Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome

Does previous gastrectomy history affect the surgical outcomes of laparoscopic cholecystectomy?

PURPOSE

This current study aimed to explore whether gastrectomy history influenced surgical outcomes while undergoing laparoscopic cholecystectomy (LC).

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for eligible studies from inception to April 29, 2023. The Newcastle-Ottawa Scale (NOS) was adopted to assess the quality of included studies. The mean differences (MDs) and 95% confidence intervals (CIs) were calculated for continuous variables, and the odds ratios (ORs) and 95% CIs were calculated for dichotomous variables. RevMan 5.4 was used for data analysis.

RESULTS

Seven studies enrolling 8193 patients were eligible for the final pooling up analysis (380 patients in the previous gastrectomy group and 7813 patients in the non-gastrectomy group). The patients in the gastrectomy group were older (MD = 11.11, 95%CI = 7.80-14.41, P < 0.01) and had a higher portion of males (OR = 3.74, 95%CI = 2.92-4.79, P < 0.01) than patients in the non-gastrectomy group patients. Moreover, the gastrectomy group had longer LC operation time (MD = 34.17, 95%CI = 25.20-43.14, P < 0.01), a higher conversion rate (OR = 6.74, 95%CI = 2.17-20.26, P = 0.01), more intraoperative blood loss (OR = 1.96, 95%CI = 0.59-3.32, P < 0.01) and longer postoperative hospital stays (MD = 1.07, 95%CI = 0.38-1.76, P < 0.01) than the non-gastrectomy group.

CONCLUSION

Patients with a previous gastrectomy history had longer operation time, a higher conversion rate, more intraoperative blood loss, and longer postoperative hospital stays than patients without while undergoing LC. Surgeons should pay more attention to these patients and make prudent decisions to avoid worse surgical outcomes as much as possible.

Laparoscopic Cholecystectomy Versus Open Cholecystectomy in Acute Cholecystitis: A Literature Review

Cholecystectomy is a common surgical procedure performed worldwide for acute cholecystitis. Acute cholecystitis occurs when the cystic duct is obstructed by a gallstone, which causes gallbladder distension and subsequent inflammation of the gallbladder. Acute cholecystitis is characterized by pain in the right upper quadrant, anorexia, nausea, fever, and vomiting. Cholecystectomy is the treatment of choice for acute cholecystitis. The two commonly performed types of cholecystectomies are open cholecystectomy and laparoscopic cholecystectomy. However, the approach of choice widely fluctuates with regard to various factors such as patient history and surgeon preference. It is imperative to understand the variations in outcomes of different approaches and how best they fit an individual patient when deciding the technique to be undertaken. This article reviews several studies and compares the two techniques in terms of procedure, mortality rate, complication rate, bile leak/injury rate, conversion rate, and bleeding rate.

Preoperative Risk Factors for Conversion from Laparoscopic to Open Cholecystectomy: A Systematic Review and Meta-Analysis

Laparoscopic cholecystectomy is a standard treatment for patients with gallstones in the gallbladder. However, multiple risk factors affect the probability of conversion from laparoscopic cholecystectomy to open surgery. A greater understanding of the preoperative factors related to conversion is crucial to improve patient safety. In the present systematic review, we summarized the current knowledge about the main factors associated with conversion. Next, we carried out several meta-analyses to evaluate the impact of independent clinical risk factors on conversion rate. Male gender (OR = 1.907; 95%CI = 1.254−2.901), age > 60 years (OR = 4.324; 95%CI = 3.396−5.506), acute cholecystitis (OR = 5.475; 95%CI = 2.959−10.130), diabetes (OR = 2.576; 95%CI = 1.687−3.934), hypertension (OR = 1.931; 95%CI = 1.018−3.662), heart diseases (OR = 2.947; 95%CI = 1.047−8.296), obesity (OR = 2.228; 95%CI = 1.162−4.271), and previous upper abdominal surgery (OR = 3.301; 95%CI = 1.965−5.543) increased the probability of conversion. Our analysis of clinical factors suggested the presence of different preoperative conditions, which are non-modifiable but could be useful for planning the surgical scenario and improving the post-operatory phase.

The Association of Preoperative Risk Factors for Laparoscopic Conversion to Open Surgery in Elective Cholecystectomy

Background

Laparoscopic cholecystectomy is a common operation worldwide, with low mortality (0.01%) and morbidity (2–8%). It has been reported 2.9 to 3.2% of elective laparoscopic cholecystectomies are converted to open surgery. Converted cases are associated with increased complications rates.

Method

Two thousand and seventy-five patients, 82.8% females and 17.2% males who underwent elective laparoscopic cholecystectomy in our hospital, between March 1, 2016, and February 28, 2018, were prospectively collected in a database. Pearson's Chi-squared and Fisher's exact tests were used to determine significance, with p <0.05 deemed statistically significant. We analyzed seven risk factors associated with conversion to open surgery; age, gender, body mass index (BMI), previous abdominal surgeries, the presence of contracted gallbladder, Mirizzi syndrome, or choledocholithiasis. Laparoscopic cholecystectomy was performed using a 3-port technique (73%) and a 4-port technique (27%).

Results

Finding associated “strong” factors to conversion: male patients, >60-years-old, previous upper abdominal surgery, contracted gallbladder, Mirizzi syndrome or choledocholithiasis. The presence of a higher or lower BMI did not influence the rate of conversion. The most impact association were males over 60 years, and males with an earlier upper abdominal surgery.

Conclusion

Laparoscopic cholecystectomy is the gold standard for gallstones and gallbladder disease; however, inflammation, adhesions, and anatomic difficulty continue to challenge the use and safety of this approach in a small number of patients. This study identifies predictors of choice for open cholecystectomy. In view of the raised morbidity and mortality associated with open cholecystectomy, distinguishing these predictors will serve to decrease the rate of conversion and address these factors preoperatively.

How to cite this article

Hanson-Viana E, Ayala-Moreno EA, Ortega-Leon LH, et al. The Association of Preoperative Risk Factors for Laparoscopic Conversion to Open Surgery in Elective Cholecystectomy. Euroasian J Hepato-Gastroenterol 2022;12(1):6–9.

