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Dhanasekara CS, Shrestha K, Grossman H, Garcia LM, Maqbool B, Luppens C, Dumas RP, Taveras Morales LR, Brahmbhatt TS, Haqqani M, Lunevicius R, Nzenwa IC, Griffiths E, Almonib A, Bradley NL, Lerner EP, Mohseni S, Trivedi D, Joseph BA, Anand T, Plevin R, Nahmias JT, Lasso ET, Dissanaike S. A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study. Surgery 2024; 176:605-613. [PMID: 38777659 DOI: 10.1016/j.surg.2024.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/27/2024] [Accepted: 03/27/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Dense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder. METHODS A multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created. RESULTS In 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%. CONCLUSION Laparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.
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Affiliation(s)
| | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Holly Grossman
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Liza M Garcia
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Baila Maqbool
- Department of Surgery, University of New Mexico, Albuquerque, NM
| | - Carolyn Luppens
- Department of Surgery, University of New Mexico, Albuquerque, NM
| | - Ryan P Dumas
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Maha Haqqani
- Department of Surgery, Boston Medical Center, Boston, MA
| | - Raimundas Lunevicius
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ikemsinachi C Nzenwa
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; Department of Surgery, Massachusetts General Hospital, MA
| | - Ewen Griffiths
- Queen Elizabeth Hospital, University Hospitals NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Ahmed Almonib
- Queen Elizabeth Hospital, University Hospitals NHS Foundation Trust, Edgbaston, Birmingham, UK
| | | | - E Paul Lerner
- Department of Surgery, University of Alberta, Canada
| | - Shahin Mohseni
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City-Mayo Clinic, Abu Dhabi, UAE; School of Medical Sciences, Orebro University, Sweden
| | - Dhanisha Trivedi
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City-Mayo Clinic, Abu Dhabi, UAE; School of Medical Sciences, Orebro University, Sweden
| | | | - Tanya Anand
- Department of Surgery, University of Arizona, Tucson, AZ
| | - Rebecca Plevin
- Department of Surgery, University of California San Francisco, CA
| | - Jeffry T Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA
| | - Erika Tay Lasso
- Department of Surgery, University of California, Irvine, Orange, CA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX.
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Hori K, Abe T, Abe N, Abe J, Okada K, Takahashi K, Harada S, Furumido J, Murai S, Kon M, Hashimoto K, Masumori N, Kakizaki H, Shinohara N. Gap analysis between trainees' subjective competencies and the competencies expected by instructors in urology: A need assessment survey in Japan. Int J Urol 2024; 31:653-661. [PMID: 38366737 DOI: 10.1111/iju.15430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 02/07/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVE According to the rapid progress in surgical techniques, a growing number of procedures should be learned during postgraduate training periods. This study aimed to clarify the current situation regarding urological surgical training and identify the perception gap between trainees' competency and the competency expected by instructors in Japan. METHODS Regarding the 40 urological surgical procedures selected via the Delphi method, we collected data on previous caseloads, current subjective autonomy, and confidence for future skill acquisition from trainees (<15 post-graduate years [PGY]), and the competencies when trainees became attending doctors expected by instructors (>15 PGY), according to a 5-point Likert scale. In total, 174 urologists in Hokkaido Prefecture, Japan were enrolled in this study. RESULTS The response rate was 96% (165/174). In a large proportion of the procedures, caseloads grew with accumulation of years of clinical practice. However, trainees had limited caseloads of robotic and reconstructive surgeries even after 15 PGY. Trainees showed low subjective competencies at present and low confidence for future skill acquisition in several procedures, such as open cystectomy, ureteroureterostomy, and ureterocystostomy, while instructors expected trainees to be able to perform these procedures independently when they became attending doctors. CONCLUSION Trainees showed low subjective competencies and low confidence for future skill acquisition in several open and reconstructive procedures, while instructors considered that these procedures should be independently performable by attending doctors. We believe that knowledge of these perception gaps is helpful to develop a practical training program.
