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Fehring L, Brinkmann H, Hohenstein S, Bollmann A, Dirks P, Pölitz J, Prinz C. Timely cholecystectomy: important factors to improve guideline adherence and patient treatment. BMJ Open Gastroenterol 2024; 11:e001439. [PMID: 39053927 DOI: 10.1136/bmjgast-2024-001439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024] Open
Abstract
OBJECTIVE Cholecystectomy is one of the most frequently performed surgeries in Germany and is performed as a treatment of acute cholecystitis (guideline S3 IIIB.8) and after endoscopic retrograde cholangiopancreatography for choledocholithiasis with simultaneous cholecystolithiasis (guideline S3 IIIC.6). This article examines the effects of a guideline update from 2017, which recommends prompt cholecystectomy within 24 hours of admission due to cholecystitis or within 72 hours after bile duct repair. In addition, it aims to identify reasons (eg, financial disincentives) and potential for improvement for non-adherence to the guidelines. DESIGN Methodologically, a retrospective analysis based on routine billing data from 84 Helios Group hospitals from 2016 and 2022, with a total of 45 393 included cases, was applied. The guideline adherence rate is used as the main outcome measure. RESULTS Results show the guideline updates led to a statistically significant increase in the proportion of cholecystectomy performed in a timely manner (guideline S3 IIIB.8: increase from 43% to 49%, p<0.001; guideline S3 IIIC.6: increase from 7% to 20%, p<0.001). Medical, structural and financial reasons for non-adherence could be identified. CONCLUSION As possible reasons for non-adherence, medical factors such as advanced age, multimorbidity and frailty could be identified. Analyses of structural factors revealed that hospitals in very rural regions are less likely to perform timely cholecystectomies, presumably due to infrastructural and personnel-capacity bottlenecks. A similar picture emerges for maximum-care hospitals, which might be explained by more severe and complex cases on average. Further evaluation indicates that an increase in and better hospital-internal participation of gastroenterologists in remuneration could lead to even greater adherence to the S3 IIIC.6 guideline.
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Affiliation(s)
- Leonard Fehring
- Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
- Gastroenterology, HELIOS Universitätsklinikum Wuppertal, Wuppertal, Nordrhein-Westfalen, Germany
| | - Hendrik Brinkmann
- Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
| | | | | | | | - Jörg Pölitz
- Helios Health Institute GmbH, Leipzig, Germany
| | - Christian Prinz
- Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
- Gastroenterology, HELIOS Universitätsklinikum Wuppertal, Wuppertal, Nordrhein-Westfalen, Germany
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Wu H, Liao B, Cao T, Ji T, Huang J, Luo Y, Ma K. Comparison of the safety profile, conversion rate and hospitalization duration between early and delayed laparoscopic cholecystectomy for acute cholecystitis: a systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1185482. [PMID: 38148916 PMCID: PMC10750350 DOI: 10.3389/fmed.2023.1185482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 11/13/2023] [Indexed: 12/28/2023] Open
Abstract
Background Although the past decade has witnessed unprecedented medical progress, no consensus has been reached on the optimal approach for patients with acute cholecystitis. Herein, we conducted a systematic review and meta-analysis to assess the differences in patient outcomes between Early Laparoscopic Cholecystectomy (ELC) and Delayed Laparoscopic Cholecystectomy (DLC) in the treatment of acute cholecystitis. Our protocol was registered in the PROSPERO database (registration number: CRD42023389238). Objectives We sought to investigate the differences in efficacy, safety, and potential benefits between ELC and DLC in acute cholecystitis patients by conducting a systematic review and meta-analysis. Methods The online databases PubMed, Springer, and the Cochrane Library were searched for randomized controlled trials (RCTs) and retrospective studies published between Jan 1, 1999 and Jan 1, 2022. Results 21 RCTs and 13 retrospective studies with a total of 7,601 cases were included in this research. After a fixed-effects model was applied, the pooled analysis showed that DLC was associated with a significantly high conversion rate (OR: 0.6247; 95%CI: 0.5115-0.7630; z = -4.61, p < 0.0001) and incidence of postoperative complications (OR: 0.7548; 95%CI: 0.6197-0.9192; z = -2.80, p = 0.0051). However, after applying a random-effects model, ELC was associated with significantly shorter total hospitalization duration than DLC (MD: -4.0657; 95%CI: -5.0747 to -3.0566; z = -7.90, p < 0.0001). Conclusion ELC represents a safe and feasible approach for acute cholecystitis patients since it shortens hospitalization duration and decreases the incidence of postoperative complications of laparoscopic cholecystectomy. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=389238, identifier (CRD42023389238).
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Affiliation(s)
- Hongsheng Wu
- Department of Hepatobiliary Pancreatic Surgery, Affiliated Huadu Hospital, Southern Medical University, Guangzhou, China
| | | | | | | | | | | | - Keqiang Ma
- Department of Hepatobiliary Pancreatic Surgery, Affiliated Huadu Hospital, Southern Medical University, Guangzhou, China
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3
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Porras Fimbres DC, Nussbaum DP, Mosca PJ. Racial disparities in time to laparoscopic cholecystectomy for acute cholecystitis. Am J Surg 2023; 226:261-270. [PMID: 37149406 DOI: 10.1016/j.amjsurg.2023.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/25/2023] [Accepted: 05/02/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Disparities in healthcare exist, yet few data are available on racial differences in time from admission to surgery. This study aimed to compare time from admission to laparoscopic cholecystectomy for acute cholecystitis between non-Hispanic Black and non-Hispanic White patients. METHODS Patients who underwent laparoscopic cholecystectomy for acute cholecystitis from 2010 to 2020 were identified using NSQIP. Time to surgery and additional preoperative, operative, and postoperative variables were analyzed. RESULTS In the univariate analysis, 19.4% of Black patients experienced a time to surgery >1 day compared with 13.4% of White patients (p < 0.0001). In the multivariable analysis, controlling for potential confounding factors, Black patients were found to be more likely than White patients to experience a time to surgery >1 day (OR 1.23, 95% CI 1.17-1.30, p < 0.0001). CONCLUSIONS Further investigation is indicated to better define the nature and significance of gender, race, and other biases in surgical care. Surgeons should be aware that biases may adversely impact patient care and should strive to identify and proactively address them to promote health equity in surgery.
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Affiliation(s)
| | - Daniel P Nussbaum
- Duke University School of Medicine, Duke University Health System, Durham, NC, USA; Department of Surgery, Duke University School of Medicine, Duke University Health System, Durham, NC, USA; Duke Network Services, Duke University Health System, Durham, NC, USA
| | - Paul J Mosca
- Duke University School of Medicine, Duke University Health System, Durham, NC, USA; Department of Surgery, Duke University School of Medicine, Duke University Health System, Durham, NC, USA; Duke Network Services, Duke University Health System, Durham, NC, USA.
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4
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Güneş Y, Teke E, Aydın MT. The Optimal Timing of Laparoscopic Cholecystectomy in Acute Cholecystitis: A Single-Center Study. Cureus 2023; 15:e38915. [PMID: 37313092 PMCID: PMC10259690 DOI: 10.7759/cureus.38915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/15/2023] Open
Abstract
Introduction Early laparoscopic cholecystectomy (ELC) is a treatment option for acute cholecystitis (AC). However, the timing of ELC is controversial. Delayed laparoscopic cholecystectomy (DLC) continues to be a common practice. This study aims to determine the optimal timing of ELC in AC. Materials and methods Patients who underwent surgery for AC between 2014 and 2020 were divided into three groups: immediate laparoscopic cholecystectomy (ILC), prolonged ELC (pELC), and DLC. The demographic, laboratory, radiological findings, and postoperative results of all patients were retrospectively reviewed. Results The study included 178 patients, with 63 in the ILC group, 27 in the pELC group, and 88 in the DLC group. Postoperative outcomes, excluding hospital stay, were similar between the groups. The total hospital stay was significantly longer in the pELC and DLC groups (p<0.05). In addition, postoperative hospital stay was longer in the pELC group (p<0.05), and 17.7% of the patients who waited for delayed surgery experienced recurrent attacks during the interval period. Conclusion ILC is recommended in AC to minimize hospital stays.
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Affiliation(s)
- Yasin Güneş
- General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, TUR
| | - Emre Teke
- General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, TUR
| | - Mehmet T Aydın
- General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, TUR
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Ishii K, Fujita Y, Suzuki E, Koyama Y, Tsujino S, Nagao A, Hosono K, Teratani T, Kubota K, Nakajima A. The Efficacy and Safety of EUS-Guided Gallbladder Drainage as a Bridge to Surgery for Patients with Acute Cholecystitis. J Clin Med 2023; 12:jcm12082778. [PMID: 37109112 PMCID: PMC10141124 DOI: 10.3390/jcm12082778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/20/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND AND AIM This study aimed to compare the efficacy and safety of endoscopic ultrasound-guided gallbladder drainage and percutaneous transhepatic gallbladder drainage as a bridge to surgery in patients with acute cholecystitis unfit for urgent cholecystectomy. METHODS This retrospective study included 46 patients who underwent cholecystectomy following endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) or percutaneous transhepatic gallbladder drainage (PTGBD) for acute cholecystitis in NTT Tokyo Medical Center. We surveyed 35 patients as the EUS-GBD group and 11 patients as the PTGBD group, and compared the rate of technical success of the cholecystectomy and periprocedural adverse events. A 7-F, 10-cm double pigtail plastic stent was used for ultrasound-guided gallbladder drainage. RESULTS The rate of technical success of cholecystectomy was 100% in both groups. Regarding postsurgical adverse events, no significant difference was noted between the two groups (EUS-GBD group, 11.4%, vs. PTGBD group, 9.0%; p = 0.472). CONCLUSIONS EUS-GBD as a BTS seems to be an alternative for patients with AC because it can ensure lower adverse events. On the other hand, there are two major limitations in this study--the sample size is small and there is a risk of selection bias.
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Affiliation(s)
- Ken Ishii
- Department of Hepato-Biliary-Pancreatic Medicine, NTT Tokyo Medical Center, 5-9-22 Higashi-Gotanda, Shinagawa-ku, Tokyo 141-8625, Japan
| | - Yuji Fujita
- Department of Hepato-Biliary-Pancreatic Medicine, NTT Tokyo Medical Center, 5-9-22 Higashi-Gotanda, Shinagawa-ku, Tokyo 141-8625, Japan
| | - Eisuke Suzuki
- Department of Hepato-Biliary-Pancreatic Medicine, NTT Tokyo Medical Center, 5-9-22 Higashi-Gotanda, Shinagawa-ku, Tokyo 141-8625, Japan
| | - Yuji Koyama
- Department of Hepato-Biliary-Pancreatic Medicine, NTT Tokyo Medical Center, 5-9-22 Higashi-Gotanda, Shinagawa-ku, Tokyo 141-8625, Japan
| | - Seitaro Tsujino
- Department of Hepato-Biliary-Pancreatic Medicine, NTT Tokyo Medical Center, 5-9-22 Higashi-Gotanda, Shinagawa-ku, Tokyo 141-8625, Japan
| | - Atsuki Nagao
- Department of Surgery, NTT Tokyo Medical Center, Tokyo 141-8625, Japan
| | - Kunihiro Hosono
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Takuma Teratani
- Department of Hepato-Biliary-Pancreatic Medicine, NTT Tokyo Medical Center, 5-9-22 Higashi-Gotanda, Shinagawa-ku, Tokyo 141-8625, Japan
| | - Kensuke Kubota
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
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Nakamura Y, Kuwahara M, Ito K, Inagaki F, Mihara F, Takemura N, Kokudo N. Percutaneous Transhepatic Gallbladder Intervention as a Bridge to Cholecystectomy: Aspiration or Drainage? World J Surg 2023; 47:1721-1728. [PMID: 37000200 DOI: 10.1007/s00268-023-06987-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Percutaneous transhepatic gallbladder aspiration (PTGBA) and percutaneous transhepatic gallbladder drainage (PTGBD) are often the first-line treatments for acute cholecystitis, instead of surgical cholecystectomy. This retrospective study aimed to compare the treatment outcomes of PTGBA and PTGBD and evaluate the risks of treatment failure among patients undergoing PTGBA before surgical cholecystectomy. METHODS We retrospectively reviewed 99 patients who underwent PTGBA or PTGBD as the first-line treatment before surgical cholecystectomy, between January 2014 and December 2019. Patient characteristics, computed tomography (CT) findings, and post-treatment outcomes were compared between the PTGBA and PTGBD groups. Additionally, risk factors, including CT findings for PTGBA failure, were assessed using multivariate univariate analysis with a backward selection model. RESULTS Acute cholecystitis was not controlled in 21 of 47 (44.7%) patients in the PTGBA group and one of 52 patients (1.9%) in the PTGBD group (P < .001). Subsequent multiple logistic regression analysis identified the contrast effect of the gallbladder bed in the arterial phase of contrast-enhanced CT (odds ratio [OR] 9.17, 95% confidence interval [CI] 2.08-40.4, P = 0.003) and onset within 3 days (odds ratio [OR] 6.29, 95% confidence interval [CI] 1.37-29.0, P = 0.018) as independent risk factors for PTGBA failure. CONCLUSIONS PTGBA is more prone to failure than PTGBD; however, it is a simpler gallbladder drainage treatment method without the need for X-ray fluoroscopy and catheter management after the procedure. Evaluating the risk of PTGBA failure using CT findings and onset date would help us choose a drainage approach more effectively.
