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

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

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

Clinical outcome of pre-operative blood transfusion for sickle cell disease patients in post-operative complications

BACKGROUND

Preoperative blood transfusion for patients with sickle cell disease is a debatable topic and it can be lifesaving. Sickle cell disease patients are at high risk for vaso-occlusive crisis due to the large concentration of sickle hemoglobin (HgbS) in their blood. Despite the current extensive research into this disease, there is still no consensus over whether blood transfusion is a preferable preoperative modality among patients undergoing elective surgical procedures.

METHOD

A retrospective observational study, which enrolled 204 patients with Sickle cell disease who underwent surgery at King Fahad Hospital of the University (KFHU) over the last five years. The primary objective was to determine whether there is evidence that preoperative blood transfusion for SCD patients undergoing surgical procedures will reduce postoperative complications related to SCD.

RESULTS

A total of 204 patients were included, of which 30% had preoperative blood transfusion. Majority of patient 44% had undergone cholecystectomy. On multivariate logistic regression analysis, patients who did not undergo blood transfusion had significantly higher risk to develop post-operative SCD complications (OR=3.07, P value= 0.002). In addition, they had significantly prolonged hospitalization (OR= 2.22, P value= 0.08). In contrast, patients who received blood transfusion had lower risk for developing post-operative SCD related complications (OR=1.87, P value= 0.29), and decrease in the duration of hospitalization by (OR=0.49, P value= 0.045).

CONCLUSION

Our study showed that patients who had not undergo preoperative blood transfusion had higher risk to develop postoperative complications and prolonged hospital stay compared to those who underwent blood transfusion.

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

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

Correlates of gallbladder stones among patients with sickle cell disease: A meta-analysis

Sickle cell disorders are the most common hemoglobinopathies worldwide. Clinical variability of sickle cell disease (SCD) and susceptibility to its complications have been attributed to hematologic, genetic, and other influencing factors. This review aimed to provide further summary and analyses of the prevalence and factors associated with cholelithiasis among patients with SCD. A systematic database search was conducted in MEDLINE (PubMed), ScienceDirect, Google Scholar, World Health Organization Virtual Health Library, Cochrane Library databases, and System for Information on Gray Literature in Europe (SIGLE). Pooled prevalence, odds ratio (OR), and standardized mean difference (SMD) with the corresponding 95% confidence interval (CI) were calculated using Comprehensive Meta-Analysis Software version 3.3. A total of 34 studies that fulfilled the eligibility criteria were included in the analyses. The overall prevalence of cholelithiasis among SCD patients was 25.3% (95% CI 19.4-32.3%). The risk of developing cholelithiasis was significantly associated with lower total hemoglobin level (SMD = -0.45; P = 0.002), lower hemoglobin F (HbF) level (SMD = -0.85; P = 0.003), higher total serum bilirubin level (SMD = 1.15; P < 0.001), higher reticulocytes count (SMD = 0.44; P = 0.007), and UDP-glucuronosyltransferase-1A1 enzyme (UGT1A1) promoter polymorphism. This review provides a comprehensive view of the high rate of cholelithiasis and its associated factors in SCD patients.

Perioperative care of children with sickle cell disease: A systematic review and clinical recommendations

Children with sickle cell disease (SCD) require specific perioperative care, and clinical practice in this area remains poorly defined. We aimed to conduct a systematic, PRISMA-based review of the literature, available clinical guidelines and practice recommendations. We also aimed to extract any valuable information for the "best of available-evidence"-based prevention of perioperative adverse events in children with SCD, and highlight the most urgent priorities in clinical research. As data sources, US National Library of Medicine, Medline, National Guideline Clearinghouse, International Guideline Network, TRIP databases were searched for any content until January 2019. We also included institutional, consortia and expert group guidelines. Included were reports/guidelines in English, French, German, and Italian. Excluded were reports on obstetrical and fetal management. We identified 202 reports/guidelines fulfilling the criteria outlined above. A majority focused on visceral, cardiovascular and orthopedic surgery procedures, and only five were multicenter randomized controlled trials and two prospective randomized studies. After grading of the quality of the evidence, the extracted data was summarized into clinical recommendations for daily practice. Additionally, we designed a risk-grading algorithm to identify contexts likely to be associated with adverse outcomes. In conclusion, we provide a systematic PRISMA-based review of the existing literature and ancillary practice and delineate a set of clinical recommendations and priorities for research.