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Affiliation(s)
- Kanta Hori
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takashige Abe
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Noriyuki Abe
- Department of Urology, Asahikawa Medical University, Asahikawa, Japan
| | - Junya Abe
- Department of Urology, Sapporo Medical University, Sapporo, Japan
| | - Kazufumi Okada
- Promotion Unit, Data Science Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Keita Takahashi
- Promotion Unit, Data Science Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Shigeru Harada
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Jun Furumido
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Sachiyo Murai
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masafumi Kon
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kohei Hashimoto
- Department of Urology, Sapporo Medical University, Sapporo, Japan
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University, Sapporo, Japan
| | - Hidehiro Kakizaki
- Department of Urology, Asahikawa Medical University, Asahikawa, Japan
| | - Nobuo Shinohara
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Hoffman M, Dunsmore V, Cliby W, Chi D, Wheeler S, Clarke-Pearson D. Surgical training of gynecologic oncology fellows: Long-term trends and implications for future education. Gynecol Oncol 2024; 184:254-258. [PMID: 38696840 DOI: 10.1016/j.ygyno.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/02/2024] [Accepted: 04/21/2024] [Indexed: 05/04/2024]
Abstract
OBJECTIVES The surgical training of gynecologic oncology (GO) fellows is critical to providing excellent care to women with gynecologic cancers. We sought to evaluate changes in techniques and surgical volumes over an 18-year period among established GO fellowships across the US. METHODS We emailed surveys to 30 GO programs that had trained fellows for at least 18 years. Surveys requested the number of surgical cases performed by a fellow for seventeen surgical procedures over each of five-time intervals. A One-Way Analysis of Variance was conducted for each procedure, averaged across institutions, to examine whether each procedure significantly changed over the 18-year span. RESULTS 14 GO programs responded and were included in the analysis using SPSS. We observed a significant increase in the use of minimally invasive (MIS) procedures (robotic hysterectomy (p < .001), MIS pelvic (p = .001) and MIS paraaortic lymphadenectomy (p = .008). There was a concurrent significant decrease in corresponding "open" procedures. There was a significant decrease in all paraaortic lymphadenectomies. Complex procedures (such as bowel resection) remained stable. However, there was a wide variation in the number of cases reported with extremely small numbers for some critical procedures. CONCLUSIONS The experience of GO fellows has shifted toward increased use of MIS. While these trends in care are appropriate, they do not diminish the need in many patients for complex open procedures. These findings should help spur the development of innovative training to maintain the ability to provide these core, specialty-defining procedures safely.
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Affiliation(s)
- Mitchel Hoffman
- Moffitt Cancer Center, University of South Florida, Tampa, FL, United States of America
| | - Victoria Dunsmore
- University of North Carolina Lineberger Cancer Center, Chapel Hill, NC, United States of America
| | - William Cliby
- Mayo Clinic, Rochester, MN, United States of America
| | - Dennis Chi
- Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Stephanie Wheeler
- University of North Carolina Lineberger Cancer Center, Chapel Hill, NC, United States of America
| | - Daniel Clarke-Pearson
- University of North Carolina School of Medicine, Chapel Hill, NC, United States of America.
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Grossman H, Holder KG, Freedle C, Dhanasekara CS, Dissanaike S. Comparing Outcomes of Sub-Total Cholecystectomy Versus Open Cholecystectomy as Bailout Procedures for the Difficult Gallbladder. Am Surg 2023; 89:5372-5378. [PMID: 36573574 DOI: 10.1177/00031348221148345] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Although laparoscopic cholecystectomy is one of the most common operations performed, there is no consensus on the best surgical approach when inflammation obscures hepatocystic anatomy in severe cholecystitis. Traditionally, this situation triggered conversion to open cholecystectomy (COC); however, in recent decades, alternative approaches have been described. We compared outcomes of bailout procedures for severe cholecystitis, primarily focusing on COC versus laparoscopic subtotal cholecystectomy (LSTC). STUDY DESIGN Retrospective review comparing outcomes of intended laparoscopic cholecystectomy cases that were converted to bailout procedures between 2015-2020 at a single institution. Bailout procedures were categorized into LSTC and COC groups. Demographics, clinical presentation, time to surgery, operative indications, operative duration, and post-operative outcomes were compared using independent sample t-tests with Welch-Satterthwaite correction or Wilcoxon rank-sum tests (continuous variables) or Fisher's exact/χ2 tests. A P-value of less than .05 was considered significant. RESULTS Final analysis included 158 subjects: 55 LSTC and 99 COC. Patient demographics and clinical presentations were similar between groups. LSTC had shorter operative time, fewer ICU admissions, and shorter length of stay than COC (P < .05). There were 9 (9.2%) cases of ileus, 4 (4.0%) cases of post-operative bleeding, and 2 (2.0%) cases of bile duct injury in COC. There was 1 (1.8%) case of ileus, 1 (1.8%) case of post-operative bleeding, and no bile duct injury in LSTC. CONCLUSION LSTC was associated with fewer complications than COC, which had higher rates of biliary injury, bleeding, ileus, ICU admission, and longer hospital stay.
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Affiliation(s)
- Holly Grossman
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Katherine G Holder
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Caroline Freedle
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | | | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Huseynov E, Aliyev V, Coban G. Bile Leakage From the Luschka Duct After Laparoscopic Sleeve Gastrectomy and Cholecystectomy: A Case Report. Cureus 2023; 15:e35684. [PMID: 37009350 PMCID: PMC10065306 DOI: 10.7759/cureus.35684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2023] [Indexed: 03/06/2023] Open
Abstract
Bile leakage may develop as a result of traumatic or iatrogenic injuries of bile ducts during laparoscopic cholecystectomy (LC). The frequency of Luschka duct injuries during LC is extremely rare. In this case, we present a case of bile leakage due to Luschka duct injury during sleeve gastrectomy (SG) and LC. The leakage was not noticed during the surgery, and on postoperative day 2, bilious drainage was seen from the drain. Magnetic resonance imaging (MRI) was helpful to determine Luschka duct injury. Biliary leakage resolved after endoscopic retrograde cholangiopancreatography (ERCP) with stent placement.