Önemli komorbid durumları olan yaşlı hastalarda epidural anestezi altında kolesistektomi

Purpose: The aim of this study was to evaluate the surgical treatment of gallstone disease with open cholecystectomy under epidural anesthesia in elderly patients with significant comorbid conditions. Materials and Methods: We retrospectively analyzed 80 consecutive elderly patients over 65 years of age with significant comorbid conditions who underwent open cholecytectomy under epidural anesthesia for the surgical treatment of gallstone disease between January 1, 2009 and December 31, 2019, all performed by one surgeon. Results: Mean age was found 77 ± 16 years. Fifty of the patients (62.5%) were females. Forty-seven patients (58.75%) showed an American Society of Anesthesiologist Physical Status (ASA, PS) of 3. The most frequently associated comorbidity involved the cardiovascular system (46 patients, 57.5%). Surgical indications were acute cholecystitis (AC) in 37 patients (46.25%) and chronic cholecystitis in 32 patients (40%). Mean operation time was 55 ± 22 minutes. Hospital stay was mean 12 ± 5 days. Total complication rate was 38.75%, and pulmonary complication was the most frequently encountered (13.75%). 30-day mortality was seen in 5 patients (6.25%). Conclusion: In older, high-risk gallstone patients, an open cholecystectomy with epidural anesthesia may be recommended. For this patient population, the mortality and morbidity rates are acceptable.

On-table hepatopancreatobiliary surgical consults for difficult cholecystectomies: A 7-year audit

BACKGROUND

Cholecystectomy is considered a general surgical operation. However, general surgeons are not trained to manage severe complications such as bile duct injury (BDI) and should refer to hepatopancreatobiliary (HPB) surgeons when difficulty arises. This study aimed to investigate the outcomes of patients who had on-table HPB consults during cholecystectomy.

METHODS

This is an audit of 50 patients who required on-table HPB consult during cholecystectomy from 2011 to 2017. Consultations were classified as "proactive" and "reactive", where consults were made before or after surgical incision, respectively. Patient demographics and perioperative details were collected.

RESULTS

The median age of the patients was 62.5 years [interquartile range (IQR) 50.8-71.3 years]. Eight (16%) patients had underlying HPB co-morbidity. Gallbladder wall was thickened in all patients (median 5 mm, IQR 4-7 mm), and common bile duct was of normal caliber in all patients (median 5 mm, IQR 4-6 mm). Median length of operation and length of stay were 165 min (IQR 124-209 min) and five days (IQR 3-7 days), respectively. Subtotal cholecystectomy was performed in 18 (36%) patients. Forty-eight patients were initially managed by laparoscopic approach, 15 (31%) required open conversion; majority (9/15, 60%) were initiated before on-table consult. Majority of referrals (98%) were reactive. Common reasons for referral included unclear anatomy or anatomical variations (30%), presence of dense adhesions and/or contracted gallbladder (18%) and impacted stones in Hartmann's pouch (16%). Three (6%) patients were referred for BDI (2 Strasberg D and 1 Strasberg E1), and two (4%) were referred for torrential bleeding from arterial injury (1 cystic artery and 1 right hepatic artery). Any morbidity and 30-day readmission were 22% and 6%, respectively. There was no 90-day mortality.

CONCLUSIONS

Calling for help in BDI is obligatory, but in other instances is a personal choice. Calling for help prior to open conversion is lacking and this awareness should be raised. Whether surgical outcomes could be improved by early HPB consult needs to be determined by larger multicenter reports.

Laparoscopic subtotal cholecystectomy; change in practice over a 10-year period

BACKGROUND

Laparoscopic subtotal cholecystectomy is a recognised safe, alternative strategy when a critical view of safety cannot be obtained. This study audits the change in practice at a District General Hospital following the adoption of subtotal cholecystectomy in 2013.

METHODS

Retrospective case series included consecutive cholecystectomies over a ten-year period in a single institution. Cases were divided into subgroups based on operation date. Primary outcome was the proportion of patients undergoing laparoscopic total cholecystectomy, laparoscopic subtotal and laparoscopic converted to open cholecystectomy. Secondary outcomes included incidence of bile leak, complication rate, return to theatre, and length of stay.

RESULTS

There were 4217 cases: 1381 in Group A (pre-adoption of subtotal cholecystectomy 2009-2012), and 2836 in Group B (post-adoption of subtotal cholecystectomy 2013-2019). The rate of laparoscopic total cholecystectomy was higher in Group A than Group B (95.4% vs. 92.8%, p < 0.001). In the subtotal group (n = 114, 14 (12.3%) patients had bile leak, 6 (5.3%) underwent re-laparoscopy, and median length of stay was 2 days.

CONCLUSION

Laparoscopic subtotal cholecystectomy appears to be an acceptable alternative technique at this centre, reducing the rate of open conversion and length of stay, with a low reintervention rate for bile leak.

Open Cholecystectomy for the New Learner-Obstacles and Challenges

Background:

Laparoscopy has become the standard of care in most general surgery procedures. This has led to a decrease in the number of open surgical procedures for surgical training, particularly as senior surgeons retire. The aim of this study was to evaluate the impact of retiring senior surgeons on our residents’ operative experience.

Methods:

Cholecystectomies performed between Jan 2010 and Dec 2016 were retrospectively reviewed. Surgeons training residents were divided into two groups based on their training experience. Group 1 were trained in the prelaparoscopic era, and group 2 were trained during the age of laparoscopy. We then evaluated the impact of retirement on the number of open cholecystectomies performed.

Results:

There were 4555 laparoscopic cholecystectomies performed at our institution over a 7-year period. Overall conversion rate was 1.5% (66/4555). Conversion rates were higher in group 1 as compared to group 2. The analysis of the number of open cases performed by each graduating resident showed reduction in the number of open cholecystectomies performed over time.

Conclusion:

The decline in the number of open cholecystectomies creates a challenge for the training of general surgery residents. To compensate, we have employed simulation curriculum with the use of cadaveric surgical anatomy courses. Additionally, with transplant curriculum, open cholecystectomy experience has increased with liver transplant exposure. Continued laparoscopic experience has also shown that advanced laparoscopic techniques such as top down dissection laparoscopically have decreased the need for conversion to open and are skills that graduating residents possess.

Development of a novel intraoperative difficulty score for minimally invasive cholecystectomy

BACKGROUND

The rate of biliary injuries from minimally invasive cholecystectomy has remained high for over two decades. To improve outcomes there are multiple bail-out methods described, including aborting the procedure, converting to open, or performing a sub-total cholecystectomy. However, the intraoperative difficulty threshold for when a bail-out method should be implemented is poorly understood.