Laparoscopic cholecystectomy for cholelithiasis in children with sickle cell disease

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

Laparoscopic cholecystectomy in adult patients with sickle cell disease

SUMMARY BACKGROUND DATA

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Gastrointestinal and hepatic complications of sickle cell disease

Sickle cell disease (SCD) is an autosomal recessive abnormality of the beta-globin chain of hemoglobin (Hb), resulting in poorly deformable sickled cells that cause microvascular occlusion and hemolytic anemia. The spleen is almost always affected by SCD, with microinfarcts within the first 36 months of life resulting in splenic atrophy. Acute liver disorders causing right-sided abdominal pain include acute vaso-occlusive crisis, liver infarction, and acute hepatic crisis. Chronic liver disease might be due to hemosiderosis and hepatitis and possibly to SCD itself if small, clinically silent microvascular occlusions occur chronically. Black pigment gallstones caused by elevated bilirubin excretion are common. Their small size permits them to travel into the common bile duct but cause only low-grade obstruction, so hyperbilirubinemia rather than bile duct dilatation is typical. Whether cholecystectomy should be done in asymptomatic individuals is controversial. The most common laboratory abnormality is an elevation of unconjugated bilirubin level. Bilirubin and lactate dehydrogenase levels correlate with one another, suggesting that chronic hemolysis and ineffective erythropoiesis, rather than liver disease, are the sources of hyperbilirubinemia. Abdominal pain is very common in SCD and is usually due to sickling, which resolves with supportive care. Computed tomography scans might be ordered for severe or unremitting pain. The liver typically shows sickled erythrocytes and Kupffer cell enlargement acutely and hemosiderosis chronically. The safety of liver biopsies has been questioned, particularly during acute sickling crisis. Treatments include blood transfusions, exchange transfusions, iron-chelating agents, hydroxyurea, and allogeneic stem-cell transplantation.

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

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

Physiologic effects of pneumoperitoneum in adults with sickle cell disease undergoing laparoscopic cholecystectomy (a case control study)

BACKGROUND

Many studies have demonstrated the adverse consequences of pneumoperitoneum. However, few studies have examined the physiologic effects of pneumoperitoneum in adults with sickle cell disease (SCD) during laparoscopic cholecystectomy (LC).

METHODS

60 ASA 1-capital PE, Cyrillic capital PE, Cyrillic patients, with cholelithiasis, scheduled for elective LC were allocated into two equal groups: group 1, normal patients without SCD (control group), and group 2, patients with SCD. The perioperative parameters of 30 SCD patients matched by age and sex to the 30 members of the non-sickler control group who underwent cholecystectomy were assessed. Study parameters (in the two groups) included heart rate (HR) per minute, mean blood pressure (MAP, mmHg), PETCO(2), and O(2) saturation (SpO(2)) at the following intervals: before induction of anesthesia in the supine position (all except PETCO(2)), after anesthesia and before CO(2) insufflations in the supine position, 15, 30, 45, 60 min after CO(2) insufflations in the anti-Trendelenburg position, at the end of CO(2) exsufflation in the supine position and 5 min after the end of CO(2) exsufflation in the supine position. Arterial blood gases, to measure pH, PaCO(2), and PaO(2), were determined after induction of anesthesia and before CO(2) insufflation in the supine position, then 30 min after CO(2) insufflations in the anti-Trendelenburg position, and 5 min after the end of CO(2) exsufflation in the supine position. Statistical significance was established at the p < 0.05 level.

