Outcomes of open cholecystectomy in the elderly: a longitudinal analysis of 21,000 cases in the prelaparoscopic era

Outcomes of hip fracture in centenarians: a systematic review and meta-analysis

PURPOSE

Outcomes of hip fractures in centenarians remain underreported owing to the small number of patients reaching 100 years of age. This review aimed to determine outcomes of hip fracture in centenarians and to identify the most common comorbidities among centenarians with hip fracture to better characterise this population.

METHODS

Published and unpublished literature databases, conference proceedings and the reference lists of included studies were searched to the 25th of January 2023. A random-effects meta-analysis was performed. Included studies were appraised using tools respective of study design.

RESULTS

Twenty-three studies (6970 centenarians) were included (retrospective period: 1990-2020). The evidence was largely moderate to low in quality. One-year mortality following a hip fracture was 53.8% (95% CI 47.2 to 60.3%). Pooled complication rate following a hip fracture in centenarians was 50.5% (95% CI 25.3 to 75.6%). Dementia (26.2%, 95% CI 15.7 to 38.2%), hypertension (15.6%, 95% CI 3.4 to 33.1%), and diabetes (5.5%, 95% CI 1.9 to 10.7%) were the most common comorbidities among centenarians with hip fracture.

CONCLUSION

Hip fractures in centenarians typically involve complex patient presentations with diverse comorbidities. However, the current evidence-base is moderate to low in quality. Effective cross-discipline communication and intervention is suggested to promote treatment outcomes.

A novel nephrectomy-specific respiratory failure index using the ACS-NSQIP dataset

PURPOSE

Post-operative pulmonary failure is a major complication of nephrectomy that may lead to severe morbidity and mortality. Hence, we aimed to derive a nephrectomy-specific post-operative respiratory failure index.

METHODS

Our cohort was derived from The American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2019. The outcome of interest was post-operative respiratory failure (PRF) defined as any incidence of unplanned intubation post-operatively or requiring mechanical ventilation post-operatively for a period > 48 h. A multivariable logistic regression model was constructed, and model calibration and performance were assessed using a ROC analysis and the Hosmer-Lemeshow test. Finally, we derived the nephrectomy-specific respiratory failure (NSRF) index and compared it to Gupta's index.

RESULTS

Seventy-nine thousand five hundred and twenty-three patients underwent nephrectomy between the years 2005 and 2019 of which nine hundred and sixty-two patients developed PRF. The final NSRF model encompassed ten variables: age, smoking status, American society of anesthesiology class, abnormal creatinine (≥ 1.5 mg/dL), anemia (< 36%), functional health status, chronic obstructive pulmonary disease, surgical approach, emergency case, and obesity (≥ 40 kg/m²). The NSRF ROC analysis provided C-statistic = 0.78, calibration R² = 0.99, and proper goodness of fit. In comparison, the C-statistics of Gupta's index was found to be 0.71 (p value < 0.001).

CONCLUSION

The NSRF is a procedure tailored index for predicting post-operative respiratory failure. It is a valuable tool in the pre-operative evaluation setting that can help identify high-risk patients who will require additional respiratory evaluation and preparation for their surgery.

Perioperative outcomes after laparoscopic cholecystectomy in elderly patients: a systematic review and meta-analysis

BACKGROUND

Laparoscopic cholecystectomy is increasingly performed in an ever ageing population; however, the risks are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of cholecystectomy in the elderly population compared to younger patients.

METHOD

A systematic literature search of PubMed, EMBASE and the Cochrane Library databases were conducted including studies reporting laparoscopic cholecystectomy in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were conversion to open surgery, bile leaks, postoperative mortality and length of stay.

RESULTS

This review identified 99 studies incorporating 326,517 patients. Increasing age was significantly associated with increased rates of overall complications (OR 2.37, CI95% 2.00-2.78), major complication (OR 1.79, CI95% 1.45-2.20), risk of conversion to open cholecystectomy (OR 2.17, CI95% 1.84-2.55), risk of bile leaks (OR 1.50, CI95% 1.07-2.10), risk of postoperative mortality (OR 7.20, CI95% 4.41-11.73) and was significantly associated with increased length of stay (MD 2.21 days, CI95% 1.24-3.18).