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Mullens CL, Ibrahim AM. Invited Commentary: Advancing the Safety of Laparoscopic Cholecystectomy-Collaboration between Radiologists and Surgeons. Radiographics 2022; 42:E147-E148. [PMID: 35904984 DOI: 10.1148/rg.220008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Cody L Mullens
- From the Department of Surgery (C.L.M., A.M.I.), Taubman College of Architecture and Urban Planning (A.M.I.), and Center for Healthcare Outcomes and Policy (A.M.I.), University of Michigan, 2800 Plymouth Rd, Building 16, Ann Arbor, MI 48109
| | - Andrew M Ibrahim
- From the Department of Surgery (C.L.M., A.M.I.), Taubman College of Architecture and Urban Planning (A.M.I.), and Center for Healthcare Outcomes and Policy (A.M.I.), University of Michigan, 2800 Plymouth Rd, Building 16, Ann Arbor, MI 48109
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Are We Forgetting Open Cholecystectomy? Indian J Surg 2022. [DOI: 10.1007/s12262-022-03325-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Riccardi M, Dughayli M, Baidoun F. Open Cholecystectomy for the New Learner-Obstacles and Challenges. JSLS 2021; 25:JSLS.2021.00026. [PMID: 34248339 PMCID: PMC8245272 DOI: 10.4293/jsls.2021.00026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- Margaret Riccardi
- Department of General Surgery, Henry Ford Wyandotte Hospital, Wyandotte, Michigan
| | - Mohamad Dughayli
- Department of General Surgery, Henry Ford Wyandotte Hospital, Wyandotte, Michigan
| | - Fadi Baidoun
- Department of General Surgery, Henry Ford Wyandotte Hospital, Wyandotte, Michigan
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Askari A, Riaz AA, Brittain R, Zhou J, Irwin S, Talbot M. Benefits of intraoperative cholangiogram for acute cholecystitis. SURGICAL PRACTICE 2021. [DOI: 10.1111/1744-1633.12491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Alan Askari
- West Hertfordshire Hospitals NHS Trust Watford UK
| | | | | | - Joel Zhou
- St. George Hospital Sydney New South Wales Australia
| | - Saskia Irwin
- St. George Hospital Sydney New South Wales Australia
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Donnellan E, Coulter J, Mathew C, Choynowski M, Flanagan L, Bucholc M, Johnston A, Sugrue M. A meta-analysis of the use of intraoperative cholangiography; time to revisit our approach to cholecystectomy? Surg Open Sci 2021; 3:8-15. [PMID: 33937738 PMCID: PMC8076912 DOI: 10.1016/j.sopen.2020.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite some evidence of improved survival with intraoperative cholangiography during cholecystectomy, debate has raged about its benefit, in part because of its questionable benefit, time, and resources required to complete. METHODS An International Prospective Register of Systematic Reviews-registered (ID CRD42018102154) meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Scopus, Web of Science, and Cochrane library from 2003 to 2018 was undertaken including search strategy "intraoperative AND cholangiogra* AND cholecystectomy." Articles scoring ≥ 16 for comparative and ≥ 10 for noncomparative using the Methodological Index for Non-Randomized Studies criteria were included. A dichotomous random effects meta-analysis using the Mantel-Haenszel method performed on Review Manager Version 5.3 was carried out. RESULTS Of 2,059 articles reviewed, 62 met criteria for final analysis. The mean rate of intraoperative cholangiography was 38.8% (range 1.6%-96.4%).There was greater detection of bile duct stones during cholecystectomy with routine intraoperative cholangiography compared with selective intraoperative cholangiography (odds ratio = 3.28, confidence interval = 2.80-3.86, P value < .001). While bile duct injury during cholecystectomy was less with intraoperative cholangiography (0.39%) than without intraoperative cholangiography (0.43%), it was not statistically significant (odds ratio = 0.88, confidence interval = 0.65-1.19, P value = .41). Readmission following cholecystectomy with intraoperative cholangiography was 3.0% compared to 3.5% without intraoperative cholangiography (odds ratio = 0.91, confidence interval = 0.78-1.06, P value = .23). CONCLUSION The use of intraoperative cholangiography still has its place in cholecystectomy based on the detection of choledocholithiasis and the potential reduction of unfavorable outcomes associated with common bile duct stones. This meta-analysis, the first to review intraoperative cholangiography use, identified a marked variation in cholangiography use. Retrospective studies limit the ability to critically define association between intraoperative cholangiography use and bile duct injury.
