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Baimas-George M, Kirks RC, Cochran A, Baker EH, Lauren Paton B, Schiffern LM, Matthews BD, Martinie JB, Vrochides D, Iannitti DA. Patient Factors Lead to Extensive Variation in Outcomes and Cost From Cholecystectomy. Am Surg 2020; 86:643-651. [PMID: 32683960 DOI: 10.1177/0003134820923311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cholecystectomy is a common procedure with significantly varied outcomes. We analyzed differences in comorbidities, outcomes, and cost of cholecystectomy by acute care surgery (ACS) versus hepatopancreaticobiliary (HPB) surgery. STUDY DESIGN Patients were retrospectively identified between 2008 and 2015. Exclusion criteria included the following: (1) part of another procedure; (2) abdominal trauma; (3) ICU admission; vasopressors. RESULTS One hundred and twenty-six ACS and 122 HPB patients were analyzed. The HPB subset had higher burden of comorbid disease and significantly lower projected 10-year survival (87.4% ACS vs 68.5% HPB, P < .0001). Median lengths of stay were longer in HPB patients (2 vs 5 days, P < .0001) as were readmission rates (30-day 5.6% vs 13.1%, P = .040; 90-day 7.9% vs 20.5%, P = .005). Median cost was higher including operative supply cost ($969.42 vs $1920.66, P < .0001) and total cost of care ($7340.66 vs $19 338.05, P < .0001). A predictive scoring system for difficult gallbladders was constructed and a phone application was created. CONCLUSION Cholecystectomy in a complicated patient can be difficult with longer hospital stays and higher costs. The utilization of procedure codes to explain disparities is not sufficient. Incorporation of comorbidities needs to be addressed for planning and reimbursement.
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Affiliation(s)
- Maria Baimas-George
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Russell C Kirks
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Allyson Cochran
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - B Lauren Paton
- 22442 Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Lynnette M Schiffern
- 22442 Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Brent D Matthews
- 22442 Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Chand P, Kaur M, Bhandari S. Preoperative Predictors of Level of Difficulty of Laparoscopic Cholecystectomy. Niger J Surg 2019; 25:153-157. [PMID: 31579368 PMCID: PMC6771185 DOI: 10.4103/njs.njs_3_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic gallbladder stone disease. This is due to its safety, reliability, cost-effectiveness, negligible mortality, shorter duration of hospitalization (early return to work), better cosmesis, minimal wound complications, and temporary paralytic ileus. In spite of these, conversion to open cholecystectomy which is sometimes required in difficult cases could be challenging. Aims and Objectives The aim of the present study is to aid the prediction of difficult cases undergoing LC, thereby better selection of patients with the least conversion rates. Materials and Methods This prospective study was conducted on 100 consecutive patients with cholecystitis, over a 2-year period from January 1, 2017, to December 31, 2018, having undergone LC. Various preoperative parameters, including age, sex, previous attacks of cholecystitis, deranged liver functions, and ultrasonographic findings, were analyzed for their effects for predicting the level of difficulty during LC. Results Twenty-five percent of the cases were correctly predicted as difficult in the age group of >65 years. Cholecystitis was more common (79%) in females, but difficulties were encountered more frequently while performing LC in males. Abnormal serum hepatic and pancreatic enzyme profiles were associated with difficulties during surgery as about 83.3% of the patients predicted as moderately difficult peroperatively had deranged liver functions. The preoperative ultrasonography findings were helpful for predicting the degree of difficulty involved in the procedure. About 33.3% of the patients that had pericholecystic fluid on ultrasound preoperatively were correctly predicted to have moderately difficult surgeries. The Chi-square test and P value were used to determine statistical significance. Conclusions Females, the absence of previous repeated attacks of cholecystitis and hospitalizations, no upper abdominal surgery in the past, normal liver function tests, normal amylase levels, nondistended and uncontracted gallbladder, absence of pericholecystic collection, afebrile, and single stone are positive preoperative predictors of safe LC in symptomatic gallbladder stone disease.