CONCLUSION

Postoperative outcomes such as overall and major complications appear to be significantly higher in all age cut-offs in this meta-analysis. This study demonstrated there is a sevenfold increase in perioperative mortality which increases by tenfold in patients > 80 years old. This study appears to confirm preconceived suspicions of higher risks in elderly patients undergoing cholecystectomy and may aid treatment planning and informed consent.

Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study

Objectives

For complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure.

Methods

We analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018.

Results

Sixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay.

Conclusion

Large difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay.

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Large difficult CBD stones can be managed either by open surgery or laparoscopically with acceptable comparable outcomes.

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No need for multiple ERCP sessions due to their related morbidities.

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Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair.

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Primary repair is better than T-tube regarding operative time and post-operative hospital stay.

Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study

Objectives

For complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure.

Methods

We analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018.

Results

Sixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay.

Conclusion

Large difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay.

Stepped wedge cluster randomised controlled trial to assess the effectiveness of an optimisation strategy for general anaesthesia on postoperative morbidity and mortality in elderly patients (the OPTI-AGED study): a study protocol

INTRODUCTION

Elderly patients constitute an increasingly large proportion of the high-risk surgical group. In adult patients, several specific intraoperative approaches such as cardiac output-guided haemodynamic therapy, depth of anaesthesia monitoring (DAM) or lung-protective ventilation (LPV) are designed to reduce postoperative mortality and surgical complications. However, none of these approaches has been specifically performed in the elderly, and no evaluation of a multimodal optimisation strategy for general anaesthesia has been achieved in this population.

AIMS

The objective of this study is to assess, in high-risk patients aged 75 years and over undergoing high-risk surgery, the effectiveness of combined optimisation of anaesthesia involving goal-directed haemodynamic therapy (GDHT), LPV and electroencephalographic DAM on postoperative morbidity and mortality. The primary outcome of the study is a composite criterion associating major postoperative complications and mortality occurring within the 30 first postoperative days. The secondary outcomes are 1-year postoperative autonomy and mortality.

METHODS AND ANALYSIS

This prospective, randomised, controlled, multicentre trial using a stepped wedge cluster design will be conducted in 27 French university centres. Patients aged 75 years and over, undergoing femoral head fractures and major intraperitoneal or vascular elective surgeries will be included after informed consent. They will benefit from usual care in the 'control group' and from a combined optimisation of general anaesthesia involving GDHT, LPV and DAM in the 'optimisation group'. The cluster's crossover will be unidirectional, from control to optimisation, and randomised. Data will be recorded at inclusion, the day of surgery, 7 days, 30 days and 1year postoperatively and collected into a hosted electronic case report form. The primary outcome of the study is a composite criterion associating major postoperative complications and mortality occurring within the 30 first postoperative days. The secondary outcomes are 1- year postoperative autonomy and mortality.

ETHICS AND DISSEMINATION

This protocol was approved by the ethics committee Sud-Est 1 and the French regulatory agency. The finding of the trial will be disseminated through peer-reviewed journals and conferences TRIAL REGISTRATION NUMBER: NCT02668250; Pre-results.

Local Anesthesia for Endovascular Treatment of Unruptured Intracranial Aneurysms: Feasibility, Safety, and Periprocedural Complications

OBJECTIVE

The aim of the study is to report the feasibility, safety, and outcomes associated with endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) under local anesthesia.

METHODS

Between March 2011 and December 2016, 184 consecutive patients with 198 UIAs were treated with coil embolization under local anesthesia at the author's center. The data about medical comorbidities according to American Society of Anesthesiologists grade, procedural details, and clinical and radiographic outcomes were reviewed.

RESULTS

A total of 388 procedures were performed under local anesthesia, and 198 procedures with UIA were included. The mean age was 63.8 ± 12.5 years, and 118 (59.6%) cases had a risk status of American Society of Anesthesiologists class III or IV. Of those 198 procedures, 196 procedures (99.0%) were completed successfully. The overall procedure-related event rate was 5% (10/198). The rates of morbidity and mortality were 0.5% (1 of 198) and 0% at 1 month, respectively. Among the 3 recurred cases (1.5%), two (1%) underwent EVT again. The mean intensive care unit stay was 0.99 ± 0.1 days, and the mean postoperative hospital stay was 3.6 ± 7.2 days.

CONCLUSIONS

Local anesthesia in the EVT of UIA is feasible and safe. It could be considered as an alternative for the patients with high risk of general anesthesia.