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Affiliation(s)
- Eoin Donnellan
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Jonathan Coulter
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Cherian Mathew
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Michelle Choynowski
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
| | - Louise Flanagan
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Magda Bucholc
- Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Londonderry, Northern Ireland
| | - Alison Johnston
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
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Ahmed O, Walsh TN. Surgical Trainee Experience with Open Cholecystectomy and the Dunning-Kruger Effect. JOURNAL OF SURGICAL EDUCATION 2020; 77:1076-1081. [PMID: 32362558 DOI: 10.1016/j.jsurg.2020.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/27/2020] [Accepted: 03/29/2020] [Indexed: 05/05/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy has become the standard approach to gallbladder surgery, but open cholecystectomy retains a role in complex cases. AIMS The aim of this study was to evaluate exposure of senior trainees in general surgery to open cholecystectomy and their experience and confidence in independent performance. METHODS General surgical trainees on a higher surgical training programme from surgical training years 5 (ST 5) to 8 (ST8) were invited to partake in an online anonymous survey. Data pertaining to case numbers, whether supervised or independently performed and level of comfort were collated and analyzed. RESULTS Twenty-six of 40 trainees responded (65%). Twenty-one (81%) had performed over 40 laparoscopic cholecystectomies with their trainer either scrubbed or un-scrubbed in theatre. As to open cholecystectomy experience, 12 trainees had assisted in 5 or fewer cases and only 3 assisted in over 20; 17 (65%) had performed 2 or fewer cases whilst assisted by their trainer while 24 of 26 trainees (92%) had no independent experience of open cholecystectomy. However, 16 felt they would be "somewhat comfortable" and 2 reported feeling "very comfortable" while only 8 reported they were "not comfortable" converting to open cholecystectomy. CONCLUSIONS This study confirms a steep decline in training opportunities in open cholecystectomy, but also raises concern about a Dunning-Kruger effect as, despite this lack of experience, the majority felt "somewhat comfortable" or "very comfortable" in converting to open surgery. Trainees need first to be familiar with safer alternatives to conversion. Surgical trainers need to consider the assessment of confidence as well as competence as an endpoint of trainee evaluation.
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Affiliation(s)
- Ola Ahmed
- Department of General and Upper Gastrointestinal Surgery, Connolly Hospital, Blanchardstown, Dublin, Ireland
| | - Thomas Noel Walsh
- Department of General and Upper Gastrointestinal Surgery, Connolly Hospital, Blanchardstown, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland.
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Martínez-Mier G, Moreno-Ley PI, Esquivel-Torres S, Gonzalez-Grajeda JL, Mendez-Rico D. Differences in Post-Cholecystectomy Bile Duct Injury Care: A Comparative Analysis of 2 Different Health-Care Public Institutions in a Low- and Middle-Income Country: Southeast Mexico. Dig Surg 2020; 37:472-479. [PMID: 32829340 DOI: 10.1159/000509706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/23/2020] [Indexed: 12/10/2022]
Abstract
BACKGROUND Mexican health system structure allows us to study the differences in bile duct injury (BDI) management. The study aimed to assess the differences in patients with complex BDI in 2 different public sector institutions using a new proposed standard terminology. METHODS Retrospective review (2008-2019) in 2 public institutions (IMSS/SESVER). Bismuth-Strasberg E injuries with hepaticojejunostomy were included. Data are presented in a tabular reporting system. The outcomes were percent of patients attaining primary patency, loss of primary patency, and actuarial primary patency rate. RESULTS Seventy-eight patients (IMSS: n = 37; SESVER: n = 41) without differences in demographic and preoperative assessment were studied. BDI occurred mostly in outside hospitals. Open cholecystectomy was the most common index operation in SESVER (73%, p = 0.02). IMSS had more surgeries (p = 0.007) and repair attempts (p = 0.06) prior to referral. Magnetic resonance cholangiopancreatography was more commonly used in IMSS patients. Biliary stents (45%) and cholangitis (29%) were more common in IMSS (p < 0.05). IMSS patients had longer follow-up than SESVER (p < 0.05). No differences in primary patency rates (IMSS: 89%, SESVER: 97%) and actuarial patency rates were noted. DISCUSSION Despite differences in referral, preoperative, and operative events, good BDI repair outcomes can be achieved. Longer follow-up is needed to monitor these outcomes.
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Affiliation(s)
- Gustavo Martínez-Mier
- Organ Transplantation and General Surgery, IMSS UMAE Hospital de Especialidades, Veracruz, Mexico, .,Organ Transplantation and General Surgery, SESVER Hospital de Alta Especialidad "Virgilio Uribe", Veracruz, Mexico,
| | - Pedro Ivan Moreno-Ley
- Organ Transplantation and General Surgery, IMSS UMAE Hospital de Especialidades, Veracruz, Mexico.,Organ Transplantation and General Surgery, SESVER Hospital de Alta Especialidad "Virgilio Uribe", Veracruz, Mexico
| | - Sergio Esquivel-Torres
- Surgical Oncology, SESVER Hospital de Alta Especialidad "Virgilio Uribe", Veracruz, Mexico
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14
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Cortez AR, Potts JR. More of less: General Surgery Resident Experience in Biliary Surgery. J Am Coll Surg 2020; 231:33-42. [DOI: 10.1016/j.jamcollsurg.2020.02.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
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15
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LeCompte MT, Robbins KJ, Williams GA, Sanford DE, Hammill CW, Fields RC, Hawkins WG, Strasberg SM. Less is more in the difficult gallbladder: recent evolution of subtotal cholecystectomy in a single HPB unit. Surg Endosc 2020; 35:3249-3257. [PMID: 32601763 DOI: 10.1007/s00464-020-07759-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/23/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Subtotal cholecystectomy (SC) is a technique to manage the difficult gallbladder and avoid hazardous dissection and biliary injury. Until recently it was used infrequently. However, because of reduced exposure to open total cholecystectomy in resident training, we recently adopted subtotal cholecystectomy as the bail-out procedure of choice for resident teaching. This study reports our experience and outcomes with subtotal cholecystectomy in the years immediately preceding adoption and since adoption. METHODS A retrospective analysis was conducted of patients undergoing SC from July 2010 to June 2019. Outcomes, including bile leak, reoperation and need for additional procedures, were analyzed. Complications were graded by the Modified Accordion Grading Scale (MAGS). RESULTS 1571 cholecystectomies were performed of which 71 were SC. Subtotal cholecystectomy patients had several indicators of difficulty including prior attempted cholecystectomy and previous cholecystostomy tube insertion. The most common indication for SC was marked inflammation in the hepatocystic triangle (51%). As our experience increased, fewer patients required open conversion to accomplish SC and SC was completed laparoscopically, usually subtotal fenestrating cholecystectomy (SFC). Most patients (85%) had a drain placed and 28% were discharged with a drain. The highest MAGS complication observed was grade 3 (11 patients, 15%). Six patients had a bile leak from the cystic duct resolved by ERCP. At mean follow-up of about 1 year no patient returned with recurrent symptoms. CONCLUSIONS Subtotal fenestrating cholecystectomy is a useful technique to avoid biliary injury in the difficult gallbladder and can be performed with very satisfactory rates of bile fistula, ERCP, and reoperation.