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Affiliation(s)
- Yuki Nakamura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Mai Kuwahara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Kyoji Ito
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Fuyuki Inagaki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Fuminori Mihara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Nobuyuki Takemura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan.
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
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Index Admission Cholecystectomy for Biliary Colic Precludes the Risk of Readmissions with Biliary Complications and should be Standard Treatment. World J Surg 2023; 47:658-665. [PMID: 36525063 PMCID: PMC9756717 DOI: 10.1007/s00268-022-06847-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Emergency biliary colic admissions can be managed with an index or elective laparoscopic cholecystectomy (LC). Opting to perform an elective LC may have significant repercussions such as the risk of readmissions before operation with further attacks or with biliary complications (e.g. cholecystitis, pancreatitis, choledocholithiasis). The risk of readmission and biliary complications in patients admitted with biliary colic but scheduled for elective surgery has never been investigated. The secondary aim was to compare rates of peri-operative morbidity between the index admission, elective and readmission LC cohorts. METHOD All patients admitted with a diagnosis of biliary colic over a 5-year period and proceeding to LC were included in the study (n = 441). The risk of being readmitted and suffering further morbidity whilst awaiting elective LC was investigated. Peri-operative morbidity was compared between the index admission, elective and readmitted LC groups using univariate and multivariate analysis. RESULTS Following a biliary colic admission, the risk of readmission whilst awaiting elective LC is significant (2 months-25%; 10 months-48%). In this group, the risks of subsequent biliary complications (18.0%) and the requirement for ERCP (6.5%) were significant. Patients who are readmitted before LC, suffer a more complicated peri-operative course (longer total length of stay, higher post-operative complications, imaging and readmission). DISCUSSION Index admission LC for biliary colic avoids the significant risk of readmission and biliary complications before surgery and should be the gold standard. Readmitted patients are likely to have higher rates of peri-operative adverse outcomes. Patients should be counselled about these risks.
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Coccolini F, Solaini L, Binda C, Catena F, Chiarugi M, Fabbri C, Ercolani G, Cucchetti A. Laparoscopic Cholecystectomy in Acute Cholecystitis: Refining the Best Surgical Timing Through Network Meta-Analysis of Randomized Trials. Surg Laparosc Endosc Percutan Tech 2022; 32:755-763. [PMID: 36223286 DOI: 10.1097/sle.0000000000001103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/28/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Acute cholecystitis (AC) is largely diffused among population worldwide. Laparoscopic cholecystectomy is the treatment of choice. Current evidence suggests a clinical benefit of early cholecystectomy. The aim of the present study was to evaluate the different "timing" ("early" vs. "delayed" cholecystectomy), through the application of network meta-analyses, to define the most adequate interval associated with the best outcomes. MATERIALS AND METHODS A network meta-analysis of randomized controlled trials was conducted. RESULTS Early cholecystectomy ≤72 hours from symptoms reduced conversion rate in comparison to: cholecystectomy ≤7 days from symptoms ( P =0.044), delayed cholecystectomy within 1 to 5 weeks from first admission ( P =0.010) and 6 to 12 weeks from symptoms resolutions ( P =0.009). Delaying cholecystectomy to 6 to 12 weeks reduces operating time in respect to early cholecystectomy ≤72 hours from symptoms ( P =0.001), within 24 hours from admission ( P =0.001), ≤72 hours from admission ( P =0.001) and ≤7 days from symptoms ( P =0.001). Cholecystectomy ≤24 hours from admission was the best strategy to reduce total in-hospital stay, whereas delaying cholecystectomy to 6 to 12 weeks was the worst strategy. The same applied when cholecystectomy was performed ≤72 hours from symptoms in respect to both delayed strategies ( P =0.001 for both comparisons) or when it was performed ≤72 hours from admission ( P =0.001 for both comparisons). Cholecystectomy ≤72 hours from symptoms onset was the best strategy to reduce postoperative complications, the worst was represented by delayed cholecystectomy at 1 to 5 weeks from first admission. CONCLUSION AC should be operated as soon as possible. AC surgical management should be considered in a dynamic time conception to optimize clinical, organizational, and economical outcomes.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa
| | - Leonardo Solaini
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, Bologna
- Department of Surgery, Morgagni-Pierantoni Hospital, Forlì
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Ospedale Morgagni-Pierantoni, AUSL Romagna, Forlì
| | - Fausto Catena
- Department of General Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa
| | - Carlo Fabbri
- Department of General Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, Bologna
- Department of Surgery, Morgagni-Pierantoni Hospital, Forlì
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, Bologna
- Department of Surgery, Morgagni-Pierantoni Hospital, Forlì
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Shabanzadeh DM, Christensen DW, Ewertsen C, Friis-Andersen H, Helgstrand F, Nannestad Jørgensen L, Kirkegaard-Klitbo A, Larsen AC, Ljungdalh JS, Nordblad Schmidt P, Therkildsen R, Vilmann P, Vogt JS, Sørensen LT. National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society. Scand J Surg 2022; 111:11-30. [PMID: 36000716 DOI: 10.1177/14574969221111027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Gallstones are highly prevalent, and more than 9000 cholecystectomies are performed annually in Denmark. The aim of this guideline was to improve the clinical course of patients with gallstone disease including a subgroup of high-risk patients. Outcomes included reduction of complications, readmissions, and need for additional interventions in patients with uncomplicated gallstone disease, acute cholecystitis, and common bile duct stones (CBDS). METHODS An interdisciplinary group of clinicians developed the guideline according to the GRADE methodology. Randomized controlled trials (RCTs) were primarily included. Non-RCTs were included if RCTs could not answer the clinical questions. Recommendations were strong or weak depending on effect estimates, quality of evidence, and patient preferences. RESULTS For patients with acute cholecystitis, acute laparoscopic cholecystectomy is recommended (16 RCTs, strong recommendation). Gallbladder drainage may be used as an interval procedure before a delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery and severe acute cholecystitis (1 RCT and 1 non-RCT, weak recommendation). High-risk patients are suggested to undergo acute laparoscopic cholecystectomy instead of drainage (1 RCT and 1 non-RCT, weak recommendation). For patients with CBDS, a one-step procedure with simultaneous laparoscopic cholecystectomy and CBDS removal by laparoscopy or endoscopy is recommended (22 RCTs, strong recommendation). In high-risk patients with CBDS, laparoscopic cholecystectomy is suggested to be included in the treatment (6 RCTs, weak recommendation). For diagnosis of CBDS, the use of magnetic resonance imaging or endoscopic ultrasound prior to surgical treatment is recommended (8 RCTs, strong recommendation). For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy (2 RCTs, weak recommendation). CONCLUSIONS Seven recommendations, four weak and three strong, for treating patients with symptomatic gallstone disease were developed. Studies for treatment of high-risk patients are few and more are needed. ENDORSEMENT The Danish Surgical Society.
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Affiliation(s)
| | | | - Caroline Ewertsen
- Department of Diagnostic Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Hans Friis-Andersen
- Department of Surgery, Regionshospitalet Horsens, Horsens, DenmarkInstitute for Clinical Medicine, Faculty of Health, University of Aarhus, Aarhus, Denmark
| | | | - Lars Nannestad Jørgensen
- Digestive Disease Center, Surgical Section, Bispebjerg Hospital, Copenhagen, DenmarkInstitute for Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Anders Christian Larsen
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, DenmarkDepartment of Clinical Medicine, The Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | | | - Palle Nordblad Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Copenhagen, Denmark
| | | | - Peter Vilmann
- Institute for Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DenmarkDepartment of Surgery, Herlev Gentofte Hospital, Herlev, Denmark
| | - Jes Sefland Vogt
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Tue Sørensen
- Digestive Disease Center, Surgical Section, Bispebjerg Hospital, Copenhagen, DenmarkInstitute for Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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10
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Lucocq J, Patil P, Scollay J. Acute cholecystitis: Delayed cholecystectomy has lesser perioperative morbidity compared to emergency cholecystectomy. Surgery 2022; 172:16-22. [PMID: 35461704 DOI: 10.1016/j.surg.2022.03.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 03/02/2022] [Accepted: 03/16/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND In comparison to delayed laparoscopic cholecystectomy, emergency laparoscopic cholecystectomy has a shorter length of stay and eliminates the risk of recurrent episodes of acute cholecystitis. Nevertheless, there is concern that emergency laparoscopic cholecystectomy is associated with higher morbidity in acute cholecystitis patients. The present large cohort study compares operation-related adverse outcomes between emergency and delayed laparoscopic cholecystectomy and determines the risk of readmission before delayed laparoscopic cholecystectomy to guide surgical decision-making. METHODS Patients diagnosed with acute cholecystitis who underwent emergency or delayed laparoscopic cholecystectomy between 2015 and 2019 were included. Perioperative outcomes were compared using univariate and multivariate analysis, adjusting for preoperative variables. The rate of readmission before delayed laparoscopic cholecystectomy was determined. RESULTS In total, 811 patients were included (median age, 58 years; male:female, 1:1.5): 227 emergency laparoscopic cholecystectomies (28.0%), 555 delayed laparoscopic cholecystectomies (68.4%), and 29 emergency laparoscopic cholecystectomies whilst awaiting delayed laparoscopic cholecystectomy (3.6%). Emergency laparoscopic cholecystectomy was associated with increased incidences of subtotal cholecystectomy (OR 1.94; P = .011), bile leak (OR 2.38; P = .013), intraoperative drains (OR 2.54; P < .001), prolonged postoperative length of stay (OR 7.26; P < .001), postoperative imaging (OR 1.83, P = .006), and postoperative readmission (OR 1.90; P = .005). There was a 13.5% risk of readmission over 2 months while waiting delayed laparoscopic cholecystectomy and a 22.5% risk over the median waiting time (5 months, 9 days). CONCLUSION Emergency laparoscopic cholecystectomy is positively associated with a multitude of operation-related adverse outcomes in acute cholecystitis, compared to delayed laparoscopic cholecystectomy. The benefit of delayed laparoscopic cholecystectomy should be balanced against the significant readmission risk before delayed laparoscopic cholecystectomy. Emergency laparoscopic cholecystectomy may be the most pragmatic strategy for centers dealing with high volumes of biliary admissions and long elective-surgery waiting times. When opting for delayed laparoscopic cholecystectomy, confirming the date of surgery before discharge may ensure timely intervention and avoid the morbidity and expense of readmission.
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Affiliation(s)
- James Lucocq
- Department of General and Upper GI Surgery, Ninewells Hospital, Dundee, United Kingdom.
| | - Pradeep Patil
- Department of General and Upper GI Surgery, Ninewells Hospital, Dundee, United Kingdom
| | - John Scollay
- Department of General and Upper GI Surgery, Ninewells Hospital, Dundee, United Kingdom
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The Need for Standardizing Diagnosis, Treatment and Clinical Care of Cholecystitis and Biliary Colic in Gallbladder Disease. Medicina (B Aires) 2022; 58:medicina58030388. [PMID: 35334564 PMCID: PMC8949253 DOI: 10.3390/medicina58030388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
Gallstones affect 20% of the Western population and will grow in clinical significance as obesity and metabolic diseases become more prevalent. Gallbladder removal (cholecystectomy) is a common treatment for diseases caused by gallstones, with 1.2 million surgeries in the US each year, each costing USD 10,000. Gallbladder disease has a significant impact on the logistics and economics of healthcare. We discuss the two most common presentations of gallbladder disease (biliary colic and cholecystitis) and their pathophysiology, risk factors, signs and symptoms. We discuss the factors that affect clinical care, including diagnosis, treatment outcomes, surgical risk factors, quality of life and cost-efficacy. We highlight the importance of standardised guidelines and objective scoring systems in improving quality, consistency and compatibility across healthcare providers and in improving patient outcomes, collaborative opportunities and the cost-effectiveness of treatment. Guidelines and scoring only exist in select areas of the care pathway. Opportunities exist elsewhere in the care pathway.