Impact of surgical delay on outcomes in elderly patients undergoing emergency surgery: A single center experience

AIM: To determine predisposing factors leading to surgical delay in elderly patients with acute abdominal conditions and its impact on surgical outcomes.

METHODS: A retrospective review of a total of 144 patients aged 60 years and older who had undergone emergency abdominal surgery between 2010 and 2013 at a regional general hospital was analysed. The operations analysed were limited to perforated or gangrenous viscus and strangulated hernia. Patient demographic features, time taken to obtain a computed tomography scan, time taken to surgery and the impact on postoperative morbidity and mortality were analysed.

RESULTS: The mean age was 70.5 ± 9.1 years and median time taken to surgery was 9 h. The overall mortality and complication rates (Clavien Dindo 3 and above) were 9% and 13.1% respectively. Diabetes mellitus was a significant predisposing factor which had an impact on surgical delays. Delays in surgery more than 24 h led to higher complication rates at 38.9% (P = 0.003), with multivariate analysis confirming it as an independent factor. Delays in obtaining a computed tomography (CT) scan was also shown to result in higher complication rates (Clavien Dindo 3 and above).

CONCLUSION: Delays in performing emergency surgery in elderly lead to higher complication rates. Obtaining CT scans early also may facilitate prompt diagnosis of certain abdominal emergencies where presentation is more equivocal and this may lead to improved surgical outcomes.

Percutaneous cholecystostomy is appropriate as definitive treatment for acute cholecystitis in critically ill patients: a single center, cross-sectional study

BACKGROUND/AIMS

Percutaneous cholecystostomy (PC) is an effective treatment for cholecystitis in high-risk surgical patients. However, there is no definitive agreement on the need for additional cholecystectomy in these patients.

METHODS

All patients who were admitted to Cheju Halla General Hospital (Jeju, Korea) for acute cholecystitis and who underwent ultrasonography-guided PC between 2007 and 2012 were consecutively enrolled in this study. Among 82 total patients enrolled, 35 underwent laparoscopic cholecystectomy after recovery and 47 received the best supportive care (BSC) without additional surgery.

RESULTS

The technical and clinical success rates for PC were 100% and 97.5%, respectively. The overall mean survival was 12.8 months. In the BSC group, mean survival was 5.4 months, and in the cholecystectomy group, mean survival was 22.4 months (p<0.01). However, there was no significant difference between these groups in multivariate analysis (relative risk [RR]=1.92; 95% CI, 0.77-4.77; p=0.16). However, advanced age (RR=1.05; 95% CI, 1.02-1.08; p=0.001) and higher class in the American Society of Anesthesiologists' physical status (RR=3.06; 95% CI, 1.37-6.83, p=0.006) were significantly associated with survival in the multivariate analysis. Among the 47 patients in the BSC group, the cholecystostomy tube was removed in 31 patients per protocol. Recurrent cholecystitis was not observed in either group of patients during the follow-up period.

CONCLUSIONS

In high-risk surgical patients, PC without additional cholecystectomy might be the best definitive management. Furthermore, the cholecystostomy drainage catheter can be safely removed in certain patients.

Emerging risk factors and prevention of perioperative pulmonary complications

Modern surgery is faced with the emergence of newer "risk factors" and the challenges associated with identifying and managing these risks in the perioperative period. Obstructive sleep apnea and obesity hypoventilation syndrome pose unique challenges in the perioperative setting. Recent studies have identified some of the specific risks arising from caring for such patients in the surgical setting. While all possible postoperative complications are not yet fully established or understood, the prevention and management of these complications pose even greater challenges. Pulmonary hypertension with its changing epidemiology and novel management strategies is another new disease for the surgeon and the anesthesiologist in the noncardiac surgical setting. Traditionally most such patients were not considered surgical candidates for any required elective surgery. Our review discusses these disease entities which are often undiagnosed before elective noncardiac surgery.

Long-term results of laparoscopic common bile duct exploration by choledochotomy for choledocholithiasis: 15-year experience from a single center

Purpose

The aim of this study is to assess the long-term results of laparoscopic common bile duct exploration (LCBDE) and validate its effectiveness as a primary treatment modality for CBD stone.

Methods

A retrospective review of the medical records of 157 patients who underwent LCBDE from 1997 to 2011 was conducted. All LCBDE were performed by choledochotomy. Clinical demographics, operative outcome, recurrence rate of CBD stones, and long-term bile duct complications were analyzed. The mean follow-up period was 51.9 months.

