p=0.159). In the examinations made on the 7th day, no hematoma or significant fluid collection was determined on USG and no wound infection was observed in any patient of either group.

Conclusion

The routine application of prophylactic subhepatic drain in laparoscopic cholecystectomy procedure did not show any benefit to the patient.

Prophylactic drainage after laparoscopic cholecystectomy for acute cholecystitis: a systematic review and meta-analysis

In the literature, there is a large evidence against the use of drains in laparoscopic cholecystectomy (LC) in elective surgery. However, evidence is lacking in the setting of acute cholecystitis (AC). The present meta-analysis was performed to assess the role of drains to reduce complications and improve recovery in LC for AC. An electronic search of the MEDLINE, Science Citation Index Expanded, SpringerLink, Scopus, and Cochrane Library database from January 1990 to July 2018 was performed to identify randomized clinical trials (RCTs) that compare prophylactic drainage with no drainage in LC for AC. Odds ratio (OR) with confidence interval (CI) for qualitative variables and mean difference (MD) with CI for continuous variables were calculated. Three RCTs were included in the meta-analysis, involving 382 patients randomized to drain (188) versus no drain (194). Morbidity was similar in both the study groups (OR 1.23; 95% CI 0.55-2.76; p = 0.61) as well as wound infection rate (OR 1.98; 95% CI 0.53-7.40; p = 0.31) and abdominal abscess rate (OR 0.62; 95% CI 0.08-4.71; p = 0.31). Abdominal pain 24 h after surgery was less severe in the no drain group (MD 0.80; 95% CI 0.46-1.14; p < 0.000). A significant difference in favor of the no drain group was found in the postoperative hospital stay (MD 1.05; 95% CI 0.87-1.22; p < 0.000). No significant difference was present with respect to postoperative fluid collection in the subhepatic area and operative time. The present study shows that prophylactic drain placement is useless to reduce complications in LC performed to treat AC. Postoperative recovery is improved if drain is not present.

Drainage versus No Drainage after Laparoscopic Cholecystectomy for Acute Cholecystitis: A Meta-Analysis

To conduct a randomized controlled trial (RCT), meta-analysis to assess the effectiveness of drains in reducing complications after laparoscopic cholecystectomy (LC) for acute cholecystitis needs to be carried out. An electronic search of PubMed, Embase, Science Citation Index, and the Cochrane Library from January 1990 to January 2018 was performed to identify randomized clinical trials that compare prophylactic drainage with no drainage in LC for acute cholecystitis. The outcomes were calculated as odds ratios (ORs) with 95 per cent confidence intervals (CIs) using RevMan 5.2. Four RCTs, which included 796 patients, were identified for analysis in our study. There was no statistically significant difference in the rate of morbidities (OR = 1.23, 95% CI 0.55-2.76, P = 0.61). Abdominal pain was more severe in the drain group 24 hours after surgery (mean difference = 0.80, 95% CI 0.47-1.14; P < 0.00001). No significant difference was present with respect to wound infection rate and hospital stay. The use of abdominal drainage does not appear to be of any benefit in patients having undergone early LC for acute cholecystitis.

Reporting of complications after laparoscopic cholecystectomy: a systematic review

BACKGROUND

Consistent measurement and reporting of outcomes, including adequately defined complications, is important for the evaluation of surgical care and the appraisal of new surgical techniques. The range of complications reported after LC has not been evaluated. This study aimed to identify the range of complications currently reported for laparoscopic cholecystectomy (LC), and the adequacy of their definitions.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for prospective studies reporting clinical outcomes of LC, between 2013 and 2016.

RESULTS

In total 233 studies were included, reporting 967 complications, of which 204 (21%) were defined. One hundred and twenty-two studies (52%) did not provide definitions for any of the complications reported. Conversion to open cholecystectomy was the most commonly reported complication, reported in 135 (58%) studies, followed by bile leak in 89 (38%) and bile duct injury in 75 (32%). Mortality was reported in 89 studies (38%).

CONCLUSION

Considerable variation was identified between studies in the choice of measures used to evaluate the complications of LC, and in their definitions. A standardised set of core outcomes of LC should be developed for use in clinical trials and in evaluating the performance of surgical units.

The Value of Abdominal Drainage After Laparoscopic Cholecystectomy for Mild or Moderate Acute Calculous Cholecystitis: A Post Hoc Analysis of a Randomized Clinical Trial

BACKGROUND

Although the preoperative management of mild and moderate (Grade I-II) acute calculous cholecystitis (ACC) has been standardized, there is no consensus on the value of abdominal drainage after early cholecystectomy.

METHODS

In a post hoc analysis of a randomized controlled trial (NCT01015417) focused on the value of postoperative antibiotic therapy in patients with ACC, we determined the value of abdominal drainage in patients having undergone laparoscopic cholecystectomy for Grades I-II ACC. All postoperative complications were analyzed after using a propensity score. A post hoc test was used to assess the statistical robustness of our results.

RESULTS

Of the 414 enrolled patients, 178 did not have abdominal drainage (forming the no-drainage group) and 236 had drainage (the drainage group). After matching on PS, the deep incisional site infection was 1.1 versus 0.8 %, p = 0.78. This result is similar for the superficial incisional site infections; the distant infections; the overall morbidity, and the readmission rate. Only the hospital length of stay was significantly longer in the drainage group (3.3 vs. 5.1 days, p = 0.003). Neither abdominal drainage nor the absence of postoperative antibiotic therapy was found to be a risk factor for deep incisional site infections.

CONCLUSIONS

The use of abdominal drainage depends on the surgeon's personal preferences but is often used in high-risk populations. However, abdominal drainage does not appear to be of any benefit (in terms of postoperative outcomes) and may even compromise recovery in patients having undergone early laparoscopic cholecystectomy for mild or moderate ACC.

Meta-analysis of drainage versus no drainage after laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVES

Routine drainage after laparoscopic cholecystectomy is still controversial. This meta-analysis was performed to assess the role of drains in reducing complications in laparoscopic cholecystectomy.

METHODS

An electronic search of Medline, Science Citation Index Expanded, Scopus, and the Cochrane Library database from January 1990 to June 2013 was performed to identify randomized clinical trials that compare prophylactic drainage with no drainage in laparoscopic cholecystectomy. The odds ratio for qualitative variables and standardized mean difference for continuous variables were calculated.

RESULTS

Twelve randomized controlled trials were included in the meta-analysis, involving 1939 patients randomized to a drain (960) versus no drain (979). The morbidity rate was lower in the no drain group (odds ratio, 1.97; 95% confidence interval, 1.26 to 3.10; P = .003). The wound infection rate was lower in the no drain group (odds ratio, 2.35; 95% confidence interval, 1.22 to 4.51; P = .01). Abdominal pain 24 hours after surgery was less severe in the no drain group (standardized mean difference, 2.30; 95% confidence interval, 1.27 to 3.34; P < .0001). No significant difference was present with respect to the presence and quantity of subhepatic fluid collection, shoulder tip pain, parenteral ketorolac consumption, nausea, vomiting, and hospital stay.

CONCLUSION

This study was unable to prove that drains were useful in reducing complications in laparoscopic cholecystectomy.