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Affiliation(s)
- Michael T LeCompte
- Division of Surgical Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA. .,University of North Carolina, 2800 Blue Ridge Rd Suite 300, Raleigh, NC, 27607, USA.
| | - Keenan J Robbins
- Section of Hepato-Pancreato-Biliary Surgery, Siteman Cancer Center, Barnes-Jewish Hospital, and Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Greg A Williams
- Section of Hepato-Pancreato-Biliary Surgery, Siteman Cancer Center, Barnes-Jewish Hospital, and Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Dominic E Sanford
- Section of Hepato-Pancreato-Biliary Surgery, Siteman Cancer Center, Barnes-Jewish Hospital, and Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Chet W Hammill
- Section of Hepato-Pancreato-Biliary Surgery, Siteman Cancer Center, Barnes-Jewish Hospital, and Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Ryan C Fields
- Section of Hepato-Pancreato-Biliary Surgery, Siteman Cancer Center, Barnes-Jewish Hospital, and Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - William G Hawkins
- Section of Hepato-Pancreato-Biliary Surgery, Siteman Cancer Center, Barnes-Jewish Hospital, and Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Siteman Cancer Center, Barnes-Jewish Hospital, and Washington University School of Medicine in St. Louis, St Louis, MO, USA.
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Purzner RH, Ho KB, Al-Sukhni E, Jayaraman S. Safe laparoscopic subtotal cholecystectomy in the face of severe inflammation in the cystohepatic triangle: a retrospective review and proposed management strategy for the difficult gallbladder. Can J Surg 2020; 62:402-411. [PMID: 31782296 DOI: 10.1503/cjs.014617] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Laparoscopic subtotal cholecystectomy (LSC) can be employed when extensive fibrosis or inflammation of the cystohepatic triangle prohibits safe dissection of the cystic duct and artery. The purpose of this study was to compare postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy (LC) or LSC. Methods In this retrospective study, we compared the postoperative outcomes of patients with severe cholecystitis who underwent LC or LSC between July 2010 and July 2016 at St. Joseph’s Health Centre, Toronto. We further stratified LSC cases on the basis of the extent of gallbladder (GB) dissection and GB remnant closure. Results A total of 105 patients who underwent LC and 46 who underwent LSC were included in the study. There were 4 bile duct injuries in the LC group and 0 in the LSC group. Bile leaks (relative risk [RR] 3.4, 95% confidence interval [CI] 1.01–11.5) and subphrenic collections (RR 3.1, 95% CI 1.3–8.0) were more common in the LSC group. Overall postoperative morbidity did not differ significantly between the 2 groups. Postoperative endoscopic retrograde cholangiopancreatography (ERCP) (RR 3.2, 95% CI 1.1–9.5) and biliary stent insertion (RR 4.6, 95% CI 1.2–17.5) were more common in the LSC group. Bile leaks appeared to be more prominent with open GB remnants but all cases of leak were successfully managed with ERCP and biliary stenting. Conclusion LSC may mitigate the risk of bile duct injury when dissection into the cystohepatic triangle is unsafe. There were more bile leaks in patients who underwent LSC; however, they were readily managed with endoscopic stents. Long-term biliary fistulae were not observed. LSC should be considered early as a means of completing difficult cholecystectomies safely without the need for cholecystostomy tube or conversion to laparotomy.