Results

LCBDE was completed in 152 patients (96.8%) and 5 patients (3.2%) had open conversion. The male/female ratio was 78/79 and mean age was 67.3 years. Stone clearance was successful in 149 of 152 patients (98.0%). Nonlethal complications were noted in 11 patients (7.2%), including bile leakage in 6 patients (3.9%). Recurrent CBD stones developed in 9 of 152 patients (5.9%). Preoperative endoscopic sphincterotomy (P = 0.492) and choledochotomy repair type (T-tube drainage vs. primary closure, P = 0.740) were not significantly related to stone recurrence. There were no signs of any type of biliary injury or stricture observed in any of the patients during the follow-up period.

Conclusion

LCBDE can be performed without increased risk of long-term complications such as bile duct stricture and recurrent CBD stones. LCBDE is a safe and effective treatment option for choledocholithiasis in terms of long-term outcome as well as short-term outcome.

Complication rate of ultrasound-guided percutaneous cholecystostomy in patients with coagulopathy

OBJECTIVE

The purpose of this article is to compare the complication rate for ultrasound-guided percutaneous cholecystostomy in patients with coagulopathy to the rate in patients with normal coagulation.

MATERIALS AND METHODS

We performed a database search for patients who underwent ultrasound-guided percutaneous cholecystostomy from January 2000 through December 2010. Patients were divided into those with normal coagulation and those with coagulopathy, as documented by abnormal laboratory values (international normalized ratio ≥ 1.5 and platelet count ≤ 50 × 10(9)/L) or history of anticoagulant medication in the preceding 5 days. Medical records were reviewed, and complication rates and subsequent treatment was recorded. Statistical analysis was performed using the Fisher exact and chi-square tests.

RESULTS

Two hundred forty-two patients underwent ultrasound-guided percutaneous cholecystostomy (132 men and 110 women; mean [± SD] age, 73.9 ± 15.9 years; range, 22-104 years). One hundred thirty-two patients were coagulopathic and 110 had normal coagulation. Major complications related to ultrasound-guided percutaneous cholecystostomy were rare (4/242 cases [1.7%]) and included hemorrhage requiring transfusion (n = 1), death directly related to the procedure (n = 1), sepsis related to the procedure (n = 1), and abscess or biloma formation (n = 1). All of these occurred in the group with normal coagulation. Fourteen additional deaths (5.8%) that occurred within 30 days of the procedure were related to comorbidities. Minor catheter-related complications (15/242 [6.2%]) were due to catheter dislodgement (n = 11 [4.5%]), failure of placement (n = 1 [0.4%]), and hemorrhage not requiring transfusion (n = 3 [1.2%]). Two of the minor hemorrhagic complications were seen in the coagulopathic group and one in the normal coagulation group (p = 0.599).

CONCLUSION

There is no difference in the complication rate for ultrasound-guided percutaneous cholecystostomy in patients who are coagulopathic compared with those who have normal coagulation.

Nationwide study of the treatment of common bile duct stones in Sweden between 1965 and 2009

BACKGROUND

Treatment of common bile duct stones has changed. Open surgery has gradually been replaced by endoscopic and laparoscopic procedures. The aims of this study were to see how common bile duct stones have been treated in Sweden, to establish whether there were differences in morbidity and mortality between these approaches, and to identify factors influencing mortality.

METHODS

All persons undergoing inpatient common bile duct exploration or endoscopic retrograde cholangiopancreatography (ERCP) during 1965-2009 in the Swedish Hospital Discharge Registry, but without a diagnosis of malignancy in the Swedish Cancer Registry, were included. The outcome death was identified by cross-linkage to the Causes of Death Registry. Registry data on possible risk factors for mortality were collected.

RESULTS

A total of 126 885 procedures were performed in 110 119 patients. Open surgery was initially the only available method, but during the 1990s ERCP became predominant. Later, laparoscopic bile duct clearance became an established but uncommon method. A 90-day mortality rate of 0·2 per cent after open surgery, 0·8 per cent after ERCP, 0 per cent after laparoscopic exploration and 0·7 per cent after combined procedures was recorded. After adjustment for confounding, there was no difference in mortality between open surgery and ERCP. Biliary reintervention within 90 days was identified as a risk factor for death, whereas a concomitant diagnosis of pancreatitis reduced the risk.