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12
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Fouad MMB, Rezk SSS, Saber AT, Khalifa A, Ibraheim P, Ibraheim SMN. Effect of the COVID-19 Pandemic on the Management of Acute Cholecystitis and Assessment of the Crisis Approach: A Multicenter Experience in Egypt. Asian J Endosc Surg 2022; 15:128-136. [PMID: 34468089 PMCID: PMC8652686 DOI: 10.1111/ases.12980] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/01/2021] [Accepted: 08/16/2021] [Indexed: 12/07/2022]
Abstract
INTRODUCTION The covid-19 pandemic has had a drastic impact on all medical services. Acute cholecystitis is a serious condition that accounts for a considerable percentage of general surgical acute admissions. Therefore, the Royal College of Surgeons' Commissioning guidance' recommended urgent admission to secondary care and early cholecystectomy. During the first wave of hospital admissions associated with COVID-19, most guidelines recommended conservative treatment in order to limit the admission rates and free up spaces for COVID-19-infected patients. However, reviews of this approach have not been widely done to assess the results and, in turn, planning our future management approach when future pressures on in-patient admissions are inevitable. METHODS Our study included all acute cholecystitis patients who needed surgical intervention in one Centre in the UK over three distinct periods (pre-COVID-19, during the first lockdown, and lockdown ease). Comparison between these groups were done regarding intraoperative and postoperative results. RESULTS The conservative management led to a high rate of readmission. Moreover, delayed cholecystectomy was associated with increased operative difficulties such as extensive adhesions, intraoperative blood loss, and/or complicated gall bladder pathologies such as perforated or gangrenous gall bladder (29.9%, 16.7%, and 24.8%, respectively). The resulting postoperative complications of surgical and nonsurgical resulted in a longer hospital stay (13.5 d). CONCLUSION The crisis approach for acute cholecystitis management failed to deliver the hoped outcome. Instead, it backfired and did the exact opposite, leading to longer hospital stays and extra burden to the patient and the healthcare system.
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Iida H, Maehira H, Mori H, Kodama H, Tokuda A, Takebayashi K, Kojima M, Kaida S, Miyake T, Tani M. Attenuation around the gallbladder on plain abdominal computed tomography as a predictor of surgical difficulty in laparoscopic cholecystectomy. Asian J Endosc Surg 2021; 14:724-731. [PMID: 33684962 DOI: 10.1111/ases.12930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/30/2021] [Accepted: 02/21/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE This study examined whether abdominal plain computed tomography (CT) can predict surgical difficulty in acute cholecystitis. METHODS We retrospectively analyzed 84 consecutive patients who underwent laparoscopic cholecystectomy for acute cholecystitis between January 2015 and December 2018. We distinguished three degrees of surgical difficulty based on the operative time and blood loss: difficult, both ≥120 minutes and ≥ 100 mL, respectively (n = 27); moderate, either ≥120 minutes or ≥ 100 mL, respectively (n = 30); and easy, both <120 minutes and < 100 mL, respectively (n = 27). We calculated the attenuation around the gallbladder on CT before surgery and compared the values among the three groups. RESULTS Mean age, albumin levels, C-reactive protein levels, and the CT attenuation around the gallbladder (P < .001) were significantly different between groups. The surgical difficulty was unrelated to the timing of surgery. The postoperative complications were more frequent in operations more than 72 hours after disease onset (P = .04) and with CT attenuation around the gallbladder of ≥1.4 (P = .036). CONCLUSION High attenuation around the gallbladder on plain CT predicted a high surgical difficulty of laparoscopic cholecystectomy. We recommend measuring the CT attenuation around the gallbladder in patients with acute cholecystitis.
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Affiliation(s)
- Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Hirokazu Kodama
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Aya Tokuda
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | | | - Masatsugu Kojima
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Sachiko Kaida
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Toru Miyake
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
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Mytton J, Daliya P, Singh P, Parsons SL, Lobo DN, Lilford R, Vohra RS. Outcomes Following an Index Emergency Admission With Cholecystitis: A National Cohort Study. Ann Surg 2021; 274:367-374. [PMID: 31567508 DOI: 10.1097/sla.0000000000003599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the differences between patients who undergo cholecystectomy following index admission for cholecystitis, and those who are managed nonoperatively. SUMMARY BACKGROUND DATA Index emergency cholecystectomy following acute cholecystitis is widely recommended by national guidelines, but its effect on clinical outcomes remains uncertain. METHODS Data collected routinely from the Hospital Episode Statistics database (all admissions to National Health Service organizations in England and Wales) were extracted between April 1, 2002 and March 31, 2015. Analyses were limited to patients aged over 18 years with a primary diagnosis of cholecystitis. Exclusions included records with missing or invalid datasets, patients who had previously undergone a cholecystectomy, patients who had died without a cholecystectomy, and those undergoing cholecystectomy for malignancy, pancreatitis, or choledocholithiasis. Patients were grouped as either "no cholecystectomy" where they had never undergone a cholecystectomy following discharge, or "cholecystectomy." The latter group was then subdivided as "emergency cholecystectomy" when cholecystectomy was performed during their index emergency admission, or "interval cholecystectomy" when a cholecystectomy was performed within 12 months following a subsequent (emergency or elective) admission. Propensity Score Matching was used to match emergency and interval cholecystectomy groups. Main outcome measures included 1) One-year total length of hospital stay due to biliary causes following an index emergency admission with cholecystitis. 2) One-year mortality; defined as death occurring within 1 year following the index emergency admission with acute cholecystitis. RESULTS Of the 99,139 patients admitted as an emergency with acute cholecystitis, 51.1% (47,626) did not undergo a cholecystectomy within 1 year of index admission. These patients were older, with more comorbidities (Charlson Comorbidity Score ≥ 5 in 23.5% vs. 8.1%, P < 0.001) when compared to patients who did have a cholecystectomy. While all-cause 1-year mortality was higher in the nonoperated versus the operated group (12.2% vs. 2.0%, P < 0.001), gallbladder-related deaths were significantly lower than all other causes of death in the non-operated group (3.3% vs. 8.9%, P < 0.001). Following matching, 1-year total hospital admission time was significantly higher following emergency compared with interval cholecystectomy (17.7 d vs. 13 d, P < 0.001). CONCLUSIONS Over 50% of patients in England did not undergo cholecystectomy following index admission for acute cholecystitis. Mortality was higher in the nonoperated group, which was mostly due to non-gallbladder pathologies but total hospital admission time for biliary causes was lower over 12 months. Increasing the numbers of emergency cholecystectomy may risk over-treating patients with acute cholecystitis and increasing their time spent admitted to hospital.
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Affiliation(s)
- Jemma Mytton
- Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Prita Daliya
- Trent Oesophago-Gastric Unit, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre Campus, Nottingham, UK
| | - Pritam Singh
- Trent Oesophago-Gastric Unit, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Simon L Parsons
- Trent Oesophago-Gastric Unit, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre Campus, Nottingham, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre Campus, Nottingham, UK
- MRC/ARUK Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | | | - Ravinder S Vohra
- Trent Oesophago-Gastric Unit, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre Campus, Nottingham, UK
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15
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Bagepally BS, Haridoss M, Sasidharan A, Jagadeesh KV, Oswal NK. Systematic review and meta-analysis of gallstone disease treatment outcomes in early cholecystectomy versus conservative management/delayed cholecystectomy. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000675. [PMID: 34261757 PMCID: PMC8280848 DOI: 10.1136/bmjgast-2021-000675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/04/2021] [Indexed: 01/07/2023] Open
Abstract
Background The effectiveness of early cholecystectomy for gallstone diseases treatment is uncertain compared with conservative management/delayed cholecystectomy. Aims To synthesise treatment outcomes of early cholecystectomy versus conservative management/delayed cholecystectomy in terms of its safety and effectiveness. Design We systematically searched randomised control trials investigating the effectiveness of early cholecystectomy compared with conservative management/delayed cholecystectomy. We pooled the risk ratios with a 95% CI, also estimated adjusted number needed to treat to harm. Results Of the 40 included studies for systematic review, 39 studies with 4483 patients are included in meta-analysis. Among the risk ratios of gallstone complications, pain (0.38, 0.20 to 0.74), cholangitis (0.52, 0.28 to 0.97) and total biliary complications (0.33, 0.20 to 0.55) are significantly lower with early cholecystectomy. Adjusted number needed to treat to harm of early cholecystectomy compared with conservative management/delayed cholecystectomy are, for pain 12.5 (8.3 to 33.3), biliary pancreatitis >1000 (50–100), common bile duct stones 100 (33.3 to 100), cholangitis (100 (25–100), total biliary complications 5.9 (4.3 to 9.1) and mortality >1000 (100 to100 000). Conclusions Early cholecystectomy may result in fewer biliary complications and a reduction in reported abdominal pain than conservative management. PROSPERO registration number 2020 CRD42020192612.
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Affiliation(s)
- Bhavani Shankara Bagepally
- ICMR-NIE Health Technology Assessment Resource Centre, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
| | - Madhumitha Haridoss
- ICMR-NIE Health Technology Assessment Resource Centre, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
| | - Akhil Sasidharan
- ICMR-NIE Health Technology Assessment Resource Centre, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
| | - Kayala Venkata Jagadeesh
- Health Technology Assessment in India (HTAIn) Secretariat, Department of Health Research, MoHFW, GOI, New Delhi, India
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Cruickshank M, Newlands R, Blazeby J, Ahmed I, Bekheit M, Brazzelli M, Croal B, Innes K, Ramsay C, Gillies K. Identification and categorisation of relevant outcomes for symptomatic uncomplicated gallstone disease: in-depth analysis to inform the development of a core outcome set. BMJ Open 2021; 11:e045568. [PMID: 34168025 PMCID: PMC8231013 DOI: 10.1136/bmjopen-2020-045568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 06/02/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Many completed trials of interventions for uncomplicated gallstone disease are not as helpful as they could be due to lack of standardisation across studies, outcome definition, collection and reporting. This heterogeneity of outcomes across studies hampers useful synthesis of primary studies and ultimately negatively impacts on decision making by all stakeholders. Core outcome sets offer a potential solution to this problem of heterogeneity and concerns over whether the 'right' outcomes are being measured. One of the first steps in core outcome set generation is to identify the range of outcomes reported (in the literature or by patients directly) that are considered important. OBJECTIVES To develop a systematic map that examines the variation in outcome reporting of interventions for uncomplicated symptomatic gallstone disease, and to identify other outcomes of importance to patients with gallstones not previously measured or reported in interventional studies. RESULTS The literature search identified 794 potentially relevant titles and abstracts of which 137 were deemed eligible for inclusion. A total of 129 randomised controlled trials, 4 gallstone disease specific patient-reported outcome measures (PROMs) and 8 qualitative studies were included. This was supplemented with data from 6 individual interviews, 1 focus group (n=5 participants) and analysis of 20 consultations. A total of 386 individual recorded outcomes were identified across the combined evidence: 330 outcomes (which were reported 1147 times) from trials evaluating interventions, 22 outcomes from PROMs, 17 outcomes from existing qualitative studies and 17 outcomes from primary qualitative research. Areas of overlap between the evidence sources existed but also the primary research contributed new, unreported in this context, outcomes. CONCLUSIONS This study took a rigorous approach to catalogue and map the outcomes of importance in gallstone disease to enhance the development of the COS 'long' list. A COS for uncomplicated gallstone disease that considers the views of all relevant stakeholders is needed.
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Affiliation(s)
- Moira Cruickshank
- Health Services Research Unit, University of Aberdeen Institute of Applied Health Sciences, Aberdeen, UK
| | - Rumana Newlands
- Health Services Research Unit, University of Aberdeen Institute of Applied Health Sciences, Aberdeen, UK
| | - Jane Blazeby
- Department of Social Medicine, University of Bristol Department of Social Medicine, Bristol, UK
| | - Irfan Ahmed
- Department of Surgery, NHS Grampian, Aberdeen, UK
| | - Mohamed Bekheit
- Department of Surgery, NHS Grampian, Aberdeen, UK
- Department of Surgery, ElKabbary Hospital, Alexandria, Egypt
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen Institute of Applied Health Sciences, Aberdeen, UK
| | - Bernard Croal
- Clinical Biochemistry, Grampian University Hospitals NHS Trust, Aberdeen, UK
| | - Karen Innes
- Health Services Research Unit, University of Aberdeen Institute of Applied Health Sciences, Aberdeen, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen Institute of Applied Health Sciences, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen Institute of Applied Health Sciences, Aberdeen, UK
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Yigit B, Cerekci E, Baran E, Citgez B. Simple Blood Tests May Be Used to Predict the Increased Risk of Conversion in Elective Laparoscopic Cholecystectomy Surgery. J Laparoendosc Adv Surg Tech A 2021; 32:408-412. [PMID: 34030474 DOI: 10.1089/lap.2021.0277] [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: 11/12/2022] Open
Abstract
Background: In this study, we aimed to evaluate the possibility if simple blood tests that can be made in majority of hospitals may be used predict to risk of conversion to laparoscopic surgery to an open approach. Patients and Methods: The hospital records of 636 patients who underwent elective laparoscopic cholecystectomy (L-C) were retrospectively reviewed, and 583 patients included in the study protocol. Preoperative laboratory tests of all patients and data of patients who underwent conversion from laparoscopic surgery to open surgery were examined. Results: Of the 583 patients who were included in the study, 404 (69.29%) were female and the mean age was 50.02 ± 12.84 (19-89) years. The cholecystectomy was completed laparoscopically in 559 (89.5%) patients. The most common symptoms seen in the patients were epigastric discomfort and right upper quadrant pain. The high level of white blood cell (WBC) count and c-reactive protein (CRP) were found to be statistically significant before surgery in patients who had a conversion to open cholecystectomy (P < .001). Conclusion: Elevation of WBC count and CRP value before elective L-C may be useful in the prediction of a high risk of conversion from laparoscopic to open approach. This finding will help the surgeon to plan the treatment and inform the patient of the possibility before surgery.