METHODS

From 1/2014 to 2/2019 cholecystectomy videos were collected, de-identified, edited to include the 2-3 minutes when the gallbladder was first visualized, and accelerated. They were then rated on a 5-point difficulty scale. Inter-coder reliability was evaluated using Krippendorff's alpha and regression models were used to evaluate the scores ability to predict the need for a bail-out technique.

RESULTS

62 videos were analyzed with a median length after editing of 37.5 (29.0-43.3) seconds. A median time of 46.2 (38.3-53.4) seconds was required for grading. The bail-out rate was 42.9%. The inter-coder reliability between 2 surgeons and 8 non-clinical reviewers was 0.675 with an average difficulty score of 3.0 (SD = 1.01). Regression models showed that the scale was able to significantly predict conversion (β=0.56,p<.01).

CONCLUSION

This novel difficulty score was able to predict conversion to a bail-out technique early in the course of minimally invasive cholecystectomy.

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

Evaluation of the conversion rate as it relates to preoperative risk factors and surgeon experience: a retrospective study of 4013 patients undergoing elective laparoscopic cholecystectomy

Background

Our aim is to determine the relationships among patient demographics, patient history, surgical experience, and conversion rate (CR) during elective laparoscopic cholecystectomies (LCs).

Methods

We analyzed data from patients who underwent LC surgery between 2005 and 2014 based on patient charts and electronic documentation. CR (%) was evaluated in 4013 patients who underwent elective LC surgery. The relationships between certain predictive factors (patient demographics, endoscopic retrograde cholangiopancreatography (ERCP), acute cholecystitis (AC), abdominal surgery in the patient history, as well as surgical experience) and CR were examined by univariate analysis and logistic regression.

Results

In our sample (N = 4013), the CR was 4.2%. The CR was twice as frequent among males than among females (6.8 vs. 3.2%, p < 0.001), and the chance of conversion increased from 3.4 to 5.9% in patients older than 65 years. The detected CR was 8.8% in a group of patients who underwent previous ERCP (8.8 vs. 3.5%, p < 0.001). From the ERCP indications, most often, conversion was performed because of severe biliary tract obstruction (CR: 9.3%). LC had to be converted to open surgery after upper and lower abdominal surgeries in 18.8 and 4.8% cases, respectively. Both AC and ERCP in the patient history raised the CR (12.3%, p < 0.001 and 8.8%, p < 0.001). More surgical experience and high surgery volume were not associated with a lower CR prevalence.

Conclusions

Patient demographics (male gender and age > 65 years), previous ERCP, and upper abdominal surgery or history of AC affected the likelihood of conversion. More surgical experience and high surgery volume were not associated with a lower CR prevalence.

Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates

Background

Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time.

Methods

Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature.

Results

28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%.

Conclusion

Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.

Acute cholecystitis: predictive clinico-radiological assessment for conversion of laparoscopic cholecystectomy

BACKGROUND

Previous studies evaluating predictive factors for the conversion from laparoscopic to open cholecystectomy have reported conflicting conclusions.

PURPOSE

To create a risk assessment model to predict the conversion from laparoscopic to open cholecystectomy in patients with acute calculous cholecystitis.

MATERIAL AND METHODS

A retrospective review of patients with acute calculous cholecystitis with available preoperative contrast-enhanced computed tomography (CT) findings who underwent laparoscopic cholecystectomy was performed. Forty-four parameters-including demographics, clinical history, laboratory data, and CT findings-were analyzed.

RESULTS

Among the included 581 patients, conversion occurred in 113 (19%) cases. Multivariate analysis identified obesity (odd ratio [OR] 2.58, P = 0.04), history of abdominal surgery (OR 1.78, P = 0.03), and prolonged prothrombin time (OR 1.98, P = 0.03) as predictors of conversion. In preoperative CT findings, the absence of gallbladder wall enhancement (OR 3.15, P = 0.03), presence of a gallstone in the gallbladder infundibulum (OR 2.11, P = 0.04), and inflammation of the hepatic pedicle (OR 1.71, P = 0.04) were associated with conversion. Inter-observer agreement for CT study interpretation was very good (range 0.81-1.00). A model was created to calculate the risk for conversion, with an area under the receiver operating characteristic curve of 0.87. The risk for conversion, estimated based on the number of factors identified, was in the range of 5.3% (with one factor) to 86.4% (with six factors).

CONCLUSION

Obesity, history of abdominal surgery, prolonged prothrombin time, absence of gallbladder wall enhancement, presence of a gallstone in the gallbladder infundibulum, and inflammation of the hepatic pedicle are associated with conversion of laparoscopic to open cholecystectomy.

The “critical view of safety (CVS)” cannot be applied—What to do? Strategies to avoid bile duct injuries

Laparoscopic cholecystectomy has become the standard procedure worldwide since the early 1990s for those patients whose gallbladder has to be removed as part of their underlying disease (NIH Consensus Statement 1992). The most common complication is iatrogenic bile duct injury, which has not improved significantly since the introduction of open laparoscopic cholecystectomy as compared with open cholecystectomy. The intraoperative injuries are mostly the result of a misinterpretation of anatomical structures due to severe inflammation or topographical variations. In order to minimize this risk, a number of improved operative techniques and behavioral measures have been formulated. Here, we present methodological and operative possibilities as well as techniques that in unclear situations can help to minimize the risk of intraoperative injuries of the biliary tract and the accompanying vascular system.

Laparoscopic cholecystectomy: which predicting factors of conversion? Two Italian center's studies

BACKGROUND

Laparoscopic cholecystectomy represents the gold standard technique for the treatment of lithiasic gallbladder disease. Although it has many advantages, laparoscopic cholecystectomy is not risk-free and in special situations there is a need for conversion into an open procedure, in order to minimize postoperative complications and to complete the procedure safely. The aim of this study was to identify factors that can predict the conversion to open cholecystectomy.

METHODS

We analyzed 1323 patients undergoing laparoscopic cholecystectomy over the last five years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome. Among these, 116 patients (8.7%) were converted into laparotomic cholecystectomy. Clinical, demographic, surgical and pathological data from these patients were included in a prospective database. A univariate analysis was performed followed by a multivariate logistic regression.