RESULTS

Induction of anesthesia produced a significant increase in HR in both groups. CO(2) insufflations led to an additional increase in HR and persisted till abdominal deflation. After CO(2) insufflations, MAP significantly increased from the baseline at 15, 30, 45, and 60 min, and just before deflation in the anti-Trendelenburg position. CO(2) insufflations led to a significant increase in end-tidal CO(2) (ETCO(2)) in the study groups, reaching a maximum level just before abdominal deflation in the anti-Trendelenburg position. Regarding SpO(2) and PaO(2), there were insignificant changes in the two study groups throughout the procedure. In group 2, none of the patients experienced vaso-occlusive crises or other SCD- related complications.

CONCLUSION

This study proved the safety of LC in patients with SCD and cholelithiasis, and that they can tolerate the physiological effects of pneumoperitoneum as non-SCD adults.

Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy

Asymptomatic cholelithiasis is increasingly diagnosed today, mainly as a result of the widespread use of abdominal ultrasonography for the evaluation of patients for unrelated or vague abdominal complaints. About 10-20% of people in most western countries have gallstones, and among them 50-70% are asymptomatic at the time of diagnosis. Asymptomatic gallstone disease has a benign natural course; the progression of asymptomatic to symptomatic disease is relatively low, ranging from 10-25%. The majority of patients rarely develop gallstone-related complications without first having at least one episode of biliary pain ("colic"). In the prelaparoscopy era, (open) cholecystectomy was generally performed for symptomatic disease. The minimally invasive laparoscopic cholecystectomy refueled the discussion about the optimal management of asymptomatic cholelithiasis. Despite some controversy, most authors agree that the vast majority of subjects should be managed by observation alone (expectant management). Selective cholecystectomy is indicated in defined subgroups of subjects, with an increased risk for the development of gallstone-related symptoms and complications. Concomitant cholecystectomy is a reasonable option for good-risk patients with asymptomatic cholelithiasis undergoing abdominal surgery for unrelated conditions. Routine cholecystectomy for all subjects with silent gallstones is a too aggressive management option, not indicated for most subjects with asymptomatic cholelithiasis. An in-depth knowledge of the natural history of gallstone disease is required to select the optimal management option for the individual subject with silent gallstones. Management options should be extensively discussed with the patient; he or she should be actively involved in the process of therapeutic decision making.

Asymptomatic cholelithiasis in children with sickle cell disease: early or delayed cholecystectomy?

SUMMARY BACKGROUND DATA

Our study aimed to evaluate the role of elective laparoscopic cholecystectomy (LC) in children with sickle cell disease (SCD) and asymptomatic cholelithiasis and, furthermore, to determine whether the outcome is related to the operation timing.

METHODS

The records of 30 children with SCD diagnosed with cholelithiasis from June 1995 to September 2005 were retraspectively reviewed. All 30 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them. The operation was accepted in the period of study by 16 children and refused by 14. During medical observation, 10 of the 14 children who refused surgery were admitted for severe biliary colics. Acute cholecystitis was diagnosed by abdominal ultrasound in 3 cases and in 1 case choledocholithiasis, ultrasonographically suspected, was confirmed by magnetic resonance cholangiopancreatography (MRCP) and treated during endoscopic retrograde cholangiopancreatography (ERCP). All children, emergency admitted, underwent LC after the onset of symptoms. The patients were divided up into 2 groups (A: asymptomatic; B: symptomatic) depending on clinical presentation and operation timing and the respective outcomes were compared.

RESULTS

Elective LC in asymptomatic children (group A) is safe with no major complications reported. During medical observation in children who refused elective surgery (group B), 6 biliary colics, 3 acute cholecystitis, and 1 choledocholithiasis were observed. Three sickle cell crises occurred in symptomatic children during biliary colics. The correlation between cholecystectomy performed in asymptomatic children (group A) and cholecystectomy performed in symptomatic children (group B) showed significant differences in the outcome. Morbidity rate and postoperative stay increased when children with SCD underwent emergency LC.