CONCLUSION

The laparoscopic technique had the lowest mortality and morbidity rates. After adjustment for confounding factors, there was no difference in mortality after open surgery and ERCP. The favourable outcome for laparoscopy may have been due to selection bias, owing to treatment of younger, healthier subjects with less severe disease.

Can elderly patients with colorectal cancer tolerate planned surgical treatment? A practical approach to a common dilemma

AIM

Analysing the effectiveness of a surgical procedure is mandatory in every modern health-care system. The aging of the population stresses the need for a good standard of care. This study tests the hypothesis that porthsmouth-physiologic operative severity score for enumeration of morbidity and mortality (P-POSSUM) and colorectal-POSSUM (CR-POSSUM) would be useful clinical auditing tools in colorectal cancer surgery for aged patients.

METHOD

One hundred and seventy-seven consecutive patients over 70 years of age underwent emergency or elective surgery from January 2003 to December 2005. Demographic, clinical and surgical information, score systems' prediction, complications and 30-day mortality data were prospectively entered in a comprehensive database. The observed over expected morbidity and mortality rate was calculated.

RESULTS

Thirty-day observed mortality was 10.3% (19/177) while P-POSSUM and CR-POSSUM expected mortality were, respectively, 11.21% (P = NS) and 13.08% (P = NS). Overall observed morbidity was 42.7%, P-POSSUM prediction was 59.3% (P = 0.002). Morbidity and mortality data were analysed for specific subgroups of patients (resection and anastomosis/resection and stoma/palliative; emergency/elective).

CONCLUSION

P-POSSUM and CR-POSSUM are useful tools to predict mortality in elderly patients. P-POSSUM significantly overestimated the risk of complications. A more accurate tool for preoperative assessment for aged patients is probably needed to predict the post-surgical outcome.

Surgery in older people: an update

In the past two decades, the rate of surgery in older people has increased more rapidly than the rate of aging of the population, so both a larger proportion and a greater number of older people are now undergoing surgery. This may partly reflect a cultural change in surgery and anaesthesia with respect to a greater willingness to undertake elective procedures in older people, although there remain areas where they have less access to surgery than do younger patients. For instance, older people are less likely to undergo operative procedures after a cancer diagnosis. Furthermore, in those who do have surgery, resection rate (i.e. curative therapy) is lower than in younger people with equivalent tumour stages, and even more so in older patients with COPD, cardiovascular disease or diabetes. This article explores the complex relationship between age and surgical outcome, provides an evidence-based overview of risk assessment and common postoperative problems in older people, and summarizes good practice points (at times necessarily pragmatic) for clinical management of the older surgical patient. There has been a substantial expansion in the literature examining risks, outcomes and interventions in older surgical patients since the previous review article of this subject published in this journal. Although we do not cover anaesthesia in older people, the review of that topic remains relevant. The American Society of Anaesthesiologists' Classification of Risk which illustrates that risk is disease- rather than age- based, is shown in Table 1. Most publications examine elective rather than emergency surgery in older people (with the exception of hip fracture), and this is reflected in the content of the paper.

Endoscopic sphincterotomy with or without cholecystectomy for choledocholithiasis in high-risk surgical patients: a decision analysis

BACKGROUND

Laparoscopic cholecystectomy (LC) is recommended for patients with choledocholithiasis after ERCP with sphincterotomy (ES) and stone extraction.

AIM

We designed a decision model to address whether ES alone versus ES followed by LC (ES + LC) is the optimal treatment in high-risk patients with choledocholithiasis.

METHODS

Our cohort were patients with obstructive jaundice who have undergone an ES with biliary clearance. Recurrent biliary complications over a 2-year period stratified by gallbladder status (in/out) and age-stratified surgical complication rates were obtained from the literature. Failure of therapy was defined as either recurrent symptoms or death attributed to biliary complications.

RESULTS

For age 70-79 years, ES failed in 15% whereas ES + LC failed in 17% of cases. Mortality in the EC + LC group was 3.4 times that of the ES alone cohort. For age 80+ years, ES was dominant with an incremental success rate of 8%. Mortality in the ES + LC was 7.6 times that of ES. For age <70, ES + LC was the dominant strategy with an incremental success rate 5%. Sensitivity analysis in the groups confirmed our conclusions.