RESULTS

On univariate analysis, the factors significantly correlated with conversion to open were the ASA score higher than 3 and the comorbidity, specifically cardiovascular disease, diabetes and chronic renal failure (P<0.001). Patients with a higher mean age had a higher risk of conversion to open (61.9±17.1 vs. 54.1±15.2, P<0.001). Previous abdominal surgery and previous episodes of cholecystitis and/or pancreatitis were not statistically significant factors for conversion. There were four deaths in the group of converted patients and two in the laparoscopic group (P<0.001). Operative morbility was higher in the conversion group (22% versus 8%, P<0.001). Multivariate analysis showed that the factors significantly correlated to conversion were: age <65 years old (P=0.031 OR: 1.6), ASA score 3-4 (P=0.013, OR:1.8), history of ERCP (P=0.16 OR:1.7), emergency procedure (P=0.011, OR:1.7); CRP higher than 0,5 (P<0.001, OR:3.3), acute cholecystitis (P<0.001, OR:1.4). Further multivariate analysis of morbidity, postoperative mortality and home discharge showed that conversion had a significant influence on overall post-operative complications (P=0.011, OR:2.01), while mortality (P=0.143) and discharge at home were less statistically influenced.

CONCLUSIONS

Our results show that most of the independent risk factors for conversion cannot be modified by delaying surgery. Many factors reported in the literature did not significantly impact conversion rates in our results.

Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study

With improved laparoscopic techniques, experience, and availability of newer tools and instruments like ultrasonic shears; laparoscopic cholecystectomy (LC) became a feasible option in cirrhotic patients, the aim of this study was to analyze the outcome of LC in cirrhotic patients.

METHODS

We retrospectively analyzed 213 cirrhotic patients underwent LC, in the period from 2011 to 2019; the overall male/female ratio was 114/99.

RESULTS

The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities.

CONCLUSION

LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.

Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study

With improved laparoscopic techniques, experience, and availability of newer tools and instruments like ultrasonic shears; laparoscopic cholecystectomy (LC) became a feasible option in cirrhotic patients, the aim of this study was to analyze the outcome of LC in cirrhotic patients.

METHODS

We retrospectively analyzed 213 cirrhotic patients underwent LC, in the period from 2011 to 2019; the overall male/female ratio was 114/99.

RESULTS

The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities.

CONCLUSION

LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.

Preoperative and Operative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy in Pakistan

Introduction

The currently available literature suggests a wide range of conversion (4.9-20%) from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) despite the increase in surgical expertise. Open cholecystectomy is important as the last resort for safe surgical practice in complicated cases. Increased number of pre-operative and perioperative risk factors need to be identified to pre-empt conversion. However, there has been a significant decrease in conversion rates over the past few decades. This study was conducted to determine conversion rates in our population and to identify any significant risks for conversion.

Methods

This prospective study was conducted at the Shifa International Hospital, Islamabad, Pakistan, including 1081 cholecystectomies, performed over a two-year period from January 2017 to January 2019. Comparison of risk factors between the two groups; laparoscopic cholecystectomy (LC) group and conversion to open cholecystectomy (OC) group was done. Statistical analysis was done using SPSS 24.0.1. P<0.05 were considered significant.

Results

In our study, the overall conversion rate was 7.78%. Factors of conversion to open cholecystectomy (OC) included age ≥65, morbid obesity, diabetes mellitus, and previous abdominal surgery. Deranged alkaline phosphatase (ALP), increased total bilirubin, increased common bile duct (CBD) diameter, and multiple stones in ultrasonography showed a statistically significant association with the conversion. Per-operative findings of increased adhesions >50%, empyema gallbladder (GB), perforated GB, and scleroatrophic GB showed a higher risk of conversion too (p <0.05). However, there was no statistical association with preoperative endoscopic retrograde cholangiopancreatography (ERCP) to OC in our population.

Conclusion

An open cholecystectomy is a safe approach for patients with complicated gallbladder disease. No doubt laparoscopic cholecystectomy is the gold standard having its outstanding benefits. This study identifies predictors of choice for OC in addition to the decision to convert to OC. In view of the raised morbidity and mortality associated with open cholecystectomy, distinguishing these predictors will serve to decrease the rate of OC and to address these factors preoperatively.

Predicting a 'difficult cholecystectomy' after mild gallstone pancreatitis

BACKGROUND

Cholecystectomy after gallstone pancreatitis may be technically demanding. The aim of this study was to investigate risk factors for a difficult cholecystectomy after mild pancreatitis.

METHODS

This was a prospective study within a randomized controlled trial on the timing of cholecystectomy after mild gallstone pancreatitis. Difficulty of cholecystectomy was scored on a 0 to 10 visual analogue scale (VAS) by the senior attending surgeon. The primary outcome 'difficult cholecystectomy' was defined by presence of one or more of the following features: a VAS score ≥ 8, duration of surgery > 75 minutes, conversion or subtotal cholecystectomy.

RESULTS

249 patients were included in the primary analysis. A difficult cholecystectomy occurred in 82 patients (33%). In the 'same-admission cholecystectomy' group 29 of 112 cholecystectomies were difficult (26%) versus 49 of 127 patients (39%) who underwent surgery after 2 weeks (p = 0.037). After multivariable analysis, male sex (OR 1.80, 95% confidence interval [CI] 1.04-3.13; p = 0.037), prior sphincterotomy (OR 1.79, 95% CI 1.01-3.16; p = 0.046), and delaying cholecystectomy for at least two weeks (OR 1.81, 95% CI 1.04-3.16; p = 0.036) were independent predictors of a difficult cholecystectomy.

CONCLUSION

Surgeons should anticipate a difficult cholecystectomy after mild gallstone pancreatitis in case of male sex, prior sphincterotomy and delayed cholecystectomy.