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Affiliation(s)
- Banu Yigit
- Department of General Surgery, SisliHamidiyeEtfal Medical Practice and Research Center, University of Health Sciences, Istanbul, Turkey
| | - Esma Cerekci
- Department of Radiology, SisliHamidiyeEtfal Medical Practice and Research Center, University of Health Sciences, Istanbul, Turkey
| | - Elif Baran
- Department of General Surgery, SisliHamidiyeEtfal Medical Practice and Research Center, University of Health Sciences, Istanbul, Turkey
| | - Bulent Citgez
- Department of General Surgery, SisliHamidiyeEtfal Medical Practice and Research Center, University of Health Sciences, Istanbul, Turkey
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Borzellino G, Khuri S, Pisano M, Mansour S, Allievi N, Ansaloni L, Kluger Y. Timing of early laparoscopic cholecystectomy for acute calculous cholecystitis: a meta-analysis of randomized clinical trials. World J Emerg Surg 2021; 16:16. [PMID: 33766077 PMCID: PMC7992835 DOI: 10.1186/s13017-021-00360-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 03/15/2021] [Indexed: 12/24/2022] Open
Abstract
Background Early cholecystectomy for acute cholecystitis has proved to reduce hospital length of stay but with no benefit in morbidity when compared to delayed surgery. However, in the literature, early timing refers to cholecystectomy performed up to 96 h of admission or up to 1 week of the onset of symptoms. Considering the natural history of acute cholecystitis, the analysis based on such a range of early timings may have missed a potential advantage that could be hypothesized with an early timing of cholecystectomy limited to the initial phase of the disease. The review aimed to explore the hypothesis that adopting immediate cholecystectomy performed within 24 h of admission as early timing could reduce post-operative complications when compared to delayed cholecystectomy. Methods The literature search was conducted based on the Patient Intervention Comparison Outcome Study (PICOS) strategy. Randomized trials comparing post-operative complication rate after early and delayed cholecystectomy for acute cholecystitis were included. Studies were grouped based on the timing of cholecystectomy. The hypothesis that immediate cholecystectomy performed within 24 h of admission could reduce post-operative complications was explored by comparing early timing of cholecystectomy performed within and 24 h of admission and early timing of cholecystectomy performed over 24 h of admission both to delayed timing of cholecystectomy within a sub-group analysis. The literature finding allowed the performance of a second analysis in which early timing of cholecystectomy did not refer to admission but to the onset of symptoms. Results Immediate cholecystectomy performed within 24 h of admission did not prove to reduce post-operative complications with relative risk (RR) of 1.89 and its 95% confidence interval (CI) [0.76; 4.71]. When the timing was based on the onset of symptoms, cholecystectomy performed within 72 h of symptoms was found to significantly reduce post-operative complications compared to delayed cholecystectomy with RR = 0.60 [95% CI 0.39;0.92]. Conclusion The present study failed to confirm the hypothesis that immediate cholecystectomy performed within 24 h of admission may reduce post- operative complications unless surgery could be performed within 72 h of the onset of symptoms.
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Affiliation(s)
- Giuseppe Borzellino
- Department of General Surgery, University Hospital of Verona, Piazzale A. Stefani 1, 37128, Verona, Italy.
| | - Safi Khuri
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Michele Pisano
- 1st Surgical Unit, Department of Emergency, ASST Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Subhi Mansour
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Niccolò Allievi
- 1st Surgical Unit, Department of Emergency, ASST Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Luca Ansaloni
- 1st General Surgery Unit, University of Pavia, Pavia, Italy
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
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EUS-guided gallbladder drainage versus laparoscopic cholecystectomy for acute cholecystitis: a propensity score analysis with 1-year follow-up data. Gastrointest Endosc 2021; 93:577-583. [PMID: 32615177 DOI: 10.1016/j.gie.2020.06.066] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/21/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EUS-guided gallbladder drainage (EUS-GBD) is a safe alternative to percutaneous cholecystostomy (PT-GBD) for acute cholecystitis. How the procedure compares with laparoscopic cholecystectomy (LC) is uncertain. The aim of the current study is to compare the outcomes of EUS-GBD with LC for acute cholecystitis. METHODS This was propensity score analysis of all patients admitted for acute cholecystitis between 2012 and 2018. Consecutive patients who received EUS-GBD or LC were included. Patients were matched for age, sex, and age-adjusted Charlson score. Outcome measurements included 30-day adverse events, mortality, recurrent cholecystitis, recurrent biliary events, reinterventions, and readmissions. RESULTS During the study period, 60 patients were selected (30 EUS-GBD vs 30 LC) after propensity score matching. Technical success rates (100% vs 100%), clinical success rates (93.3% vs 100%, P = 1), lengths of hospital stay (6.8 [8.1] vs 5.5 [2.7], P = 1), 30-day adverse events (4 [13.3%] vs 4 [13.3%], P = 1), and mortality rates (2 [6.7%] vs 0 [0%], P = .492) were similar. The rates of recurrent biliary events (3 [10%] vs 3 [10%], P = .784), reinterventions (4 [13.3%] vs 3 [10%], P = 1), and unplanned readmissions (3 [10%] vs 3 [10%], P = .784) in 1 year were also similar. CONCLUSIONS The outcomes of EUS-GBD for acute cholecystitis were comparable with LC with acceptable rates of recurrent acute cholecystitis. These results support the role of EUS-GBD as an alternative to LC in patients who may or may not be surgically fit to undergo definitive cholecystectomy.
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Preoperative Magnetic Resonance Cholangiopancreatography for Detecting Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis. Diagnostics (Basel) 2021; 11:diagnostics11030383. [PMID: 33668281 PMCID: PMC7996298 DOI: 10.3390/diagnostics11030383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 02/19/2021] [Accepted: 02/20/2021] [Indexed: 12/24/2022] Open
Abstract
Previous studies have shown that signal intensity variations in the gallbladder wall on magnetic resonance imaging (MRI) are associated with necrosis and fibrosis in the gallbladder of acute cholecystitis (AC). However, the association between MRI findings and operative outcomes remains unclear. We retrospectively identified 321 patients who underwent preoperative magnetic resonance cholangiopancreatography (MRCP) and early laparoscopic cholecystectomy (LC) for AC. Based on the gallbladder wall signal intensity on MRI, these patients were divided into high signal intensity (HSI), intermediate signal intensity (ISI), and low signal intensity (LSI) groups. Comparisons of bailout procedure rates (open conversion and laparoscopic subtotal cholecystectomy) and operating times were performed. The recorded bailout procedure rates were 6.8% (7/103 cases), 26.7% (31/116 cases), and 40.2% (41/102 cases), and the median operating times were 95, 110, and 138 minutes in the HSI, ISI, and LSI groups, respectively (both p < 0.001). During the multivariate analysis, the LSI of the gallbladder wall was an independent predictor of both the bailout procedure (odds ratio [OR] 5.30; 95% CI 2.11–13.30; p < 0.001) and prolonged surgery (≥144 min) (OR 6.10, 95% CI 2.74–13.60, p < 0.001). Preoperative MRCP/MRI assessment could be a novel method for predicting surgical difficulty during LC for AC.
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21
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Current Management of Acute Calculous Cholecystitis. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-020-00282-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Bekki T, Abe T, Amano H, Hanada K, Kobayashi T, Noriyuki T, Ohdan H, Nakahara M. Validation of the Tokyo guideline 2018 treatment proposal for acute cholecystitis from a single-center retrospective analysis. Asian J Endosc Surg 2021; 14:14-20. [PMID: 32285589 DOI: 10.1111/ases.12801] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The revised Tokyo guideline 2018 (TG18) recommends early laparoscopic cholecystectomy (LC) in patients with acute cholecystitis (AC) who satisfy the Charlson Comorbidity Index criteria and the ASA Physical Status Classification (ASA-PS). Our study aims to determine the efficacy of the TG18 treatment strategy. METHODS We enrolled 324 patients who had been diagnosed with AC according to the TG18 and who underwent cholecystectomy between 2010 and 2018. Perioperative variables and surgical outcomes were analyzed according to the TG18 treatment strategy and severity grading. RESULTS The Charlson Comorbidity Index and ASA-PS scores were significantly higher in patients with Grade II and Grade III AC than in those with Grade I AC. In patients with a higher severity grading, LC failed, necessitating blood transfusion and bailout surgery. Among patients treated by the TG18 strategy were a higher proportion with Grade I or II AC; their ASA-PS scores were significantly lower than patients with Grade III AC. Compared to patients not treated by the TG18 strategy, this group demonstrated significant differences in the achievement of LC, bailout surgery, postoperative hospital stays, and 90-day mortality rates. Intraoperative blood loss and blood transfusion were significantly higher in those not treated by the TG18 strategy. CONCLUSIONS Our study shows that the TG18 treatment strategy is well-designed and efficacious. Given the high rate of blood transfusion and conversion surgery in treatment strategies other that TG18, special attention should be paid when selecting the optimal treatment strategy.
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Affiliation(s)
- Tomoaki Bekki
- Department of Surgery, Onomichi General Hospital, Hiroshima, Japan
| | - Tomoyuki Abe
- Department of Surgery, Onomichi General Hospital, Hiroshima, Japan
| | - Hironobu Amano
- Department of Surgery, Onomichi General Hospital, Hiroshima, Japan.,Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, Hiroshima, Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshio Noriyuki
- Department of Surgery, Onomichi General Hospital, Hiroshima, Japan.,Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Decker G, Goergen M, Philippart P, Costa PMD. Laparoscopic Cholecystectomy for Acute Cholecystitis in Geriatric Patients. Acta Chir Belg 2020. [DOI: 10.1080/00015458.2001.12098638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- G. Decker
- Department of Digestive and Endoscopic Surgery, Brugmann University Hospital, Free University of Brussels, Belgium
| | - M. Goergen
- Department of Digestive and Endoscopic Surgery, Brugmann University Hospital, Free University of Brussels, Belgium
| | - P. Philippart
- Department of Digestive and Endoscopic Surgery, Brugmann University Hospital, Free University of Brussels, Belgium
| | - P. Mendes da Costa
- Department of Digestive and Endoscopic Surgery, Brugmann University Hospital, Free University of Brussels, Belgium
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Pisano M, Allievi N, Gurusamy K, Borzellino G, Cimbanassi S, Boerna D, Coccolini F, Tufo A, Di Martino M, Leung J, Sartelli M, Ceresoli M, Maier RV, Poiasina E, De Angelis N, Magnone S, Fugazzola P, Paolillo C, Coimbra R, Di Saverio S, De Simone B, Weber DG, Sakakushev BE, Lucianetti A, Kirkpatrick AW, Fraga GP, Wani I, Biffl WL, Chiara O, Abu-Zidan F, Moore EE, Leppäniemi A, Kluger Y, Catena F, Ansaloni L. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg 2020; 15:61. [PMID: 33153472 PMCID: PMC7643471 DOI: 10.1186/s13017-020-00336-x] [Citation(s) in RCA: 162] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC. MATERIALS AND METHODS The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached. RESULTS The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal. CONCLUSIONS, KNOWLEDGE GAPS AND RESEARCH RECOMMENDATIONS ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.
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Affiliation(s)
- Michele Pisano
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Niccolò Allievi
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | | | - Djamila Boerna
- Department of Surgery, St. Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Federico Coccolini
- General Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Andrea Tufo
- HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | | | - Jeffrey Leung
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Marco Ceresoli
- Department of General and Emergency Surgery, University of Milano-Bicocca, Milan, Italy
| | - Ronald V. Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Elia Poiasina
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Nicola De Angelis
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital and University Paris-Est, Creteil, France
| | - Stefano Magnone
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Paola Fugazzola
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Ciro Paolillo
- Emergency Room Brescia Spedali Civili General Hospital, Brescia, Italy
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center-CECORC, Riverside University Health System Medical Center, Moreno Valley, CA USA
| | | | - Belinda De Simone
- Department of General Surgery, Azienda USL-IRCSS di Reggio Emilia, Guastalla Hospital, Guastalla, Italy
| | - Dieter G. Weber
- Department of General Surgery Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | - Boris E. Sakakushev
- Research Institute at Medical University Plovdiv/University Hospital St George, Plovdiv, Bulgaria
| | | | - Andrew W. Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Gustavo P. Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Imitaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Osvaldo Chiara
- General Surgery Trauma Team ASST-GOM Niguarda, Milan, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine, UAE University, Al Ain, UAE
| | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO USA
| | - Ari Leppäniemi
- Abdominal Center Helsinki University Hospital, Helsinki, Finland
| | - Yoram Kluger
- Department of General Surgery, the Rambam Academic Hospital, Haifa, Israel
| | - Fausto Catena
- Emergency Surgery, University Parma Hospital, Parma, Italy
| | - Luca Ansaloni
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
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Mora-Guzmán I, Di Martino M, Gancedo Quintana A, Martin-Perez E. Laparoscopic Cholecystectomy for Acute Cholecystitis: Is the Surgery Still Safe beyond the 7-Day Barrier? J Gastrointest Surg 2020; 24:1827-1832. [PMID: 31388885 DOI: 10.1007/s11605-019-04335-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/19/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. The aim of this study was to assess the outcomes of ELC in patients with delayed presentation. METHODS Retrospective analysis of 381 patients who underwent ELC for ACC between January 2010 and September 2018. Included patients were classified into two groups according to the timing of surgery from the onset of symptoms: group 1 (G1) within the first 7 days and group 2 (G2) beyond 7 days. RESULTS There were no significant differences regarding conversion rate (G1 8.6% vs. G2 11.8%; p = 0.527), operative time (G1 100 min [75-120] vs. G2 120 min [71-150]; p = 0.060), bile duct injuries (G1 0.3% vs. G2 0%; p = 1), major postoperative complications (G1 11% vs. G2 5.9%; p = 0.557), reoperation rates (G1 1.4% vs. G2 0%; p = 1), length of stay (G1 4 days [3-7] vs. G2 5 days [3-7]; p = 0.539), readmissions (G1 3.7% vs. G2 5.9%; p = 0.633) and costs (G1 6035 € [3693-8330] vs. G2 7243 € [4921-11,336]; p = 0.395). CONCLUSION ELC may be considered for patients with ACC who can tolerate surgery with more than 1 week of symptom duration.