CONCLUSIONS

Management of choledocholithiasis by ES and stone clearance, but without cholecystectomy, should be considered for patients aged 70+. For low-risk patients, ES + LC should be performed to prevent recurrent biliary complications.

Relationship among hospital ERCP volume, length of stay, and technical outcomes

BACKGROUND

The relationship between hospital procedure volume and outcome has been recognized for various specialties and procedures. Although increasingly used and in existence for 40 years, to date, data on the relationship between hospital volume and outcome of ERCP are scant.

OBJECTIVE

We sought to examine health-related outcomes after ERCP in relation to hospital procedure volume.

DESIGN

Secondary analysis of a national administrative database. We used the National Inpatient Sample (NIS) database to evaluate health-related outcomes among patients who underwent ERCP from 1998 to 2001.

MAIN OUTCOME MEASUREMENTS

Logistic and multiple regression models were used to estimate the association of hospital ERCP volume with length of stay (LOS), rates of procedural failure, and mortality. Fixed effect models were used to adjust for all time invariant hospital characteristics for each hospital within the dataset.

RESULTS

Data from 2629 hospitals that performed 199,625 ERCPs were evaluated. The median number of ERCPs performed in participating hospitals was 49 per year (range, 1-1004), with 25% of hospitals performing > or =100 ERCPs per year and 5% performing > or =200 per year. Significant trends in the relationship between volume and outcome were observed with respect to LOS and procedural failure: the median LOS was lower in high-volume (> or =200 ERCP/y) than low-volume (< or =100 ERCP/y) hospitals (6.9 vs 7.8 days, p < 0.0001) and the mean difference in expected LOS was 1.08 days (p < 0.0001). Multivariate regressions with hospital level fixed effects found significant negative relationships between procedure volume and procedure failure rates, but no significant effect on inpatient mortality rates was detected.

LIMITATIONS

NIS database permits analyses of only inpatient ERCPs. It precludes analysis of procedural complications, reinterventions, and influence of individual provider volume on outcomes.

CONCLUSIONS

Inpatients who undergo ERCP at high-volume hospitals have shorter LOS and lower procedural failure rates than those undergoing ERCP at low-volume hospitals. These findings have important implications for health care policy decision making and resource utilization.

US-guided Percutaneous Cholecystostomy: Features Predicting Culture-Positive Bile and Clinical Outcome

PURPOSE

To assess sonographic and clinical features that might be used to predict infected bile and/or patient outcome from ultrasonography (US)-guided percutaneous cholecystostomy.

MATERIALS AND METHODS

Between February 1997 and August 2002 at one institution, 112 patients underwent US-guided percutaneous cholecystostomy (59 men, 53 women; average age, 69.3 years). All US images were scored on a defined semiquantitative scale according to preset parameters: (a) gallbladder distention, (b) sludge and/or stones, (c) wall appearance, (d) pericholecystic fluid, and (e) common bile duct size and/or choledocholithiasis. Separate and total scores were generated. Retrospective evaluation of (a) the bacteriologic growth of aspirated bile and its color and (b) clinical indices (fever, white blood cell count, bilirubin level, liver function test results) was conducted by reviewing medical records. For each patient, the clinical manifestation was classified into four groups: (a) localized right upper quadrant symptoms, (b) generalized abdominal symptoms, (c) unexplained sepsis, or (d) sepsis with other known infection. Logistic regression models, exact Wilcoxon-Mann-Whitney test, and the Kruskal-Wallis test were used.

RESULTS

Forty-seven (44%) of 107 patients had infected bile. A logistic regression model showed that wall appearance, distention, bile color, and pericholecystic fluid were not individually significant predictors for culture-positive bile, leaving sludge and/or stones (P =.003, odds ratio = 1.647), common bile duct status (P =.02, odds ratio = 2.214), and total score (P =.007, odds ratio = 1.267). No US covariates or clinical indices predicted clinical outcome. Clinical manifestation was predictive of clinical outcome (P =.001) and aspirating culture-positive bile (P =.008); specifically, 30 (86%) of 35 patients with right upper quadrant symptoms had their condition improve, compared with one (7%) of 15 asymptomatic patients with other known causes of infection.

CONCLUSION

US variables can be used to predict culture-positive bile but not patient outcome. Clinical manifestation is important because patients with right upper quadrant symptoms have the best clinical outcome.