Predictive Factors for a Long Postoperative Stay after Emergency Laparoscopic Cholecystectomy Using the 2013 Tokyo Guidelines: A Retrospective Study

Laparoscopic cholecystectomy (LC) is widely used for treating early acute cholecystitis (AC) and substantially reduces hospital costs. This study aimed to identify and evaluate risk factors associated with long postoperative hospital stays (PHSs) in patients undergoing emergency LC for AC according to the 2013 Tokyo Guidelines (TG13). Clinical data of patients who underwent emergency LC for AC between 2011 and 2017 were retrospectively collected. Patients were divided into early discharge (ED, discharge in three days or less postoperatively) and late discharge (LD, discharge in more than three days postoperatively) groups based on clinical progression and PHS after LC. Preoperative characteristics and perioperative outcomes were analysed as potential risk factors for LD. Among 149 patients, 104 (69.8%) were discharged within 3 days postoperatively, whereas 45 (30.2%) had long PHSs. Main causes of LD were fever and inflammation. Univariate analysis of preoperative risk factors revealed significant differences in age, white blood cell count, C-reactive protein, total bilirubin (T-bil), and alkaline phosphatase (ALP) levels; anticoagulation therapy; and TG13 severity grade. Multivariate analysis revealed that TG13 severity grade II, age >65 years, and elevated T-bil and ALP levels are independent factors for long PHS. Older age, worse biliary function, and increased TG13 severity grade might predict prolonged PHSs in AC patients undergoing emergency LC.

2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population

Background

Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide.

Aim

The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population.

Material and methods

The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences.

Results

The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain.

Discussion and conclusions

The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

Predicting Conversion from Laparoscopic to Open Cholecystectomy: A Single Institution Retrospective Study

BACKGROUND

Laparoscopic cholecystectomy (LC) is the standard surgical treatment for benign gallbladder disease. Nevertheless, conversion to open cholecystectomy (OC) is needed in some cases. The aim of this study is to calculate our institutional conversion rate and to identify the variables that are implicated in increasing the risk of conversion (LC-OC).

MATERIALS AND METHODS

We carried out a retrospective study of all cases of LC performed at the American University of Beirut Medical Center between 2000 and 2015. Each (LC-OC) case was randomly matched to a laparoscopically completed case by the same consultant within the same year of practice, as the LC-OC case, in a 1:5 ratio. Forty-eight parameters were compared between the two study groups.

RESULTS

Forty-eight out of 4668 LC were converted to OC over the 15-year study period; the conversion rate in our study was 1.03%. The variables that were found to be most predictive of conversion were male gender, advanced age, prior history of laparotomy, especially in the setting of prior gunshot wound, a history of restrictive or constrictive lung disease and anemia (Hb < 9 g/dl). The most common intraoperative reasons for conversion were perceived difficult anatomy or obscured view secondary to severe adhesions or significant inflammation. Patients who were in the LC-OC arm had a longer length of hospital stay.

CONCLUSION

Advance age, male gender, significant comorbidities and history of prior laparotomies have a high risk of conversion. Patients with these risk factors should be counseled for the possibility of conversion to open surgery preoperatively. Further research is needed to determine whether these high risks patients should be operated on by surgeons with more extensive experience in minimal invasive surgery.

Risk Factors for Open Conversion in Minimally Invasive Cholecystectomy

Background and Objectives:

Open conversion (OC) occurs in 5 to 10% of laparoscopic cholecystectomies (LCs) and results in suboptimal outcomes. Herein, we report our experience with OC in cholecystectomy performed with the minimally invasive (MIS) approach.

Methods:

Data from 960 minimally invasive cholecystectomies performed in the University of Illinois at Chicago (UIC) Division of General, Minimally Invasive, and Robotic Surgery were retrospectively compiled. Patient demographics and outcomes were analyzed for the major indicators that may predispose to OC.

Results:

Male gender and intraoperative diagnosis of acute or gangrenous cholecystitis were identified as statistically significant individual predictors for OC. Conversion incidence was significantly lower in every paired demographic combination when compared with the laparoscopic data.

Conclusions:

Our retrospective study identified some specific factors associated with significantly higher risk of OC in both laparoscopic and robotic cholecystectomy. The impact of these risk factors seems to be lesser in the robotic than in the laparoscopic approach. Further investigation is necessary to validate these findings.

A case report on a left sided gallbladder: A rare finding during cholecystectomy

•

Cholecystectomy is a common procedure increasingly performed in the day surgery setting.

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A true left sided gallbladder is a rare finding. Retrospective studies suggest a prevalence of 0.1–0.7%.

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Exact aetiology and pathway for its anatomical variation is has yet to be determined.

•

It can be associated with number of other structural variation affect the biliary system the knowledge of which is paramount in hepatobiliary surgery.

Introduction

Cholecystectomy is the surgical removal of gallbladder for symptomatic gallstones disease or where exist the risk of gallbladder malignancy. Its performed routinely across the globe often as day surgery. In this case report, we describe an incidental intra operative finding of a left sided gallbladder creating a technical challenge for the surgeon.

Case

We describe the case of 35 year old female who presented with RUQ pain. Ultrasound examination revealed gallstones. Intraoperative findings during routine cholecystectomy were of a left sided gallbladder. The surgical procedure in performing laparoscopic surgery required an extra port placement for safe and effective dissection.

Discussion

The finding of left sided gallbladder is a rare congenital anomaly and has a prevalence of 0.1–0.7%. A true left sided gallbladder is one that is found to the left of the ligamentum teres and falciform ligament and the cystic artery always crosses in front of the CBD from right to left. There are various abnormalities associated this anatomical variant from abnormality of the biliary tree to the porto-venous anatomy. Failure to recognise these variations can lead to serious complications especially in hepatobiliary surgery.

Conclusion

The finding of left sided gallbladder is an abnormality which is often discovered intraoperatively. It may provide the surgeon with operative challenges in performing the surgery safely and increase the incidence of morbidity. If there is any clinical suspicion of the presence of a left sided gallbladder, pre-operative CT angiography and/or intraoperative cholangiography should be performed to minimise the risk of intraoperative complications.

External validation of the Cairns Prediction Model (CPM) to predict conversion from laparoscopic to open cholecystectomy

BACKGROUND

Valid and user-friendly prediction models for conversion to open cholecystectomy allow for proper planning prior to surgery. The Cairns Prediction Model (CPM) has been in use clinically in the original study site for the past three years, but has not been tested at other sites.

METHODS

A retrospective, single-centred study collected ultrasonic measurements and clinical variables alongside with conversion status from consecutive patients who underwent laparoscopic cholecystectomy from 2013 to 2016 in The Townsville Hospital, North Queensland, Australia. An area under the curve (AUC) was calculated to externally validate of the CPM.

RESULTS

Conversion was necessary in 43 (4.2%) out of 1035 patients. External validation showed an area under the curve of 0.87 (95% CI 0.82-0.93, p = 1.1 × 10^-14).