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Affiliation(s)
- Ismael Mora-Guzmán
- Department of General and Digestive Surgery, Hospital Universitario de la Princesa, Diego de León Street, 62-4th Floor, 28006, Madrid, Spain
| | - Marcello Di Martino
- Department of General and Digestive Surgery, Hospital Universitario de la Princesa, Diego de León Street, 62-4th Floor, 28006, Madrid, Spain.
| | - Alvaro Gancedo Quintana
- Department of General and Digestive Surgery, Hospital Universitario de la Princesa, Diego de León Street, 62-4th Floor, 28006, Madrid, Spain
| | - Elena Martin-Perez
- Department of General and Digestive Surgery, Hospital Universitario de la Princesa, Diego de León Street, 62-4th Floor, 28006, Madrid, Spain
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Predictive factors for developing acute cholangitis and/or cholecystitis in patients undergoing delayed cholecystectomy: A retrospective study. Asian J Surg 2020; 44:280-285. [PMID: 32709456 DOI: 10.1016/j.asjsur.2020.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/27/2020] [Accepted: 07/05/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND /Objective: We evaluated the risk of acute cholangitis and/or cholecystitis while waiting for cholecystectomy for gallstones. METHODS We retrospectively enrolled 168 patients who underwent cholecystectomy for gallstones after conservative therapy. We compared clinical data of 20 patients who developed acute cholangitis and/or cholecystitis while waiting for cholecystectomy (group A) with 148 patients who did not develop (group B). We investigated surgical outcomes and risk factors for developing acute cholangitis and/or cholecystitis. RESULTS Preoperatively, significant numbers of patients with previous history of acute grade II or III cholecystitis (55.0% vs 10.8%; p < 0.001) and biliary drainage (20.0% vs 2.0%; p = 0.004) were observed between groups A and B. White blood cell counts (13500/μL vs 8155/μL; p < 0.001) and C-reactive protein levels (12.6 vs 5.1 mg/dL; p < 0.001) were significantly higher in group A than in group B; albumin levels (3.2 vs 4.0 g/dL; p < 0.001) were significantly lower in group A. Gallbladder wall thickening (≥5 mm) (45.0% vs 18.9%; p = 0.018), incarcerated gallbladder neck stones (55.0% vs 22.3%; p = 0.005), and peri-gallbladder abscess (20.0% vs 1.4%; p = 0.002) were significantly more frequent in group A than in group B. A higher conversion rate to open surgery (20.0% vs 2.0%; p = 0.004), longer operation time (137 vs 102 min; p < 0.001), and higher incidence of intraoperative complications (10.0% vs 0%; p = 0.014) were observed in group A, compared with group B. CONCLUSION A history of severe cholecystitis may be a risk factor for acute cholangitis and/or cholecystitis in patients waiting for surgery; it may also contribute to increased surgical difficulty.
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El Zanati H, Nassar AHM, Zino S, Katbeh T, Ng HJ, Abdellatif A. Gall Bladder Empyema: Early Cholecystectomy during the Index Admission Improves Outcomes. JSLS 2020; 24:e2020.00015. [PMID: 32425482 PMCID: PMC7208918 DOI: 10.4293/jsls.2020.00015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES We aim to evaluate our policy of index admission management of gall bladder empyema and the effect of the timing of surgery on the outcomes. METHODS We analyzed a series of 5400 laparoscopic cholecystectomies. Data were collected prospectively over 26 y. Patients were divided into two groups: group 1, intervention within 72 h, and group 2, intervention after 72 h of admission. We had a policy of intention to treat during the index admission, but delays sometimes occurred because of late referral, a need to optimize patients, availability of theater time, or the biliary surgeon being on leave. The groups were then compared with regard to the duration of surgery, the difficulty grading, complications, hospital stay, and conversion rate. RESULTS A total of 372 patients were included; 160 (43%) operated on within 72 h (group 1) and 212 (57%) after 72 h (group 2). There was no statistically significant difference between the two groups with regard to the operation time, conversion rate, and complications rate. The difference in total hospital stay was, however, statistically significant. CONCLUSION Surgical management of empyema should be offered as soon as possible after admission as with any acute cholecystitis. Surgery carried out after 72 h of admission is only associated with longer hospital stay but no statistically significant differences in other outcome parameters. In the presence of specialist expertise, fitness for surgery should be the determining factor of whether or not to offer surgery to these patients, regardless of the interval since their admission.
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Affiliation(s)
- Hisham El Zanati
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Ahmad H M Nassar
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Samer Zino
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Tarek Katbeh
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Hwei Jene Ng
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Ayman Abdellatif
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
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Vaccari S, Cervellera M, Lauro A, Palazzini G, Cirocchi R, Gjata A, Dibra A, Ussia A, Brighi M, Isaj E, Agastra E, Casella G, Di Matteo FM, Santoro A, Falvo L, Tarroni D, D'andrea V, Tonini V. Laparoscopic cholecystectomy: which predicting factors of conversion? Two Italian center's studies. MINERVA CHIR 2020; 75:141-152. [PMID: 32138473 DOI: 10.23736/s0026-4733.20.08228-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy represents the gold standard technique for the treatment of lithiasic gallbladder disease. Although it has many advantages, laparoscopic cholecystectomy is not risk-free and in special situations there is a need for conversion into an open procedure, in order to minimize postoperative complications and to complete the procedure safely. The aim of this study was to identify factors that can predict the conversion to open cholecystectomy. METHODS We analyzed 1323 patients undergoing laparoscopic cholecystectomy over the last five years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome. Among these, 116 patients (8.7%) were converted into laparotomic cholecystectomy. Clinical, demographic, surgical and pathological data from these patients were included in a prospective database. A univariate analysis was performed followed by a multivariate logistic regression. RESULTS On univariate analysis, the factors significantly correlated with conversion to open were the ASA score higher than 3 and the comorbidity, specifically cardiovascular disease, diabetes and chronic renal failure (P<0.001). Patients with a higher mean age had a higher risk of conversion to open (61.9±17.1 vs. 54.1±15.2, P<0.001). Previous abdominal surgery and previous episodes of cholecystitis and/or pancreatitis were not statistically significant factors for conversion. There were four deaths in the group of converted patients and two in the laparoscopic group (P<0.001). Operative morbility was higher in the conversion group (22% versus 8%, P<0.001). Multivariate analysis showed that the factors significantly correlated to conversion were: age <65 years old (P=0.031 OR: 1.6), ASA score 3-4 (P=0.013, OR:1.8), history of ERCP (P=0.16 OR:1.7), emergency procedure (P=0.011, OR:1.7); CRP higher than 0,5 (P<0.001, OR:3.3), acute cholecystitis (P<0.001, OR:1.4). Further multivariate analysis of morbidity, postoperative mortality and home discharge showed that conversion had a significant influence on overall post-operative complications (P=0.011, OR:2.01), while mortality (P=0.143) and discharge at home were less statistically influenced. CONCLUSIONS Our results show that most of the independent risk factors for conversion cannot be modified by delaying surgery. Many factors reported in the literature did not significantly impact conversion rates in our results.
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Affiliation(s)
- Samuele Vaccari
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
| | - Maurizio Cervellera
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
| | - Augusto Lauro
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy -
| | - Giorgio Palazzini
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | | | - Arben Gjata
- Department of General Surgery, University of Medicine, Tirana, Albania
| | - Arvin Dibra
- Department of General Surgery, University of Medicine, Tirana, Albania
| | - Alessandro Ussia
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
| | - Manuela Brighi
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
| | - Elton Isaj
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
| | - Ervis Agastra
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
| | - Giovanni Casella
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Filippo M Di Matteo
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Alberto Santoro
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Laura Falvo
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Danilo Tarroni
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Vito D'andrea
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Valeria Tonini
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
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Borzellino G, Khuri S, Pisano M, Mansour S, Allievi N, Ansaloni L, Kluger Y. Timing of early laparoscopic cholecystectomy for acute calculous cholecystitis revised: Protocol of a systematic review and meta-analysis of results. World J Emerg Surg 2020; 15:1. [PMID: 31911813 PMCID: PMC6942279 DOI: 10.1186/s13017-019-0285-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/20/2019] [Indexed: 12/24/2022] Open
Abstract
Background Early laparoscopic cholecystectomy has been adopted as the treatment of choice for acute cholecystitis due to a shorter hospital length of stay and no increased morbidity when compared to delayed cholecystectomy. However, randomised studies and meta-analysis report a wide array of timings of early cholecystectomy, most of them set at 72 h following admission. Setting early cholecystectomy at 72 h or even later may influence analysis due to a shift towards a more balanced comparison. At this time, the rate of resolving acute cholecystitis and the rate of ongoing acute process because of failed conservative treatment could be not so different when compared to those operated with a delayed timing of 6-12 weeks. As a result, randomised comparison with such timing for early cholecystectomy and meta-analysis including such studies may have missed a possible advantage of an early cholecystectomy performed within 24 h of the admission, when conservative treatment failure has less potential effects on morbidity. This review will explore pooled data focused on randomised studies with a set timing of early cholecystectomy as a maximum of 24 h following admission, with the aim of verifying the hypothesis that cholecystectomy within 24 h may report a lower post-operative complication rate compared to a delayed intervention. Methods A systematic review of the literature will identify randomised clinical studies that compared early and delayed cholecystectomy. Pooled data from studies that settled the early intervention within 24 h from admission will be explored and compared in a sub-group analysis with pooled data of studies that settled early intervention as more than 24 h. Discussion This paper will not provide evidence strong enough to change the clinical practice, but in case the hypothesis is verified, it will invite to re-consider the timing of early cholecystectomy and might promote future clinical research focusing on an accurate definition of timing for early cholecystectomy for acute cholecystitis.
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Affiliation(s)
- Giuseppe Borzellino
- Department of General Surgery, University Hospital of Verona Italy, Piazzale A. STEFANI 1, 37128 Verona, Italy
| | - Safi Khuri
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Michele Pisano
- 1st Surgical Unit, Department of Emergency, Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Subhi Mansour
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Niccolò Allievi
- 1st Surgical Unit, Department of Emergency, Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Luca Ansaloni
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
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Manangi M, Vishweshwara R, Dharini D, Santhosh CS, Kumar S, Ramesh MK, Rao KS. Laparoscopic cholecystectomy in acute cholecystitis: A feasible option regardless of timing. FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_83_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ángel-González MS, Díaz-Quintero CA, Aristizabal-Arjona F, Turizo Agámez Á, Molina-Céspedes I, Velásquez-Martínez MA, Isaza-Gómez E, Ocampo-Muñoz M. Controversias en el manejo de la colecistitis aguda tardía. REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
La colecistitis aguda es la inflamación de la vesícula biliar, en la mayoría de los casos, explicada por la presencia de cálculos mixtos o de colesterol que producen obstrucción y desencadenan factores inflamatorios diversos. La colecistectomía por vía laparoscópica se ha convertido en su tratamiento estándar y definitivo. El procedimiento quirúrgico debe realizarse idealmente en las primeras 72 horas después de iniciados los síntomas, lo que habitualmente se denomina como cuadro agudo. Existe controversia sobre cuál es el manejo más adecuado cuando han pasado más de 72 horas del inicio de los síntomas, condición denominada ‘colecistitis aguda tardía’, cuando se considera que el proceso inflamatorio es mayor y, el procedimiento, técnicamente más complejo y peligroso. Para esta condición, se han establecido dos estrategias iniciales de manejo: la cirugía temprana –durante la hospitalización inicial– o el tratamiento conservador con antibióticos para la supuesta resolución completa de la inflamación, es decir, ‘enfriar el proceso’; varias semanas después, se practica una colecistectomía laparoscópica tardía –diferida o electiva–. Existen muchas publicaciones sobre ambas estrategias, en las que se exponen los beneficios y probables complicaciones de cada una; en la actualidad, se sigue debatiendo sobre el momento óptimo para practicar la intervención quirúrgica. Los trabajos más recientes y con mayor peso epidemiológico, resaltan los beneficios de la cirugía temprana pues, aunque las complicaciones intraoperatorias ocurren en las mismas proporciones, la cirugía en la hospitalización inicial reduce los costos, los reingresos y los tiempos hospitalarios. Después de revisar la literatura disponible a favor y en contra, este artículo pretende recomendar el procedimiento temprano, inclusive cuando hayan pasado más de tres días de iniciados los síntomas y, solo en casos muy seleccionados, diferir la cirugía.