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Affiliation(s)
- Roderick H. Purzner
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Purzner, Ho, Al-Sukhni, Jayaraman); and the Hepatopancreatobiliary Surgery Service, St. Joseph’s Health Centre, Toronto, Ont. (Al-Sukhni, Jayaraman)
| | - Karen B. Ho
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Purzner, Ho, Al-Sukhni, Jayaraman); and the Hepatopancreatobiliary Surgery Service, St. Joseph’s Health Centre, Toronto, Ont. (Al-Sukhni, Jayaraman)
| | - Eisar Al-Sukhni
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Purzner, Ho, Al-Sukhni, Jayaraman); and the Hepatopancreatobiliary Surgery Service, St. Joseph’s Health Centre, Toronto, Ont. (Al-Sukhni, Jayaraman)
| | - Shiva Jayaraman
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Purzner, Ho, Al-Sukhni, Jayaraman); and the Hepatopancreatobiliary Surgery Service, St. Joseph’s Health Centre, Toronto, Ont. (Al-Sukhni, Jayaraman)
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17
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The impossible gallbladder: aspiration as an alternative to conversion. Surg Endosc 2019; 34:1868-1875. [DOI: 10.1007/s00464-019-07268-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 11/12/2019] [Indexed: 12/13/2022]
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18
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Bingmer K, Ofshteyn A, Stein SL, Marks JM, Steinhagen E. Decline of open surgical experience for general surgery residents. Surg Endosc 2019; 34:967-972. [DOI: 10.1007/s00464-019-06881-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 05/29/2019] [Indexed: 11/24/2022]
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Khan AA, Rakinic J, Kim RH, Mellinger JD, Ganai S. National Trends in General Surgery Resident Exposure to Complex Oncology-Relevant Cases. JOURNAL OF SURGICAL EDUCATION 2019; 76:378-386. [PMID: 30253983 DOI: 10.1016/j.jsurg.2018.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/19/2018] [Accepted: 09/01/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To evaluate trends in surgical resident exposure to complex oncologic procedures in order to determine whether additional fellowship training is necessary. DESIGN An observational study of national Accreditation Council for Graduate Medical Education case log statistical reports was conducted to determine the average number of cases for selected oncology-relevant procedures completed during training. Linear regression and Cusick trend tests were used to assess temporal trends with the null hypothesis assuming an estimated slope of zero. Instrumental variable estimation was used to study the effect of duty-hour restrictions on oncologic cases per year. SETTING United States general surgery residency training programs. PARTICIPANTS Graduating surgical residents completing their training between 2000 and 2016. RESULTS Across the study interval, mean case volume was 950.6 ± 29.7 (standard deviation) cases with 38.9 ± 3.1 complex oncologic cases per graduating resident. Decreasing trends were noted for average exposure to lymphadenectomies (-7.8 cases/decade; 95% confidence interval [CI] -8.8 to -6.8) and low rectal procedures (-0.9 cases/decade; 95% CI -1.2 to -0.6). There was no clinically important change in complex soft-tissue resections and foregut cases. A significant increase was seen in number of hepatopancreaticobiliary procedures (+3.9 cases/decade; 95% CI 3.1-4.7). Using instrumental variable estimation, there was a modest decline in cancer-relevant cases by 5.0 cases/decade (95% CI 4.5-5.6), while there was an increase in 38.5 total cases/decade (95% CI 10.4-66.7) associated with duty-hour restrictions. CONCLUSIONS Case numbers for several complex oncologic procedures remain low, justifying a need for further fellowship training depending on individual resident experience.
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Affiliation(s)
- Amir A Khan
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Jan Rakinic
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Roger H Kim
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - John D Mellinger
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Sabha Ganai
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois; Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, Illinois.
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Abtar HK, Mhana TM, Zbibo R, Mneimneh M, Asmar AE. First case report of bile leak from the duct of Luschka in a patient with mini-gastric bypass: The challenge of management. Ann Med Surg (Lond) 2018; 35:29-32. [PMID: 30263115 PMCID: PMC6156743 DOI: 10.1016/j.amsu.2018.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 09/06/2018] [Accepted: 09/18/2018] [Indexed: 01/24/2023] Open
Abstract
Introduction The incidence of Bile duct injury after laparoscopic cholecystectomy approaches 0.11%–1.4%. Ducts of Luschka are the second most common site of bile leaks. The rarity of these ducts with cases of anatomical alterations in the gastrointestinal tract such as mini-gastric bypass makes the management a challenging option. Presentation of case Hereby we present a unique case of 28 year old female patient with mini-gastric bypass who had done uneventful cholecystectomy. Day 3 postoperatively patient complained of diffuse abdominal pain. Computed tomography showed free fluid in the abdomen. Liver enzymes were normal. Relaparoscopy showed leaking bile duct of Luschka, which was closed by surgical clips and drains left in the spaces. However bile leak continued for 4 weeks then stopped. Patient did well after all. Discussion Endoscopic retrograde cholangiopancreatography with sphincterotomy played a crucial role for diagnosis and treatment of bile leaks with success rate near 94%. However no data were available using this method in a patient with Mini-gastric bypass procedure. Many authors have argued the role of relaparoscopy, but it is still an important way for adequate drainage and control of bile leakage. The only significant factor in determining clinical outcome in cases of non-surgical management is the type of bile duct injury. Conclusion To the best of our knowledge, this is the first case report of bile leak from duct of Luschka after mini-gastric bypass treated successfully with relaparoscopy and drainage. Herein we will discuss all the available options of treatment and the challenge of it. The combination of Duct of Luschka in a patient with mini-gastric bypass is unique in the literature. The challenge of management especially endoscopic one puts a great pressure on both surgeons and gastroenterologists. NO single data available in the literature in doing ERCP by any method in a patient with mini-gastric bypass.