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Affiliation(s)
- Prem Chand
- Department of Surgery, Government Medical College, Patiala, Punjab, India
| | - Manpreet Kaur
- Department of Surgery, Government Medical College, Patiala, Punjab, India
| | - Sumit Bhandari
- Department of Surgery, Government Medical College, Patiala, Punjab, India
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de Bari O, Wang TY, Liu M, Paik CN, Portincasa P, Wang DQH. Cholesterol cholelithiasis in pregnant women: pathogenesis, prevention and treatment. Ann Hepatol 2014. [PMID: 25332259 DOI: 10.1016/s1665-2681(19)30975-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Epidemiological and clinical studies have found that gallstone prevalence is twice as high in women as in men at all ages in every population studied. Hormonal changes occurring during pregnancy put women at higher risk. The incidence rates of biliary sludge (a precursor to gallstones) and gallstones are up to 30 and 12%, respectively, during pregnancy and postpartum, and 1-3% of pregnant women undergo cholecystectomy due to clinical symptoms or complications within the first year postpartum. Increased estrogen levels during pregnancy induce significant metabolic changes in the hepatobiliary system, including the formation of cholesterol-supersaturated bile and sluggish gallbladder motility, two factors enhancing cholelithogenesis. The therapeutic approaches are conservative during pregnancy because of the controversial frequency of biliary disorders. In the majority of pregnant women, biliary sludge and gallstones tend to dissolve spontaneously after parturition. In some situations, however, the conditions persist and require costly therapeutic interventions. When necessary, invasive procedures such as laparoscopic cholecystectomy are relatively well tolerated, preferably during the second trimester of pregnancy or postpartum. Although laparoscopic operation is recommended for its safety, the use of drugs such as ursodeoxycholic acid (UDCA) and the novel lipid-lowering compound, ezetimibe would also be considered. In this paper, we systematically review the incidence and natural history of pregnancy-related biliary sludge and gallstone formation and carefully discuss the molecular mechanisms underlying the lithogenic effect of estrogen on gallstone formation during pregnancy. We also summarize recent progress in the necessary strategies recommended for the prevention and the treatment of gallstones in pregnant women.
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Affiliation(s)
- Ornella de Bari
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, USA
| | - Tony Y Wang
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, USA; Department of Biomedical Engineering, Washington University, St. Louis, USA
| | - Min Liu
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Chang-Nyol Paik
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, USA
| | - Piero Portincasa
- Clinica Medica "A. Murri", Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
| | - David Q-H Wang
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, USA
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Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study. Am J Surg 2013; 206:457-63. [PMID: 23871320 DOI: 10.1016/j.amjsurg.2013.02.004] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 01/26/2013] [Accepted: 02/07/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration are safe and efficient methods that have recently been used for the treatment of bile duct stones. The aim of this study was to compare the efficacy, safety, and surgical outcomes of the laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (ERCP+LC). METHODS One hundred twenty patients were prospectively randomized into 2 groups: LCBDE with LC in a single intervention and LC after ERCP. RESULTS The success rate of the LCBDE+LC group (96.5%) was found to be higher than for the ERCP+LC group (94.4%). Complication rates of the LCBDE+LC and ERCP+LC group were 7% and 11.1%, respectively. Complications requiring ERCP in the postoperative period after LCBDE+LC have been noted in 3.5% of cases. CONCLUSIONS Laparoscopic CBD exploration provides an alternative therapeutic approach that has less morbidity, is cost-effective, and allows earlier recovery with a reduced period of short-term disability.
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Chen Q, Li WJ, Wan YY, Yu CD, Li WG. Fibroblast growth factor receptor 4 Gly388Arg polymorphism associated with severity of gallstone disease in a Chinese population. GENETICS AND MOLECULAR RESEARCH 2012; 11:548-55. [PMID: 22535390 DOI: 10.4238/2012.march.8.3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The etiology of gallstone disease is multifactorial; supersaturation of bile with cholesterol is a primary cause for gallstone formation. In previous studies, we found that fibroblast growth factor receptor 4 (FGFR4) plays an important role in maintaining bile acid homeostasis by regulating the expression of cholesterol 7α-hydroxylase (CYP7A1), a rate-limiting enzyme for bile acid biosynthesis. The Gly388Arg (G-388R) polymorphism of FGFR4 affects stabilization and activation of FGFR4. Consequently, we studied the FGFR4 gene as a candidate gene for genetic susceptibility to gallstone disease. We found that overexpression of FGFR4, especially the G-388R mutant of FGFR4, inhibits luciferase activity of CYP7A1 reporter in HepG2 cells, indicating that the G-388R mutant of FGFR4 may have greater inhibitory activity against bile acid biosynthesis. To investigate the association of FGFR4 polymorphism with gallstone disease, 117 patients with gallstone disease and 457 controls were genotyped for FGFR4 polymorphism G-388R by PCR-RFLP. Although the incidence of gallstone disease was not greater in patients with the FGFR4 RR genotype, the ratio of gallstone patients with acute cholecystitis in the FGFR4 RR genotype (42%) was significantly higher than that in other genotypes of FGFR4 (P = 0.019). In conclusion, the FGFR4 polymorphism is a genetic risk factor contributing to aggravation of gallstone disease.