CONCLUSIONS

In comparison with most previously published models, which have an AUC of approximately 0.80 or less, the CPM has the highest AUC of all published prediction models both for internal and external validation.

Open Cholecystectomy Has a Place in the Laparoscopic Era: a Retrospective Cohort Study

Laparoscopic cholecystectomy (LC) is considered the gold standard for treatment of symptomatic gallbladder stones and has replaced the traditional open cholecystectomy (OC). The aim of this study is to evaluate the proper indications of the primary OC and conversion from LC and their predictive factors. This study includes all patients who underwent cholecystectomy between January 2011 and June 2016, whether open from the start (group A), conversion from laparoscopic approach (group B), or laparoscopic cholecystectomy (group C). There were 3269 patients underwent cholecystectomy. LC was completed in 3117 (95.4%) patients. The overall conversion rate was 83 (2.5%). The main two causes of conversion were adhesion in 35 (42.2%) patients and unclear anatomy in 29 (34.9%) patients. Primary OC was indicated in 69 (2.1%) patients due to previous history of upper abdominal operations in 16 (23.2%) patients and anesthetic problem in 21 (30.4%) patients. Age >60 years, male sex, diabetic patients, history of endoscopic retrograde cholangiopancreatography, dilated common bile duct, gallbladder status, adhesion, and previous upper abdominal operation were demonstrated to be independent risk factors for OC. Open cholecystectomy still has a place in the era of laparoscopy. Conversion should not be a complication, but it represents a valuable choice to avoid an additional risk. Safe OC required training because of the causes of conversion, usually unsafe anatomy, occurrence of complications, or anesthetic problems, in order to prevent disastrous complications.

Risk factors for conversion of laparoscopic cholecystectomy to open surgery - A systematic literature review of 30 studies

BACKGROUND

The study aims to evaluate the methodological quality of publications relating to predicting the need of conversion from laparoscopic to open cholecystectomy and to describe identified prognostic factors.

METHOD

Only English full-text articles with their own unique observations from more than 300 patients were included. Only data using multivariate analysis of risk factors were selected. Quality assessment criteria stratifying the risk of bias were constructed and applied.

RESULTS

The methodological quality of the studies were mostly heterogeneous. Most studies performed well in half of the quality criteria and considered similar risk factors, such as male gender and old age, as significant. Several studies developed prediction models for risk of conversion. Independent risk factors appeared to have additive effects.

CONCLUSION

A detailed critical review of studies of prediction models and risk stratification for conversion from laparoscopic to open cholecystectomy is presented. One study is identified of high quality with a potential to be used in clinical practice, and external validation of this model is recommended.

Difficult Laparoscopic Cholecystectomy and Trainees: Predictors and Results in an Academic Teaching Hospital

Laparoscopic cholecystectomy (LC) is one of the first laparoscopic procedures performed by surgical trainees. This study aims to determine preoperative and/or intraoperative predictors of difficult LC and to compare complications of LC performed by trainees with that performed by trained surgeons. A cohort of 180 consecutive patients with cholelithiasis who underwent LC was analyzed. We used univariate and binary logistic regression analyses to predict factors associated with difficult LC. We compared the rate of complications of LCs performed by trainees and that performed by trained surgeons using Pearson's chi-square test. Patients with impacted stone in the neck of the gallbladder (GB) (OR, 5.0; 95% CI, 1.59-15.77), with adhesions in the Triangle of Calot (OR, 2.9; 95% CI, 1.27-6.83), or with GB rupture (OR, 3.4; 95% CI, 1.02-11.41) were more likely to experience difficult LC. There was no difference between trainees and trained surgeons in the rate of cystic artery injury (p = .144) or GB rupture (p = .097). However, operative time of LCs performed by trained surgeons was significantly shorter (median, 45 min; IQR, 30-70 min) compared with the surgical trainees' operative time (60 min; IQR, 50-90 min). Surgical trainees can perform difficult LC safely under supervision with no increase in complications albeit with mild increase in operative time.

Can the timing of laparoscopic cholecystectomy after biliary pancreatitis change the conversion rate to open surgery?

BACKGROUND

Biliary pancreatitis (BP) constitutes 30-55% of all cases of acute pancreatitis. Laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease. We aimed to compare and evaluate the relation between the timing of LC and the rates and reasons of conversion to open surgery (OS) after BP.

METHODS

Data were collected of patients who presented for the first time with acute BP and underwent LC. The patients were divided into two groups: early cholecystectomy (Group 1), patients who underwent cholecystectomy during the first pancreatitis attack upon admission and before discharge from hospital (1-3 days); and late cholecystectomy (Group 2), patients who received medical treatment during their first pancreatitis episode and underwent surgery after 4-10 weeks. Sex, Ranson scores, American Society of Anesthesiology scores, and conversion reasons were compared.

RESULTS

Group 1 and Group 2 included 75 patients (20 men, 55 women) and 87 patients (25 men, 62 women), respectively. The mean age was 44.7 years (range, 21-82 years). Obscure anatomy with adhesions was detected in 16 patients (5 in Group 1, 11 in Group 2) as the leading cause of conversion to OS, but it was not statistically significant (p=0.054). Acute inflammation with empyema and peripancreatic liquid collection was observed in 14 patients (12 in Group 1, 2 in Group 2), and conversion to OS was statistically significantly higher in Group 1 (p=0.016).

CONCLUSION

Timing of LC does not influence the conversion rates to OS after BP.

Preoperative hypoalbuminemia is an independent risk factor for conversion from laparoscopic to open cholecystectomy in patients with cholecystolithiasis

INTRODUCTION

Laparoscopic cholecystectomy (LC) is regarded as the first choice for patients with cholecystolithiasis, but some patients require conversion to open cholecystectomy (OC) because of inflammation-related incidents. Therefore, the aim of this study is to explore the risk factors for conversion to OC in patients undergoing elective LC for cholecystolithiasis.

METHODS

This study included 461 patients who underwent elective LC for cholecystolithiasis were between April 2000 and September 2010. Receiver-operator curve (ROC) analysis was used to define the ideal cut-off values of clinicolaboratory characteristics, and the area under the ROC for conversion was also measured. Univariate and multivariate analyses using preoperative clinicolaboratory characteristics were performed to investigate the most significant risk factors for conversion to OC in patients with cholecystolithiasis.