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Affiliation(s)
- Houssam Khodor Abtar
- Makassed General Hospital, Department of Surgery, Beirut, Lebanon
- Corresponding author. Makassed General Hospital, P.O. Box: 11-6301, Riad EI-Solh, 11072210, Beirut, Lebanon.
| | | | - Riad Zbibo
- Makassed General Hospital, Department of Surgery, Beirut, Lebanon
| | | | - Antoine el Asmar
- Sahel General Hospital, Department of Radiology, Beirut, Lebanon
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21
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Pavlidis ET, Pavlidis TE. The Role of Open Cholecystectomy in the Current Era of Laparoscopic Surgery and the Trainee Experience. Am Surg 2018. [DOI: 10.1177/000313481808400307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Efstathios T. Pavlidis
- Second Surgical Propedeutic Department Aristotle University of Thessaloniki Medical School Hippocration Hospital Thessaloniki, Greece
| | - Theodoros E. Pavlidis
- Second Surgical Propedeutic Department Aristotle University of Thessaloniki Medical School Hippocration Hospital Thessaloniki, Greece
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Chuang SH, Hung MC, Huang SW, Chou DA, Wu HS. Single-incision laparoscopic common bile duct exploration in 101 consecutive patients: choledochotomy, transcystic, and transfistulous approaches. Surg Endosc 2018. [PMID: 28643057 DOI: 10.1007/s00464-017-5658-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Laparoscopic surgery for choledocholithiasis is still evolving. Only a few reports of single-incision laparoscopic common bile duct exploration (LCBDE) have been published. METHODS One hundred and one consecutive patients underwent single-incision LCBDE (SILCBDE) by one surgeon with straight instruments during a 42-month period. RESULTS Choledochotomies were performed on 61 patients (60.4%). The success rate of intrahepatic duct exploration was 68.0% (17/25) for patients undergoing transcystic choledochoscopic bile duct explorations following longitudinal cystic ductotomies. The ductal clearance rate was 100%. Eighteen procedures (17.8%) were converted, including one open surgery. Nineteen patients (18.8%) experienced 26 episodes of complications; the majority (19 episodes) were classified as Clavien-Dindo grade I. Excluding those patients with Mirizzi syndrome (McSherry type II), multivariate logistic regressions showed that patients who were older or had complicated cholecystitis had higher procedure conversion rates and that higher modified APACHE II scores, higher white blood cell counts, and longer operative times were independent risk factors for complications. Based on operative times, 20 successful SILCBDEs were needed to get through the learning phase. A higher transcystic approach rate (46.5 vs. 8.3%; P < 0.01) and a shorter operative time (207 ± 62 vs. 259 ± 66 min; P < 0.01) were observed in the experienced phase. Compared with our early series of multi-incision LCBDE, the SILCBDE group had a higher bile duct stone clearance rate (100 vs. 94.4%; P < 0.05) and a higher proportion of patients with concomitant acute cholecystitis (59.6 vs. 22.2%; P < 0.01). CONCLUSIONS LCBDE with a 100% ductal clearance rate is possible following an algorithm for various approaches. SILCBDE is feasible under a low threshold for procedure conversion. A transcystic approach should be tried first if indicated, and a longitudinal cystic ductotomy to the cystocholedochal junction is beneficial. Prospective, randomized trials comparing single-incision and multi-incision LCBDE are anticipated.
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Affiliation(s)
- Shu-Hung Chuang
- Division of General Surgery, Department of Surgery, Show Chwan Memorial Hospital, 542, Sec 1 Chung-Shan Rd., Changhua, 500, Taiwan
- IRCAD-AITS Show Chwan Health Care System, Changhua, Taiwan
| | - Min-Chang Hung
- Division of General Surgery, Department of Surgery, Show Chwan Memorial Hospital, 542, Sec 1 Chung-Shan Rd., Changhua, 500, Taiwan
- IRCAD-AITS Show Chwan Health Care System, Changhua, Taiwan
| | - Shih-Wei Huang
- Division of General Surgery, Department of Surgery, Show Chwan Memorial Hospital, 542, Sec 1 Chung-Shan Rd., Changhua, 500, Taiwan
- IRCAD-AITS Show Chwan Health Care System, Changhua, Taiwan
| | - Dev-Aur Chou
- Division of General Surgery, Department of Surgery, Show Chwan Memorial Hospital, 542, Sec 1 Chung-Shan Rd., Changhua, 500, Taiwan.