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Brunée L, Hauters P, Closset J, Fromont G, Puia-Negelescu S. Assessment of the optimal timing for early laparoscopic cholecystectomy in acute cholecystitis: a prospective study of the Club Coelio. Acta Chir Belg 2019; 119:309-315. [PMID: 30354853 DOI: 10.1080/00015458.2018.1529344] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background: The optimal timing for cholecystectomy in patients with acute cholecystitis remains controversial. The aim of this study is to assess prospectively the impact of the duration of symptoms on outcomes in early laparoscopic cholecystectomy (ELC) for acute cholecystitis. Methods: The series consisted of 276 consecutive patients who underwent ELC for acute cholecystitis in 2016. The patients were divided into three groups according to the timing of surgery: within the first 3 days (group 1), between 4 and 7 days (group 2) and beyond 7 days (group 3) from the onset of symptoms. Results: The percentage of surgical procedure rated as difficult was respectively: 12% in G1, 18% in G2 and 38% in G3 (p < .001). Accordingly, we observed an increased mean operative time within groups but no significant difference in the conversion rate. We noted a different overall postoperative complication rate within groups, respectively: 9% in G1, 14% in G2 and 24% in G3 (p < .04). The median hospital stay was also different within groups, respectively: 3 in G1, 4 in G2 and 6 days in G3 (p < .001). On univariate analysis, age ≥60, male gender, ASA 3, WBC ≥13.000/µL, CRP ≥100 mg/l and delay between onset of symptoms and surgery were factors statistically associated with increased morbidity rate. On multivariate analysis, the delay was the only independent predictive factor of postoperative morbidity (OR: 1,08, 95% CI: 1.01-1.61, p < .031). Conclusion: Our study confirms that it is ideal to perform ELC within 3 days of symptoms onset and reasonable between 4 to 7 days. We do not recommend performing ELC beyond 7 days because of more difficult procedure and significantly increased risk of post-operative complications.
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Affiliation(s)
| | | | - J. Closset
- Erasme University Hospital, Bruxelles – B, Belgium
| | - G. Fromont
- Hôpital de Bois-Bernard, Bois-Bernard – F, Belgium
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Jabbar SAA, Ahmed Z, Mirza A, Nassar AHM. Laparoscopic Training Opportunities in an Emergency Biliary Service. JSLS 2019; 23:JSLS.2019.00031. [PMID: 31488943 PMCID: PMC6708413 DOI: 10.4293/jsls.2019.00031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives: Optimizing single-session management of biliary emergencies whilst maximizing laparoscopic training opportunities is challenging. We analyzed training opportunities available in an emergency biliary department and its impact on service provision and patient outcomes. Methods: A single surgeon's practice of 2049 emergency laparoscopic cholecystectomies and common bile duct explorations was prospectively analyzed. Training involved a modular stepwise approach incorporating access, gallbladder bed dissection, pedicle dissection, intra- corporeal tying, and cholangiogram ± common bile duct exploration. Training cases were identified, trainee involvement ascertained, and parameters predictive of a training case were established. Results: Thirty percent of laparoscopic cholecystectomies were performed in part or completely by trainees, with a training component in 30% of bile duct explorations. Trainee involvement increased mean operating time by approximately 10 minutes. There was no difference in minor (5% vs 5%, P = .8) or major complications (1% vs 0.9%, P = .7) on trainee versus consultant cases. Postoperative hospital stay was greater in consultant cases (2.87 vs 4.44 days, P = .0025). Multivariate analysis identified predictors of trainee cases including lower age (OR, 1.3; 95% CI, 1.1-1.7), female sex (OR, 1.6; 95% CI, 1.3-2), normal-weight subjects (OR, 1.54; 95% CI, 1.3-1.9), lower difficulty grade (1-2) (OR, 1.8; 95% CI, 1.4-2.2), and American Society of Anesthesiologists score ≤ 2 (OR, 1.8; 95% CI, 1.4-2.4). Conclusions: Surgical training is possible in a singlesession biliary emergency service without significantly impacting theatre utilization times or early patient outcomes. Further dedicated studies will allow individual learning curves to be determined.
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Affiliation(s)
- Salman A A Jabbar
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Zubir Ahmed
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Ahmad Mirza
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Ahmad H M Nassar
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
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Jaffey JA, Pavlick M, Webster CR, Moore GE, McDaniel KA, Blois SL, Brand EM, Reich CF, Motschenbacher L, Hostnik ET, Su D, Lidbury JA, Raab O, Carr SV, Mabry KE, Fox-Alvarez W, Townsend S, Palermo S, Nakazono Y, Ohno K, VanEerde E, Fieten H, Hulsman AH, Cooley-Lock K, Dunning M, Kisielewicz C, Zoia A, Caldin M, Conti-Patara A, Ross L, Mansfield C, Lynn O, Claus MA, Watson PJ, Swallow A, Yool DA, Gommeren K, Knops M, Ceplecha V, de Rooster H, Lobetti R, Dossin O, Jolivet F, Papazoglou LG, Pappalardo MCF, Manczur F, Dudás-Györki Z, O'Neill EJ, Martinez C, Gal A, Owen RL, Gunn E, Brown K, Harder LK, Griebsch C, Anfinsen KP, Gron TK, Marchetti V, Heilmann RM, Pazzi P, DeClue AE. Effect of clinical signs, endocrinopathies, timing of surgery, hyperlipidemia, and hyperbilirubinemia on outcome in dogs with gallbladder mucocele. Vet J 2019; 251:105350. [PMID: 31492387 DOI: 10.1016/j.tvjl.2019.105350] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 07/27/2019] [Accepted: 07/28/2019] [Indexed: 12/21/2022]
Abstract
Gallbladder mucocele (GBM) is a common extra-hepatic biliary syndrome in dogs with death rates ranging from 7 to 45%. Therefore, the aim of this study was to identify the association of survival with variables that could be utilized to improve clinical decisions. A total of 1194 dogs with a gross and histopathological diagnosis of GBM were included from 41 veterinary referral hospitals in this retrospective study. Dogs with GBM that demonstrated abnormal clinical signs had significantly greater odds of death than subclinical dogs in a univariable analysis (OR, 4.2; 95% CI, 2.14-8.23; P<0.001). The multivariable model indicated that categorical variables including owner recognition of jaundice (OR, 2.12; 95% CI, 1.19-3.77; P=0.011), concurrent hyperadrenocorticism (OR 1.94; 95% CI, 1.08-3.47; P=0.026), and Pomeranian breed (OR, 2.46; 95% CI 1.10-5.50; P=0.029) were associated with increased odds of death, and vomiting was associated with decreased odds of death (OR, 0.48; 95% CI, 0.30-0.72; P=0.001). Continuous variables in the multivariable model, total serum/plasma bilirubin concentration (OR, 1.03; 95% CI, 1.01-1.04; P<0.001) and age (OR, 1.17; 95% CI, 1.08-1.26; P<0.001), were associated with increased odds of death. The clinical utility of total serum/plasma bilirubin concentration as a biomarker to predict death was poor with a sensitivity of 0.61 (95% CI, 0.54-0.69) and a specificity of 0.63 (95% CI, 0.59-0.66). This study identified several prognostic variables in dogs with GBM including total serum/plasma bilirubin concentration, age, clinical signs, concurrent hyperadrenocorticism, and the Pomeranian breed. The presence of hypothyroidism or diabetes mellitus did not impact outcome in this study.
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Affiliation(s)
- J A Jaffey
- Department of Veterinary Medicine and Surgery, Veterinary Health Center, University of Missouri, 900 East Campus Drive, Columbia, MO, 65211, USA.
| | - M Pavlick
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, 200 Westboro Road, North Grafton, MA, 01536, USA
| | - C R Webster
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, 200 Westboro Road, North Grafton, MA, 01536, USA
| | - G E Moore
- Department of Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, IN, 47907, USA
| | - K A McDaniel
- Department of Veterinary Medicine and Surgery, Veterinary Health Center, University of Missouri, 900 East Campus Drive, Columbia, MO, 65211, USA
| | - S L Blois
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, N1G 2W1, Canada
| | - E M Brand
- Veterinary Medical Center, College of Veterinary Medicine, Michigan State University, East Lansing, MI, USA
| | - C F Reich
- Veterinary Medical Center, College of Veterinary Medicine, Michigan State University, East Lansing, MI, USA
| | - L Motschenbacher
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, 1352 Boyd Avenue, C-325, St Paul, MN, USA
| | - E T Hostnik
- Department of Veterinary Clinical Sciences, Veterinary Medical Center, Ohio State University, 601 Vernon L Tharp Street Columbus, OH, 43210, USA
| | - D Su
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, TN, 37996, USA
| | - J A Lidbury
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, 4474 TAMU, College Station, TX, 77843, USA
| | - O Raab
- Department of Companion Animals, Atlantic Veterinary College, University of Prince Edward Island, 550 University Avenue, Charlottetown, Prince Edward Island, C1A 4P3, Canada
| | - S V Carr
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Tech, 215 Duck Pond Drive, Blacksburg, VA, 24061, USA
| | - K E Mabry
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Tech, 215 Duck Pond Drive, Blacksburg, VA, 24061, USA
| | - W Fox-Alvarez
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, 32608, USA
| | - S Townsend
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, 32608, USA
| | - S Palermo
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Y Nakazono
- Department of Veterinary Internal Medicine, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - K Ohno
- Department of Veterinary Internal Medicine, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - E VanEerde
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, IA, 50010, USA
| | - H Fieten
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - A H Hulsman
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - K Cooley-Lock
- Department of Clinical Sciences, College of Veterinary Medicine, P.O. Box 6100, Mississippi State University, Mississippi State, MS, 39762-6100, USA
| | - M Dunning
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Leicestershire, LE12 5RD, United Kingdom
| | - C Kisielewicz
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Leicestershire, LE12 5RD, United Kingdom
| | - A Zoia
- San Marco Veterinary Clinic, via Sorio 114c, 35141, Padua, Italy
| | - M Caldin
- San Marco Veterinary Clinic, via Sorio 114c, 35141, Padua, Italy
| | - A Conti-Patara
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, WA, 99164, USA
| | - L Ross
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, 36849, USA
| | - C Mansfield
- Faculty of Veterinary Science, The University of Melbourne, 250 Princes Highway, Werribee, Victoria, 3030, Australia
| | - O Lynn
- Faculty of Veterinary Science, The University of Melbourne, 250 Princes Highway, Werribee, Victoria, 3030, Australia
| | - M A Claus
- Comparative Health Research Group, College of Veterinary Medicine, School of Veterinary and Life Sciences, Murdoch University, Murdoch, Western Australia, 6150, Australia
| | - P J Watson
- Department of Veterinary Medicine, University of Cambridge, Cambridge, CB3 0ES, United Kingdom
| | - A Swallow
- Department of Veterinary Medicine, University of Cambridge, Cambridge, CB3 0ES, United Kingdom
| | - D A Yool
- Division of Veterinary Clinical Sciences, Hospital for Small Animals, Royal (Dick) School of Veterinary Studies, The University of Edinburgh, Midlothian, EH25 9RG, United Kingdom
| | - K Gommeren
- Department of Clinical Sciences, Small Animal Medicine, Faculty of Veterinary Medicine, University of Liege, Liege, Belgium
| | - M Knops
- Department of Clinical Sciences, Small Animal Medicine, Faculty of Veterinary Medicine, University of Liege, Liege, Belgium
| | - V Ceplecha
- Small Animal Clinic, Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno, Palackeho 1/3, 612 42, Brno, Czech Republic
| | - H de Rooster
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - R Lobetti
- Bryanston Veterinary Hospital, P.O. Box 67092, Bryanston, South Africa
| | - O Dossin
- Department of Small Animal Clinical Sciences, ENVT and IRSD, Université de Toulouse, INSERM, INRA, ENVT, UPS, Toulouse, France
| | - F Jolivet
- Department of Small Animal Clinical Sciences, ENVT and IRSD, Université de Toulouse, INSERM, INRA, ENVT, UPS, Toulouse, France
| | - L G Papazoglou
- Department of Clinical Sciences, School of Veterinary Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - M C F Pappalardo
- Vet Support, Small Animal Intensive Care Medicine, Sao Paulo, 04082-002, Brazil
| | - F Manczur
- Department and Clinic of Internal Medicine, University of Veterinary Medicine, H-1400, P.O. Box 2, Hungary
| | - Z Dudás-Györki
- Department and Clinic of Internal Medicine, University of Veterinary Medicine, H-1400, P.O. Box 2, Hungary
| | - E J O'Neill
- Department of Veterinary Clinical Studies, School of Veterinary Medicine, University of Dublin, Belfield, Dublin 4, Ireland
| | - C Martinez
- Department of Veterinary Clinical Studies, School of Veterinary Medicine, University of Dublin, Belfield, Dublin 4, Ireland
| | - A Gal
- School of Veterinary Science, Massey University, Palmerston North, 4410, New Zealand
| | - R L Owen
- School of Veterinary Science, Massey University, Palmerston North, 4410, New Zealand
| | - E Gunn
- University of Glasgow Small Animal Hospital, Bearsden Road, Glasgow, G61 1QH, United Kingdom
| | - K Brown
- University of Glasgow Small Animal Hospital, Bearsden Road, Glasgow, G61 1QH, United Kingdom
| | - L K Harder
- Small Animal Hospital, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, D-30559, Hannover, Germany
| | - C Griebsch
- University Veterinary Teaching Hospital Sydney, The University of Sydney, 65 Parramatta Road, 2050, Camperdown, New South Wales, Australia
| | - K P Anfinsen
- Department of Companion Animal Clinical Sciences, NMBU School of Veterinary Science, N-0033, Oslo, Norway