RESULTS

Multivariate analysis using nine parameters selected by univariate analyses demonstrated that γ-glutamyltransferase (<20/>20 IU/L) (odds ratio, 8.777; 95% confidence interval, 1.132-68.06; P = 0.038), albumin (<3.8/>3.8 g/dL) (odds ratio, 0.329; 95% confidence interval, 0.127-0.850; P = 0.022), and platelet count (<27/>27 × 10⁴ /mm³ ) (odds ratio, 2.573; 95% confidence interval, 1.048-6.319; P = 0.039) were associated with conversion. Among these three parameters, ROC curve analysis disclosed that albumin (0.705) had the largest area under the ROC (γ-glutamyltransferase, 0.622, platelet count, 0.536) for conversion.

CONCLUSIONS

Preoperative hypoalbuminemia is the most important risk factor for conversion to OC in patients undergoing elective LC for cholecystolithiasis.

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Anticipation of complications after laparoscopic cholecystectomy: prediction of individual outcome

BACKGROUND

Complication rates after a laparoscopic cholecystectomy are still up to 10 %. Knowledge of individual patient risk profiles could help to reduce morbidity.

AIM

The aim of this study is to create risk profiles for specific complications to anticipate on individual outcome.

PATIENTS AND METHODS

Individual patient outcome for a specific post-operative complication was assessed from a retrospective database of two major teaching hospitals, using uni- and multivariable analyses.

RESULTS

A total of 4359 patients were included of which 346 developed one or more complications (8 %). Five risk profiles were found to predict specific complications: older patients (>65 year) are at risk for pneumonia (OR 7.0, 95 % CI 3.3-15.0, p < 0.001) and bleeding (OR 2.2, 95 % CI 1.2-3.9, p = 0.014), patients with acute cholecystitis are at risk for intra-abdominal abscess (OR 5.9, 95 % CI 3.4-10.1, p < 0.001), bile leakage (OR 3.6, 95 % CI 2.0-6.6, p < 0.001) and pneumonia (OR 3.5, 95 % CI 1.6-7.6, p < 0.002), previous history of cholecystitis is predictive for wound infection (OR 5.1, 95 % CI, (2.7-9.7), p < 0.001), intra-abdominal abscess (OR 6.1, 95 % CI 2.8-13.8, p < 0.001), post-operative bleeding (OR 4.8, 95 % CI 2.1-11.1, p < 0.001), bile leakage (OR 7.2, 95 % CI 3.4-15.4, p < 0.001) and pneumonia (OR 3.9, 95 % CI 1.3-11.9, p = 0.018), pre-operative ERCP is predictive for intra-abdominal abscess (OR 3.3, 95 % CI 2.0-5.7, p < 0.001), post-operative bleeding (OR 2.1, 95 % CI 1.2-3.9, p = 0.058) and pneumonia (OR 3.8, 95 % CI 1.9-7.8, p = 0.001), and converted patients are at risk for wound infection (OR 4.0, 95 % CI 2.1-7.7, p < 0.001) and intra-abdominal abscess (OR 3.5, 95 % CI 1.6-7.7, p = 0.002).

CONCLUSION

Individual risk prediction of outcome after laparoscopic cholecystectomy is feasible. This facilitates individual pre-operative doctor-patient communication and may tailor surgical strategies.

[Not Available]

OBJECTIVES

Database review to analyse age and sex differences in complication and conversion rates and influence on return to normal daily activities and work after laparoscopic cholecystectomy (LC).

METHODS

658 patients had a laparoscopic cholecystectomy for proven gallstones between 9/4/2001 and 15/2/2006 under the care of one surgeon (F. H.) at Benenden hospital, Kent, UK.

RESULTS

We had a 65.5% response rate with 431 replies at a mean follow up of 22.4 months (2.3-52.8). There was a male to female ratio of 5:23 with a mean age of 54.2 years (22-83). Using linear regression we found no significant correlation with operative time and variables of age and sex (df = 2, 251, R (2) = 0.03, F = 0.574, p < 0.564). No significant correlation with number of complications and age or sex (df = 2, 334, R (2) = 0.004, F = 1.615, p < 0.200). Age (Exp(B) = 1.040, p < 0.51) and sex (Exp(B) = 0.863, p < 0.855) had no effect on conversion. No difference was found in relation to age and sex with return to normal daily activities (df = 2, 307, F = 0.904, p < 0.406). Age was a non-significant predictor of return to work (Beta = 0.040, p < 0.572) however men return to work significantly sooner (Beta = 0.191, p < 0.007).

CONCLUSIONS

Operative time, number of complications, conversion to open and return to normal daily activities may not be affected by age or sex of patients. Hospital stay may be longer in older patients. Men appear to return to work sooner. Further analysis with validated questionnaires are required.

Is routine single-incision laparoscopic cholecystectomy feasible? A retrospective observational study

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) has been shown to be safe for uncomplicated gallbladder diseases. Routinely applying SILC is debatable.

METHODS

Two hundred SILCs were performed with single-incision multiple-port longitudinal-array and self-camera techniques.

RESULTS

Eighty-eight (44%) procedures were scheduled for complicated diseases. The routine group had a higher comorbidity rate, a lower preoperative endoscopic retrograde cholangiopancreatography rate, a higher intraoperative cholangiography rate, a higher proportion of complicated gallbladder diseases, shorter operative time, more intraoperative blood loss, and lower postoperative pethidine dose than the selective group (the first 73 patients). The conversion and complication rates showed no statistical difference. It took fewer cases but longer time to pass the learning phase of SILC for complicated gallbladder diseases. The multivariate analysis showed that male sex and complicated gallbladder diseases were associated with a higher procedure conversion rate, and increased patient age was related to a higher complication rate.

CONCLUSIONS

Routine SILC for benign gallbladder diseases is feasible in the experienced phase. Practicing SILC for uncomplicated gallbladder diseases helps to achieve competence in this technique for complicated diseases.

Predicting prolonged hospital stay after laparoscopic cholecystectomy

INTRODUCTION

Widespread application of laparoscopic cholecystectomy (LC) has resulted in a high complication rate and leads to prolonged hospital stays. This study aimed to investigate the preoperative and intraoperative clinical factors that relate to prolongation of hospital stay.