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Affiliation(s)
- Q Chen
- Department of Hepatobiliary Pancreas and Vessel Surgery, Chenggong Hospital of Xiamen University, Xiamen, China
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A novel classification system to address financial impact and referral decisions for bile duct injury in laparoscopic cholecystectomy. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2011; 2011:371245. [PMID: 21912446 PMCID: PMC3170787 DOI: 10.1155/2011/371245] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 06/27/2011] [Accepted: 07/12/2011] [Indexed: 12/20/2022]
Abstract
Purpose. The study was undertaken to evaluate a novel
classification system developed to estimate financial cost of bile
duct injury (BDI) and to aid in decision making for referral.
Study Design. A retrospective review of
patients referred for BDI was performed. Grade I injuries involve the
duct of Luschka or accessory right hepatic ducts, grade II includes
all other biliary injuries, and grade III includes all vasculobiliary
injuries. Groups were compared using standard statistical methods.
Results. There were 14 grade I, 74 grade II,
and 20 grade III injuries. There was a significant difference in the
cost and mortality of grade I ($12,457, 0%), grade II ($46,481, 1.4%),
and grade III ($69,368, 15%,
P = 0.002
and
P = 0.030,
resp.) injuries. Grade II and III injuries were significantly more
likely to require surgical repair (OR 27.7,
P < 0.001).
Conclusion. We have presented a simple
classification system that is able to accurately predict cost and need
for surgical repair.
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Hepatobiliary and splenic infection. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00039-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Debru E, Dawson A, Leibman S, Richardson M, Glen L, Hollinshead J, Falk GL. Does routine intraoperative cholangiography prevent bile duct transection? Surg Endosc 2005; 19:589-93. [PMID: 15759189 DOI: 10.1007/s00464-004-8711-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2004] [Accepted: 10/26/2004] [Indexed: 12/19/2022]
Abstract
BACKGROUND The role of routine intraoperative cholangiography is controversial. The aim of this study was to assess the impact of routine intraoperative cholangiography on the incidence of common bile duct injuries, and to evaluate the operative outcome of laparoscopic cholecystectomy carried out in a major teaching hospital and review the literature. METHODS Prospectively collected data on 3,145 laparoscopic cholecystectomies performed mainly by surgical trainees in the period 1990 to 2002 using routine intraoperative cholangiography with fluoroscopy were reviewed. RESULTS The mean age of the study sample (65.6% male, 34.4% female) was 54 years, and 16.9% of the patients had clinical acute cholecystitis. The conversion rate to open cholecystectomy was 4.3%. Intraoperative cholangiography was attempted for 90.7% of the patients with a 95.9% success rate. Five patients (0.16%) had common bile duct injuries. Four injuries had occurred in the first 5 years. One injury (0.06%) had occurred after 1995. This injury was identified intraoperatively and repaired laparoscopically. Routine intraoperative cholangiography prevented one definite common bile duct transection. CONCLUSIONS In this series using routine intraoperative cholangiography, there was a low rate and severity of common bile duct injuries, with a high intraoperative recognition rate. There was no bile duct transection or major injury requiring common bile duct reconstruction. Although intraoperative cholangiography helped in the immediate identification of injuries and the institution of appropriate therapy, injury was not completely prevented.
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Affiliation(s)
- E Debru
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, The University of Sydney, Hospital Road, Sydney, NSW, 2139, Australia
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Newton E, Mandavia S. Surgical complications of selected gastrointestinal emergencies: pitfalls in management of the acute abdomen. Emerg Med Clin North Am 2003; 21:873-907, viii. [PMID: 14708812 DOI: 10.1016/s0733-8627(03)00087-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Complaints referable to the abdomen are common emergency department presentations. Many of these conditions prove to be benign and self-limited, whereas others are potentially catastrophic. Because serious and benign intra-abdominal conditions share many relatively nonspecific symptoms, it is often difficult to identify patients who have life-threatening problems early in the course of their disease. Apart from relieving the patient's symptoms, the emergency physician's primary role is to detect and stabilize life-threatening conditions in a rapid and cost-effective manner.
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Affiliation(s)
- Edward Newton
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, 1200 North State Street, Room G1011, Los Angeles, CA 90033, USA.
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