| | - T K Gron
- Department of Companion Animal Clinical Sciences, NMBU School of Veterinary Science, N-0033, Oslo, Norway
| | - V Marchetti
- Department of Veterinary Science, University of Pisa, Via Livornese lato monte, 56122, San Piero a Grado, Pisa, Italy
| | - R M Heilmann
- Small Animal Clinic, Veterinary Teaching Hospital, College of Veterinary Medicine, University of Leipzig, An den Tierkliniken 23, DE-04103, Leipzig, Saxony, Germany
| | - P Pazzi
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Old Soutpan Road, Onderstepoort, 0110, South Africa
| | - A E DeClue
- Pride Veterinary Centre, Riverside Road, Pride Park, Derby, UK
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Cholecystectomy after endoscopic retrograde cholangiopancreatography - effect of time on treatment outcomes. GASTROENTEROLOGY REVIEW 2018; 13:251-257. [PMID: 30302173 PMCID: PMC6173079 DOI: 10.5114/pg.2018.78292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 06/12/2018] [Indexed: 11/23/2022]
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Bazzi ZT, Kinnear N, Bazzi CS, Hennessey D, Henneberg M, Otto G. Impact of an acute surgical unit on outcomes in acute cholecystitis. ANZ J Surg 2018; 88:E835-E839. [DOI: 10.1111/ans.14802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Zacharia T. Bazzi
- Department of Surgery; Lyell McEwin Hospital; Adelaide South Australia Australia
| | - Ned Kinnear
- Department of Surgery; Lyell McEwin Hospital; Adelaide South Australia Australia
- Department of Urology; Austin Health; Melbourne Victoria Australia
| | - Ciara S. Bazzi
- Department of Surgery; Modbury Hospital; Adelaide South Australia Australia
| | - Derek Hennessey
- Department of Urology; Austin Health; Melbourne Victoria Australia
| | - Maciej Henneberg
- Department of Medical Sciences; The University of Adelaide; Adelaide South Australia Australia
| | - Greg Otto
- Department of Surgery; Lyell McEwin Hospital; Adelaide South Australia Australia
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Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: an up-to-date meta-analysis of randomized controlled trials. Surg Endosc 2018; 32:4728-4741. [DOI: 10.1007/s00464-018-6400-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 08/20/2018] [Indexed: 01/29/2023]
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Nondrainage after Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis Does Not Increase the Postoperative Morbidity. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8436749. [PMID: 30065946 PMCID: PMC6051323 DOI: 10.1155/2018/8436749] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 05/23/2018] [Accepted: 06/06/2018] [Indexed: 12/03/2022]
Abstract
Background It is now established that prophylactic drainage is not needed after laparoscopic cholecystectomy (LC) for chronic calculous cholecystitis. However, the benefit of drains versus their potential harm for acute calculous cholecystitis (ACC) following laparoscopic LC has been questioned. Therefore, we conducted a comparative study to assess the need for drainage. Methods Between January 2014 and October 2016, 212 patients with ACC undergoing LC undergo either drainage (n= 106) or no drainage (n= 106). The primary end points were the number of patients with postoperative drain-related complications, early and late Visual Analogue Scale (VAS) score, and hospital stay. Secondary end points included estimated blood loss, postoperative recovery, analgesia requirement, and cosmetic satisfaction result. Results There was no bile duct injury and mortality in both groups. The overall complication rate was 12.5% with no significant difference between those with or without drainage (P=0.16). Normal activity resumption was significantly faster and the postoperative hospital stay was slightly shorter in the nondrainage group (P =0.03 and P= 0.04, respectively). The early VAS score in the drainage group was significantly higher (p< 0.05). There were no significant differences between the two groups in postoperative hematology test, late VAS score, and patient satisfaction of cosmetic outcome. Conclusion Routine drainage for patients with ACC after LC may not be justified with similar drain-related complications compared with nondrainage group.
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Thangavelu A, Rosenbaum S, Thangavelu D. Timing of Cholecystectomy in Acute Cholecystitis. J Emerg Med 2018; 54:892-897. [PMID: 29752150 DOI: 10.1016/j.jemermed.2018.02.045] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 02/24/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Cholecystitis is an inflammation of the gallbladder that most commonly occurs as a result of obstruction of the cystic duct by gallstones. The current standard of treatment for acute cholecystitis is cholecystectomy. OBJECTIVE Our goal was to discuss the benefits of and compare early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy in the treatment of acute cholecystitis. MATERIALS AND METHODS A Medline literature search was performed dating from January 1982 to July 2015. We limited the search to human studies written in English and using the keywords "Acute Cholecystitis," early vs. delayed laparoscopic cholecystectomy, surgical management, and surgical complications. RESULTS There were 225 articles reviewed, of which 25 met criteria for selection. Our recommendations are based on these 25 articles. CONCLUSION Early laparoscopic cholecystectomy is preferred over delayed, due to overall better quality of life, lower morbidity rates, and lower hospital cost. Ultimately, management of acute cholecystitis by emergency physicians should be made based on patient's clinical status and available resources in their particular hospital.
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Affiliation(s)
- Arasi Thangavelu
- Department of Emergency Medicine, Archbold Medical Center, Thomasville, Georgia; Florida State University, College of Medicine, Tallahassee, Florida
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Kerwat D, Zargaran A, Bharamgoudar R, Arif N, Bello G, Sharma B, Kerwat R. Early laparoscopic cholecystectomy is more cost-effective than delayed laparoscopic cholecystectomy in the treatment of acute cholecystitis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 10:119-125. [PMID: 29497322 PMCID: PMC5822851 DOI: 10.2147/ceor.s149924] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This economic evaluation quantifies the cost-effectiveness of early laparoscopic cholecystectomy (ELC) versus delayed laparoscopic cholecystectomy (DLC) in the management of acute cholecystitis. The two interventions were assessed in terms of outcome measures, including utilities, to derive quality-adjusted life years (QALYs) as a unit of effectiveness. This study hypothesizes that ELC is more cost-effective than DLC. Materials and methods In this economic evaluation, existing literature was compiled and analyzed to estimate the incremental cost-effectiveness of ELC versus DLC. Six randomized controlled trials were used to schematically represent the probabilities of each decision tree branch. To calculate health outcomes, quality of life scores were sourced from three articles and multiplied by the expected length of life postintervention to give QALYs. From an National Health Service (NHS) perspective, one QALY may be sacrificed if the incremental cost-effectiveness ratio is above £20,000–£30,0000 in cost savings. Results This economic evaluation calculated the average net present values of ELC to be £3920 and DLC to be £4565, demonstrating that ELC is the less-expensive intervention, with potential cost savings of £645 per operation. When scaling these savings up to a population approximately comparable to the size of the UK, full-scale implementation of ELC rather than DLC will potentially save the NHS £30,000,000 per annum. Conclusion ELCs are cost-effective from the perspective of the NHS. As such, policy should review existing guidelines and consider the merits of ELC versus DLC, improving resource allocation. The findings of this article advocate that ELC should become a standard practice.
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Affiliation(s)
| | | | | | - Nadia Arif
- Department of Medicine, Brighton and Sussex Medical School, Brighton
| | - Grace Bello
- Department of Medicine, St George's University of London, London
| | | | - Rajab Kerwat
- Department of Medicine, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, London, UK
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Patel SS, Kohli DR, Savas J, Mutha PR, Zfass A, Shah TU. Surgery Reduces Risk of Complications Even in High-Risk Veterans After Endoscopic Therapy for Biliary Stone Disease. Dig Dis Sci 2018; 63:781-786. [PMID: 29380173 DOI: 10.1007/s10620-018-4940-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 01/19/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND In otherwise healthy patients, randomized trials have shown reduced mortality with cholecystectomy (CCY) when compared to non-operative management after endoscopic retrograde cholangiopancreatography (ERCP) for biliary stone disease. These findings may not apply to veterans with multiple comorbidities, who have an increased risk of postoperative complications. AIMS Our study assessed the benefit of CCY among veterans with multiple comorbidities. METHODS Medical records of patients undergoing ERCP for biliary stone-related diseases from July 2008 to December 2016 were reviewed. Among patients who did not undergo CCY, risk of postoperative complications or death with CCY was estimated using the American College of Surgeons National Surgery Quality Improvement Program risk calculator. Charlson comorbidity index (CCI) and American Society of Anesthesiologists classification system (ASA) were used to assess patient's functional status. The primary outcome was incidence of recurrent biliary events or death with non-operative management, compared to estimated risk of serious postoperative complications or death with CCY. RESULTS A total of 152 patients met inclusion criteria, 81 of whom did not undergo CCY. Patients managed non-operatively were older and less medically fit than patients who underwent CCY. Biliary complications recurred in 23 patients managed non-operatively, including 3 deaths due to cholangitis. Among patients with CCI ≥ 3 and ASA ≥ 3 who were managed non-operatively (n = 43), the risk of serious biliary events was significantly higher than estimated risk of serious postoperative complications with laparoscopic CCY (26 vs 5%, p < 0.001). CONCLUSION Our study suggests that non-operative management is associated with a higher risk of complications than laparoscopic CCY, even among veterans with significant comorbidities.
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Affiliation(s)
- Samarth S Patel
- Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University, MCV Box 980342, Richmond, VA, 23298-0342, USA. .,Division of Gastroenterology, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.
| | - Divyanshoo R Kohli
- Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University, MCV Box 980342, Richmond, VA, 23298-0342, USA.,Division of Gastroenterology, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Jeannie Savas
- Department of Surgery, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Pritesh R Mutha
- Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University, MCV Box 980342, Richmond, VA, 23298-0342, USA.,Division of Gastroenterology, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Alvin Zfass
- Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University, MCV Box 980342, Richmond, VA, 23298-0342, USA.,Division of Gastroenterology, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Tilak U Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University, MCV Box 980342, Richmond, VA, 23298-0342, USA.,Division of Gastroenterology, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
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Yuval JB, Mizrahi I, Mazeh H, Weiss DJ, Almogy G, Bala M, Kuchuk E, Siam B, Simanovsky N, Eid A, Pikarsky AJ. Delayed Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis: Is it Time for a Change? World J Surg 2018; 41:1762-1768. [PMID: 28251270 DOI: 10.1007/s00268-017-3928-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND Our aim was to evaluate the advantages and limitations of delayed laparoscopic cholecystectomy (LC) in a tertiary center. MATERIALS AND METHODS A retrospective analysis of all patients admitted to our institution with acute calculous cholecystitis (ACC) between January 2003 and December of 2012 was performed. Data collected included patient demographics and comorbidities, presenting symptoms, laboratory findings, imaging results, length of stay (LOS), time to surgery, and surgical complications. RESULTS A total of 1078 patients were admitted with ACC. There were 593 females (55%), and the mean age was 57 ± 0.6 years. Mean LOS at initial admission, re-admission until surgery, and following surgery was 7.9 ± 0.2, 1.5 ± 0.1, and 3.4 ± 0.2 days, respectively. Percutaneous cholecystostomy (PC) tube was inserted in 24% of the patients. Only 640 (59%) patients eventually underwent LC. Mean time to surgery was 97 ± 9.8 days, and 16.4% of patients were readmitted in this time period resulting in a mean total LOS of 10.6 ± 0.2 days. Conversion rate to open surgery was 5.8% and bile duct injury occurred in 1.1%. Postoperative complications occurred in 9.8% of the patients, and 30-day mortality was 0.6%. Patients with more severe inflammation according to Tokyo Criteria grade were more likely to undergo PC, were more likely to be readmitted while waiting for LC, and also had more postoperative complications. CONCLUSIONS Delayed LC is associated with significant loss of follow-up, long LOS, and higher than expected use of PC. Conversion rates are lower than in the literature while rates of bile duct injury and mortality are comparable. We believe these data as well as the available literature are sufficient to change our hospital policy regarding the surgical treatment of ACC from delayed to early same admission surgery in appropriate cases.