Abdominal surgical emergencies in the elderly

The evaluation of abdominal pain can be considerably more challenging in elderly patients. A higher likelihood of life-threatening pathology combined with a myriad of diagnostic pitfalls in this population mandate a more cautious approach with greater use of diagnostic resources and specialist consultation.

Long-term results from laparoscopic common bile duct exploration

BACKGROUND

The aim of this study was to evaluate the long-term results after laparoscopic common bile duct exploration (LCBDE).

METHODS

A retrospective review of 175 consecutive patients who underwent attempted LCBDE between 1992 and 1999 was conducted. Laparoscopic transcystic exploration was accomplished in 110 patients and laparoscopic choledochotomy in 52 patients. Conversion to an open common bile duct exploration was required for 13 patients (7.4%). Retained common bile duct stones occurred in eight patients (4.6%). The 30-day postoperative morbidity was 6.9%, and there was no 30-day mortality. All the patients (alive and localized) received a questionnaire evaluating long-term results.

RESULTS

Of the 175 patients, 169 (4 unrelated deaths and 2 patients lost to follow-up evaluation) received and 152 (90%) returned the questionnaire. The follow-up period ranged from 6 to 72 months (median, 36 months). One patient developed recurrent common bile duct stones. There were no signs or evidence of common bile duct stricture in any patient.

CONCLUSION

The LCBDE procedure can be performed without increased risk of late bile duct complications.

Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct

BACKGROUND

Laparoscopic exploration of the common bile duct is becoming more popular, although endoscopic sphincterotomy remains the usual treatment for bile duct stones. However, loss of the biliary sphincter causes permanent duodenobiliary reflux, and recurrent stone disease and biliary neoplasia may be a consequence.

METHODS

A systematic literature review was conducted to compare laparoscopic exploration with endoscopic sphincterotomy. A text word search of the Medline, Pubmed and Cochrane databases, and a manual search of the citations from these references, was used.

RESULTS

Endoscopic sphincterotomy is associated with a median (range) mortality rate of 1 (0-6) per cent, compared with 1 (0-5) per cent for laparoscopic bile duct exploration. The median (range) rate of pancreatitis following endoscopic sphincterotomy is 3 (1-19) per cent; this is a rare complication after laparoscopic duct exploration. The combined morbidity rate for laparoscopic cholecystectomy and endoscopic sphincterotomy is 13 (3-16) per cent, which is greater than 8 (2-17) per cent for laparoscopic bile duct exploration. Randomized trials are few and contain relatively small numbers of patients. They show little overall difference in rates of duct clearance, but a higher mortality rate and number of hospital admissions are noted for endoscopic sphincterotomy compared with laparoscopic bile duct exploration. Endoscopic sphincterotomy is associated with recurrent stone formation (up to 16 per cent) with associated cholangitis. It is also associated with bacterobilia and chronic mucosal inflammation. The late development of bile duct cancer has been reported in up to 2 per cent of patients.

CONCLUSION

Laparoscopic exploration of the common bile duct may be a better way of removing stones than endoscopic sphincterotomy plus laparoscopic cholecystectomy. :

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

BACKGROUND

The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial.

METHODS

Over the three-year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio-pancreatography.

RESULTS

Transcystic stenting was the 'intention-to-treat' basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1-15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio-pancreatography, was 98%. A second endoscopic retrograde cholangio-pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis.

CONCLUSION

A treatment option open to all surgeons for non-jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.

Laparoscopic surgery in older adults

This article provides an overview of the current role of laparoscopic surgery in older patients. A retrospective review and analysis of the recent English-language literature on laparoscopic procedures with special attention devoted to those articles focused on geriatric patients was performed. Laparoscopic surgery has rapidly become the fastest-growing discipline within the surgical arena and new applications for laparoscopy continue to be reported. The primary benefits to patients of these developments are smaller scars, decreased postoperative pain, and more-rapid return to normal activity. As society ages, more older patients will present with pathology amenable to laparoscopic intervention. Several aspects of laparoscopy impose unique physiologic stresses and, as such, may alter surgical risk to the geriatric patient. In addition, older patients often have delayed surgical interventions because of more-conservative medical management or unusual symptomatology, which may further complicate the laparoscopic approach. These limitations may alter the risk-to-benefit ratio of laparoscopic versus open procedures. Despite this lack of elucidation of full-risk profiles, laparoscopic approaches should be considered regardless of a patient's age.