- IRCAD-AITS Show Chwan Health Care System, Changhua, Taiwan.
| | - Hurng-Sheng Wu
- Division of General Surgery, Department of Surgery, Show Chwan Memorial Hospital, 542, Sec 1 Chung-Shan Rd., Changhua, 500, Taiwan
- IRCAD-AITS Show Chwan Health Care System, Changhua, Taiwan
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Fry DE, Pine M, Nedza SM, Reband AM, Huang CJ, Pine G. Comparison of Risk-Adjusted Outcomes in Medicare Open versus Laparoscopic Cholecystectomy. Am Surg 2018. [DOI: 10.1177/000313481808400108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
More than 90 per cent of cholecystectomies are performed laparoscopically and this has resulted in concern that surgeons will not have sufficient experience to perform open procedures when clinical circumstances require it. We reviewed the open cholecystectomies (OCs) of Medicare patients from 2010 to 2012 in hospitals with 20 or more cases, created risk-adjusted models for adverse outcomes which were evaluated for 90-days after discharge, and compared the hospital-level outcomes with laparoscopic cholecystectomy performed in the same hospitals for the same period of time. Results demonstrated that inpatient deaths, inpatient prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day readmissions were statistically the same with an overall adverse outcome rate of 21.6 per cent in OC versus 20.9 per cent in laparoscopic cholecystectomy. Conversion of laparoscopic to open procedures was not associated with increased adverse outcomes. Laparoscopic cholecystectomy provides patients with many advantages, but when clinical circumstances are necessary, OC continues to be performed with the same overall adverse outcome rates, and the conversion process is not associated with poorer results in this high-risk population of patients.
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Affiliation(s)
- Donald E. Fry
- MPA Healthcare Solutions, Chicago, Illinois
- Departments of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Susan M. Nedza
- MPA Healthcare Solutions, Chicago, Illinois
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Greenwood V, Shames B, Tanious A, Shames ML, Indes JE. Trends in open abdominal exposure among vascular surgery trainees. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.03.448] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Coffin SJ, Wrenn SM, Callas PW, Abu-Jaish W. Three decades later: investigating the rate of and risks for conversion from laparoscopic to open cholecystectomy. Surg Endosc 2017; 32:923-929. [DOI: 10.1007/s00464-017-5767-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 07/14/2017] [Indexed: 01/06/2023]
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26
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Halawani HM, Tamim H, Khalifeh F, Mailhac A, Taher A, Hoballah J, Jamali FR. Outcomes of Laparoscopic vs Open Common Bile Duct Exploration: Analysis of the NSQIP Database. J Am Coll Surg 2017; 224:833-840.e2. [DOI: 10.1016/j.jamcollsurg.2017.01.062] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/18/2017] [Accepted: 01/23/2017] [Indexed: 01/16/2023]
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Manning A, Frazee R, Abernathy S, Isbell C, Isbell T, Regner J, Munoz-Maldonado Y, Smith R. Protocol-Driven Management of Suspected Common Duct Stones. J Am Coll Surg 2017; 224:645-649. [PMID: 28093301 DOI: 10.1016/j.jamcollsurg.2016.12.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 12/13/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Common duct stones can be diagnosed by magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS)/ERCP, and intraoperative cholangiogram (IOC). In 2015, our group adopted a standard approach of preoperative EUS/ERCP followed by laparoscopic cholecystectomy for patients with an admission bilirubin >4.0 mg/dL. For bilirubin <4.0 mg/dL, laparoscopic cholecystectomy with IOC was the initial procedure. Postoperative EUS/ERCP with endoscopic sphincterotomy was pursued for positive IOC. Exclusions included clinical suspicion of malignancy and surgically altered anatomy making endoscopic management impractical. STUDY DESIGN A retrospective comparison of protocol and pre-protocol (baseline) patients was performed, looking at patient demographics, presence of pancreatitis, common duct stone risk factors, comorbidities, length of hospitalization, and postoperative morbidity. Statistical analysis was performed with t-test, chi-square, and Wilcoxon rank-sum test with significance at p < 0.05. RESULTS There were 56 patients in each group, with a mean ± SD age of 50.5 ± 20.88 years and 49.3 ± 20.92 years, respectively (p = NS). There were no significant differences between baseline and protocol patients with respect to individual and cumulative preoperative comorbidities, pancreatitis, elevation of liver function tests, bilirubin, common duct size, and postoperative morbidity. There were fewer endoscopies (22 vs 35; p = 0.014), and shorter length of stay in protocol patients (2.8 days vs 3.8 days; p = 0.025). CONCLUSIONS Protocol-driven management of patients with suspected common duct stones reduced the number of endoscopies and length of hospitalization, with no change in postoperative morbidity. This approach has the potential to decrease endoscopy-related morbidity and overall cost without affecting quality of care.
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Affiliation(s)
- Anthony Manning
- Department of Surgery, Baylor Scott & White Healthcare, Temple, TX
| | - Richard Frazee
- Department of Surgery, Baylor Scott & White Healthcare, Temple, TX.
| | | | - Claire Isbell
- Department of Surgery, Baylor Scott & White Healthcare, Temple, TX
| | - Travis Isbell
- Department of Surgery, Baylor Scott & White Healthcare, Temple, TX
| | - Justin Regner
- Department of Surgery, Baylor Scott & White Healthcare, Temple, TX
| | | | - Randall Smith
- Department of Surgery, Baylor Scott & White Healthcare, Temple, TX
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