CONCLUSIONS

Elective LC should be the gold standard in children with SCD and asymptomatic cholelithiasis to prevent the potential complications of biliary colics, acute cholecystitis, and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.

Surgery in sickle cell disease

Persons with sickle cell disease (SCD) are more likely to undergo surgery than are the general population during their lifetime. For example, cholecystectomy as a consequence of gallstones is more frequent in persons with SCD, as is hip arthroplasty in younger people as a result of avascular necrosis of the femoral head. Because surgery exposes patients to many of the factors that are known to precipitate red blood cell sickling, persons with SCD undergoing surgery require meticulous clinical care to prevent perioperative sickle cell-related complications. Even with meticulous care, approximately 25% to 30% of patients will have a postoperative complication. This article provides readers with information about the role of surgery in SCD and the measures that should be taken to ensure patients are well cared for in the perioperative period.

Laparoscopic cholecystectomy in children with chronic hemolytic anemia. Is the outcome related to the timing of the procedure?

BACKGROUND

The aim of this study was to evaluate whether the outcome in children with chronic hemolytic anemia (CHA) and cholelithiasis undergoing laparoscopic cholecystectomy (LC) is related to the operation timing.

METHODS

From June 1995 to December 2004, 46 children with CHA were referred to our division of surgery for cholelithiasis. All 46 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them before the onset of symptoms. The operation was accepted in the period of study by 24 children and refused by 22. The patients were divided into three groups (group A, asymptomatic; group B, symptomatic; and group C, emergency admitted) depending on clinical presentation and operation timing, and the respective outcomes were compared.

RESULTS

Elective LC in asymptomatic children (group A) is safe with no major complications reported. In children who refused surgery (groups B and C), we observed four sickle cell crises, four acute cholecystitis, and two choledocholithiasis, and all these complications were related to waiting. Two sickle cell crises occurred in symptomatic children waiting for surgery during biliary colic. The risk of emergency admission in children with cholelithiasis and CHA awaiting surgery was found to be high: 28% of the children admitted in emergency after a mean of 32 months (range, 22-36). Morbidity rate and postoperative stay increased when children with hemoglobinopathies underwent emergency LC.

CONCLUSIONS

Elective LC should be the gold standard in children with CHA and asymptomatic cholelithiasis in order to prevent the potential complications of cholecystitis and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.

Preoperative transfusion in sickle cell disease: a survey of practice in England

OBJECTIVES

To gather data on current preoperative transfusion practice and postoperative complications in sickle cell disease (SCD) as a prelude to a randomised trial.

METHODS

A prospective one year survey of 114 SCD patients undergoing elective surgery in 31 English hospitals was undertaken.

RESULTS

43%, 39% and 23% of patients respectively [corrected] received no transfusion, top-up and exchange transfusion preoperatively. Overall postoperative complication rates were 18%, 26% and 17%, with SCD related complications of 12%, 8% and 0% respectively. 85% of patients with [corrected]HbSC/HbSss(+)thalassaemia and 71% of obstetric and gynaecology patients were not transfused preoperatively, whereas 59% patients undergoing ENT procedures and 83% of hip replacements had top-up and exchange transfusions respectively. Multivariable logistic regression analysis revealed that having moderate/high risk procedures was a predictor of postoperative complications (OR 4.9 (95% CL: 1.3 to 18), P = 0.017) [corrected] while preoperative transfusion was not (OR 1.7, (95% CL: [corrected] 0.5 to 6), P = 0.41).

CONCLUSION

The lack of clear benefit of transfusion confirms the need for a randomised controlled trial of transfusion vs. no transfusion in patients with HbSS and HbSss(0)thalassaemia.

[Laparoscopic cholecystectomy in sickle cell disease]

STUDY AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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