Does cholecystectomy after endoscopic sphincterotomy prevent the recurrence of biliary complications?

BACKGROUND

The intact gallbladder after endoscopic sphincterotomy is thought to be a potential risk factor for recurrent biliary complications. The aim of this non-randomized prospective study was to investigate whether cholecystectomy soon after endoscopic sphincterotomy could prevent the recurrence of biliary complications.

METHODS

From January 1991 to October 1995, 140 patients with intact gallbladder underwent endoscopic sphincterotomy for clearance of stones in the bile duct. Of the 140 patients, 46 underwent elective cholecystectomy soon after sphincterotomy (group A) and 94 did not (group B). All 140 patients had quantitative cholescintigraphy after normalization of liver function and were followed on a regular basis with liver biochemistry, sonography, and/or computed tomography. Endoscopic retrograde cholangiography was also performed if a recurrent biliary problem was suspected.

RESULTS

After a median 43 months (range 23 to 80) of follow-up, 5 patients in group A developed bile duct stones whereas 12 patients in group B had recurrent stones; 4 patients in group A versus 6 patients in group B had recurrent biliary symptoms. One patient in group A and 5 patients in group B with recurrent biliary stones were without symptoms. In group B, the age, gender, diameter of the bile duct, preexisting cholelithiasis, abnormal filling of the gallbladder on quantitative cholescintigraphy, and presence of juxtapapillary diverticulum were not found to be the significant factors affecting the recurrence of biliary symptoms or stones. Endoscopic removal of recurrent biliary stones was successful in all patients. Three patients in group B underwent cholecystectomy after abatement of symptoms.

CONCLUSION

Elective cholecystectomy after endoscopic sphincterotomy does not reduce the incidence of recurrent biliary complications.

Cholecystectomy in patients aged 80 and older

BACKGROUND

We assessed whether the increase in performance of laparoscopic cholecystectomy has affected patients aged 80 and older and if outcomes of a laparoscopic approach in this population would show improvement over those for open surgery.

METHODS

We analyzed an 11-state discharge database obtained from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Release 1 contains a 20% sample of United States hospitals for the period 1988 to 1992. Diagnosis-related group (DRG) codes 197 and 198 were searched, and demographics, type of surgery, and outcome measures were analyzed.

RESULTS

In 5 years, 350,451 patients underwent cholecystectomy with the DRG codes listed. Of those, 18,500 patients were aged 80 to 105. The total number of cholecystectomies increased each year. Performance of laparoscopic cholecystectomy rose rapidly and that of open cholecystectomy decreased. Overall mortality with laparoscopic cholecystectomy was 1.8%, was lower than that of open cholecystectomy, was lower in women, and decreased with time.

CONCLUSIONS

Patients aged 80 and older have participated in the increased performance of cholecystectomy and the switch to laparoscopic cholecystectomy. This has a low mortality, low length of stay, and higher proportion of patients being discharged to home compared with patients having open cholecystectomy.

Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bileduct calculi in high-risk patients

BACKGROUND

Morbidity and mortality after surgical treatment of bileduct stones increase with age and associated diseases. A proposed alternative therapy is endoscopic sphincterotomy (ES) with the gallbladder left in situ, and we elected to compare this option with standard open surgery in high-risk patients.

METHODS

98 patients (mean age 80 years) with symptoms likely to be due to bileduct stones or a recent episode of biliary pancreatitis were randomised to be treated either by open cholecystectomy with operative cholangiography and (if necessary) bileduct exploration (n=48) or by endoscopic sphincterotomy alone (n=50).

FINDINGS

The procedure was accomplished successfully in 94% of the surgery group and 88% of the ES group, and there were no significant differences in immediate morbidity (23% vs 16%) or mortality (4% vs 6%). During mean follow-up of 17 months biliary symptoms recurred in three surgical patients, none of whom underwent repeat surgery, and in 10 ES patients, seven of whom had biliary surgery. By multivariate regression analysis endoscopic sphincterotomy was an independent predictor of recurrent biliary symptoms (odds ratio 6.9; 95% Cl 1.46 to 32.54).

INTERPRETATION

In elderly or high-risk patients, surgery is preferable to endoscopic sphincterotomy with the gallbladder left in situ as a definitive treatment for bileduct stones or non-severe biliary pancreatitis.