METHODS

We studied 370 patients who underwent LC for gallbladder disease between 2008 and 2012. Clinical risk factors were retrospectively collected. The clinical pathway for LC was indicated for all patients, and they were divided into two groups according to postoperative length of stay (LOS): the normal duration group (LOS ≤5 days) and the long duration (LD) group (LOS ≥6 days). Multiple regression analysis was used to predict risk factors that identified hospital prolongation to create a LOS prediction score.

RESULTS

The normal duration group was 236 patients and the LD group was 134. Seventeen patients (4.6%) required conversion from laparoscopic to open surgery. LOS was 4.82 days in the normal duration group and 12.08 days in the LD group. In the LD group, 18.7% of the patients stayed more than 14 days, but no patients were readmitted. Thirteen clinical factors were statistically different between the two groups. ASA score and LC difficulty were the most predictive risk factors for LOS prolongation. LOS prediction score consisted of eight variables selected from 13 factors; it helped determine the likelihood of whether a patients' hospital stay was prolonged (sensitivity, 82.1%; specificity, 75.0%).

CONCLUSION

Thirteen factors closely related to hospital stay duration and LOS prediction score could predict the prolongation of a patient's hospital stay.

Understanding the reasons for the refusal of cholecystectomy in patients with cholelithiasis: how to help them in their decision?

BACKGROUND

Cholelithiasis is prevalent surgical disease, with approximately 60,000 admissions per year in the Unified Health System in Brazil. Is often asymptomatic or oligosymptomatic and major complications arise from the migration of calculi to low biliary tract. Despite these complications are severe and life threatening, some patients refuse surgical treatment.

AIM

To understand why individuals with cholelithiasis refuse cholecystectomy before complications inherent to the presence of gallstones in the bile duct and pancreatitis occur.

METHODS

To investigate the universe of the justifications for refusing to submit to surgery it was performed individual interviews according to a predetermined script. In these interviews, was evaluate the knowledge of individuals about cholelithiasis and its complications and the reasons for the refusal of surgical treatment. Were interviewed 20 individuals with cholelithiasis who refused or postponed surgical treatment without a plausible reason. To these interviews, was applied the technique of thematic analysis (Minayo, 2006).

RESULTS

The majority of respondents had good knowledge of their disease and its possible complications, were well oriented and had surgical indications by their physicians. The refusal for surgery was justified primarily on negative experiences of themselves or family members with surgery, including anesthesia; fear of pain or losing their autonomy during surgery and postoperative period, preferring to take the risk and wait for complications to then solve them compulsorily.

CONCLUSION

The reasons for the refusal to surgical resolution of cholelithiasis were diverse, but closely related to personal (or related persons) negative surgical experiences or complex psychological problems that must be adequately addressed by the surgeon and other qualified professionals.

Clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones or cholecystitis: a systematic review and economic evaluation

BACKGROUND

Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of choice for people who present with biliary pain or acute cholecystitis and evidence of gallstones. However, some people do not experience a recurrence after an initial episode of biliary pain or cholecystitis. As most of the current research focuses on the surgical management of the disease, less attention has been dedicated to the consequences of conservative management.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management in people presenting with uncomplicated symptomatic gallstones (biliary pain) or cholecystitis.

DATA SOURCES

We searched all major electronic databases (e.g. MEDLINE, EMBASE, Science Citation Index, Bioscience Information Service, Cochrane Central Register of Controlled Trials) from 1980 to September 2012 and we contacted experts in the field.

REVIEW METHODS

Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies that enrolled people with symptomatic gallstone disease (pain attacks only and/or acute cholecystitis). Two reviewers independently extracted data and assessed the risk of bias of included studies. Standard meta-analysis techniques were used to combine results from included studies. A de novo Markov model was developed to assess the cost-effectiveness of the interventions.

RESULTS

Two Norwegian RCTs involving 201 participants were included. Eighty-eight per cent of people randomised to surgery and 45% of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications [risk ratio = 6.69; 95% confidence interval (CI) 1.57 to 28.51; p = 0.01], in particular acute cholecystitis (risk ratio = 9.55; 95% CI 1.25 to 73.27; p = 0.03), and less likely to undergo surgery (risk ratio = 0.50; 95% CI 0.34 to 0.73; p = 0.0004), experience surgery-related complications (risk ratio = 0.36; 95% CI 0.16 to 0.81; p = 0.01) or, more specifically, minor surgery-related complications (risk ratio = 0.11; 95% CI 0.02 to 0.56; p = 0.008) than those randomised to surgery. Fifty-five per cent of people randomised to observation did not require an operation during the 14-year follow-up period and 12% of people randomised to cholecystectomy did not undergo the scheduled operation. The results of the economic evaluation suggest that, on average, the surgery strategy costs £1236 more per patient than the conservative management strategy but was, on average, more effective. An increase in the number of people requiring surgery while treated conservatively corresponded to a reduction in the cost-effectiveness of the conservative strategy. There was uncertainty around some of the parameters used in the economic model.

CONCLUSIONS

The results of this assessment indicate that cholecystectomy is still the treatment of choice for many symptomatic people. However, approximately half of the people in the observation group did not require surgery or suffer complications in the long term indicating that a conservative therapeutic approach may represent a valid alternative to surgery in this group of people. Owing to the dearth of current evidence in the UK setting a large, well-designed, multicentre trial is needed.

STUDY REGISTRATION

The study was registered as PROSPERO CRD42012002817.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Predicting conversion from laparoscopic to open cholecystectomy presented as a probability nomogram based on preoperative patient risk factors

BACKGROUND

We aim to develop a risk stratification tool to preoperatively predict conversion (CONV) from a laparoscopic to open cholecystectomy.

METHODS

Multiple risk factors were analyzed with multivariate logistic regression and presented as probability nomograms.

RESULTS

Of 732 patients, 47 (6.4%) required CONV. Among 40 preoperative risk factors evaluated, 5 variables were found to have significant association with CONV: 2 clinical variables, previous upper abdominal surgery (odds ratio [OR] 95.2) and obesity defined as body mass index greater than 30 kg/m(2) (OR 12.3), and 3 ultrasound parameters, visible choledocholithiasis (OR 19.8), impacted stone at the neck of the gallbladder (OR 5.9), and gallbladder wall width in millimeters (OR 2.1). Nomograms based on this multivariate model demonstrate the individual preoperative probability of CONV. Internal validation using receiver operator curve analysis showed an area under the curve of .97.

CONCLUSION

Four probability nomograms were developed as a practical individual risk stratification tool to predict probability of CONV.