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Affiliation(s)
- Jonathan B Yuval
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Kiryat Hadassah, 91120, Jerusalem, Israel.
| | - Ido Mizrahi
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Kiryat Hadassah, 91120, Jerusalem, Israel
| | - Haggi Mazeh
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Kiryat Hadassah, 91120, Jerusalem, Israel
| | - Daniel J Weiss
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Kiryat Hadassah, 91120, Jerusalem, Israel
| | - Gidon Almogy
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Kiryat Hadassah, 91120, Jerusalem, Israel
| | - Miklosh Bala
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Kiryat Hadassah, 91120, Jerusalem, Israel
| | - Eran Kuchuk
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Kiryat Hadassah, 91120, Jerusalem, Israel
| | - Baha Siam
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Kiryat Hadassah, 91120, Jerusalem, Israel
| | - Natalia Simanovsky
- Department of Radiology, Hadassah-Hebrew University Medical Center, POB 12000, Kiryat Hadassah, 91120, Jerusalem, Israel
| | - Ahmed Eid
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Kiryat Hadassah, 91120, Jerusalem, Israel
| | - Alon J Pikarsky
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Kiryat Hadassah, 91120, Jerusalem, Israel
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Murray AC, Markar S, Mackenzie H, Baser O, Wiggins T, Askari A, Hanna G, Faiz O, Mayer E, Bicknell C, Darzi A, Kiran RP. An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK. Surg Endosc 2018; 32:3055-3063. [PMID: 29313126 DOI: 10.1007/s00464-017-6016-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/19/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Evidence supports early laparoscopic cholecystectomy for acute cholecystitis. Differences in treatment patterns between the USA and UK, associated outcomes and resource utilization are not well understood. METHODS In this retrospective, observational study using national administrative data, emergency patients admitted with acute cholecystitis were identified in England (Hospital Episode Statistics 1998-2012) and USA (National Inpatient Sample 1998-2011). Proportions of patients who underwent emergency cholecystectomy, utilization of laparoscopy and associated outcomes including length of stay (LOS) and complications were compared. The effect of delayed treatment on subsequent readmissions was evaluated for England. RESULTS Patients with a diagnosis of acute cholecystitis totaled 1,191,331 in the USA vs. 288 907 in England. Emergency cholecystectomy was performed in 628,395 (52.7% USA) and 45,299 (15.7% England) over the time period. Laparoscopy was more common in the USA (82.8 vs. 37.9%; p < 0.001). Pre-treatment (1 vs. 2 days; p < 0.001) and total ( 4 vs. 7 days; p < 0.001) LOS was lower in the USA. Overall incidence of bile duct injury was higher in England than the USA (0.83 vs. 0.43%; p < 0.001), but was no different following laparoscopic surgery (0.1%). In England, 40.5% of patients without an immediate cholecystectomy were subsequently readmitted with cholecystitis. An additional 14.5% were admitted for other biliary complications, amounting to 2.7 readmissions per patient in the year following primary admission. CONCLUSION This study highlights management practices for acute cholecystitis in the USA and England. Despite best evidence, index admission laparoscopic cholecystectomy is performed less in England, which significantly impacts subsequent healthcare utilization.
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Affiliation(s)
- A C Murray
- Division of Colorectal Surgery, New York Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor: 8, New York, NY, 10032, USA.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - S Markar
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - H Mackenzie
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - O Baser
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - T Wiggins
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Askari
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - G Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - O Faiz
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - E Mayer
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - C Bicknell
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - R P Kiran
- Division of Colorectal Surgery, New York Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor: 8, New York, NY, 10032, USA. .,Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA.
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Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, Iwashita Y, Hibi T, Pitt HA, Umezawa A, Asai K, Han HS, Hwang TL, Mori Y, Yoon YS, Huang WSW, Belli G, Dervenis C, Yokoe M, Kiriyama S, Itoi T, Jagannath P, Garden OJ, Miura F, Nakamura M, Horiguchi A, Wakabayashi G, Cherqui D, de Santibañes E, Shikata S, Noguchi Y, Ukai T, Higuchi R, Wada K, Honda G, Supe AN, Yoshida M, Mayumi T, Gouma DJ, Deziel DJ, Liau KH, Chen MF, Shibao K, Liu KH, Su CH, Chan ACW, Yoon DS, Choi IS, Jonas E, Chen XP, Fan ST, Ker CG, Giménez ME, Kitano S, Inomata M, Hirata K, Inui K, Sumiyama Y, Yamamoto M. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 25:55-72. [PMID: 29045062 DOI: 10.1002/jhbp.516] [Citation(s) in RCA: 406] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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45
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Inoue K, Ueno T, Douchi D, Shima K, Goto S, Takahashi M, Morikawa T, Naitoh T, Shibata C, Naito H. Risk factors for difficulty of laparoscopic cholecystectomy in grade II acute cholecystitis according to the Tokyo guidelines 2013. BMC Surg 2017; 17:114. [PMID: 29183352 PMCID: PMC5706415 DOI: 10.1186/s12893-017-0319-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 11/20/2017] [Indexed: 01/11/2023] Open
Abstract
Background The Tokyo Guidelines 2013 classifies acute cholecystitis (AC) into three grades and recommends appropriate therapy for each grade. For grade II AC, either early laparoscopic cholecystectomy (LC) or percutaneous transhepatic gallbladder drainage (PTGBD) should be performed. This study aimed to identify the risk factors for difficulty of LC for treating grade II AC. Methods Totally, 122 patients who underwent LC for grade II AC were enrolled and divided into difficult LC (DLC) and nondifficult LC (NDLC) groups. The DLC group included patients who experienced one of the following conditions: conversion from LC to open cholecystectomy, operating time ≥ 180 min, or blood loss ≥300 ml. Preoperative characteristics and postoperative outcomes were analyzed. Results In univariate analysis, risk factors included male sex, interval between symptom onset and admission, interval between symptom onset and LC, and anticoagulant therapy. The incidence of postoperative complications was higher in the DLC group than in the NDLC group (23.5% vs. 4.6%, p = 0.0016). According to receiver operating characteristic curves, the optimal cutoff value was calculated, and multivariate analysis showed that male sex [odds ratio (OR), 5.76; 95% confidence interval (CI), 1.979–19.51; p = 0.0009) and interval between symptom onset and LC of over 96 h (OR, 6.32; 95% CI, 2.126–20.15; p = 0.0009) were independent risk factors for difficulty of LC. Conclusions In patients with grade II AC, LC was technically difficult when performed over 96 h after symptom onset. Moreover, male sex was a risk factor. Therefore, PTGBD should be considered in these patients. Electronic supplementary material The online version of this article (10.1186/s12893-017-0319-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Koetsu Inoue
- Department of surgery, South Miyagi Medical Center, 38-1 Aza-nishi, Ogawara, Shibata-gun, Miyagi, 989-1253, Japan.
| | - Tatsuya Ueno
- Department of surgery, South Miyagi Medical Center, 38-1 Aza-nishi, Ogawara, Shibata-gun, Miyagi, 989-1253, Japan
| | - Daisuke Douchi
- Department of surgery, South Miyagi Medical Center, 38-1 Aza-nishi, Ogawara, Shibata-gun, Miyagi, 989-1253, Japan
| | - Kentaro Shima
- Department of surgery, South Miyagi Medical Center, 38-1 Aza-nishi, Ogawara, Shibata-gun, Miyagi, 989-1253, Japan
| | - Shinji Goto
- Department of surgery, South Miyagi Medical Center, 38-1 Aza-nishi, Ogawara, Shibata-gun, Miyagi, 989-1253, Japan
| | - Michinaga Takahashi
- Department of surgery, South Miyagi Medical Center, 38-1 Aza-nishi, Ogawara, Shibata-gun, Miyagi, 989-1253, Japan
| | - Takanori Morikawa
- Department of surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Takeshi Naitoh
- Department of surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Chikashi Shibata
- Division of Gastroenterological Surgery, Department of Surgery, Tohoku Medical and Pharmaceutical University Hospital, 1-12-1 Hukumuro Miyagino-ku, Sendai, Miyagi, 983-8512, Japan
| | - Hiroo Naito
- Department of surgery, South Miyagi Medical Center, 38-1 Aza-nishi, Ogawara, Shibata-gun, Miyagi, 989-1253, Japan
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Determinants of variability in management of acute calculous cholecystitis. Surg Endosc 2017; 32:1858-1866. [PMID: 29052064 DOI: 10.1007/s00464-017-5874-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 09/04/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND While evidence supports early compared to delayed cholecystectomy as optimal management of acute calculous cholecystitis (ACC), significant variability in practice remains. The purpose of this study was to identify variables associated with early cholecystectomy, to target opportunities to improve adherence to best practices. METHODS Adult patients admitted to surgical units with ACC at two hospitals in a university hospital network between June 2010 and January 2015 were reviewed. Patients with concurrent pancreatitis, cholangitis or severe ACC (with organ system failure) were excluded. Early cholecystectomy was defined as surgery performed during same admission and within 7 days of presentation. Non-operative management was defined as admission for ACC treated conservatively, with or without eventual delayed cholecystectomy. The primary outcome was early cholecystectomy versus initial non-operative management; secondary outcomes included time to cholecystectomy, complications, and total hospital length of stay (LOS). RESULTS A total of 374 patients were included. Two hundred and forty six patients (66%) underwent early cholecystectomy, 60 (16%) were treated non-operatively and had delayed cholecystectomy, and 68 (18%) were only treated non-operatively. Median time to OR from initial presentation was 38 h [22-63] for early cholecystectomy patients and 69 days [29-116] for the non-operative patients who had delayed cholecystectomy. When comparing both groups, early cholecystectomy patients were younger and were treated more often at site 1. There were no differences in complications during hospitalization, but early cholecystectomy patients had a lower median total LOS (3 [2-5] vs. 5 [4-9], p < 0.001), and they had fewer gallstone-related events after discharge (1 vs. 18%, p < 0.001). On multiple logistic regression analysis, lower age, hospital site and lower risk of concurrent choledocholithiasis were all significantly associated with early cholecystectomy (p < 0.05). CONCLUSION Our data supports early cholecystectomy as best practice in management of ACC with no differences in complications during hospitalization, shorter median LOS and fewer gallstone-related events compared to non-operative management. We identified patient and institutional factors associated with early cholecystectomy. This suggests that multiple strategies will be necessary to promote adherence to best practices in the management of ACC within our institution.
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Outcomes of Consistent Conservative Management for Acute Cholecystitis Followed by Delayed Cholecystectomy. Surg Laparosc Endosc Percutan Tech 2017; 27:404-408. [PMID: 28906420 DOI: 10.1097/sle.0000000000000458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study's objective was to assess outcomes of a totally conservative strategy for acute cholecystitis (AC) followed by delayed elective cholecystectomy. PATIENTS AND METHODS Consecutive patients who underwent cholecystectomy for AC were divided into the Emergent and Elective cholecystectomy groups. Patients in the elective cholecystectomy group were divided into early, medium, and late groups according to time from symptoms onset. RESULTS The success rate for conservative management reached 97.2%. Increased blood loss and a higher conversion rate were significantly associated with the emergent group. Patients in the late group had significantly lower operative time and tended to have lower blood loss and less frequent conversion to open surgery than those in the early and medium groups. CONCLUSIONS Most AC cases could be managed conservatively, and elective cholecystectomy was performed safely regardless of the time. Elective cholecystectomy carried out in late phase was likely to be associated with decreased surgical difficulty.
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Koea JB. General surgery's game changer and the unanswered question. ANZ J Surg 2017; 87:531-532. [PMID: 28768387 DOI: 10.1111/ans.14051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 04/03/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Jonathan B Koea
- Upper Gastrointestinal Unit, Department of Surgery, North Shore Hospital, Auckland, New Zealand
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Sert İ, İpekci F, Engin Ö, Karaoğlan M, Çetindağ Ö. Outcomes of early cholecystectomy (within 7 days of admission) for acute cholecystitis according to diagnosis and severity grading by Tokyo 2013 Guideline. Turk J Surg 2017; 33:80-86. [PMID: 28740955 DOI: 10.5152/ucd.2016.3305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 11/01/2015] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The timing of early cholecystectomy in acute cholecystitis is still controversial, and data regarding the use of Tokyo 2013 guideline for diagnosis and severity grading in Acute Cholecystitis is limited. The aim of this study was to evaluate the clinical and pathologic outcomes of early cholecystectomy after 72 hr and within seven days of index admission according to Tokyo 2013 guideline for diagnosis and severity grading of Acute cholecystitis (in patients with Acute cholecystitis. MATERIAL AND METHODS Medical charts of 172 patients who underwent early cholecystectomy after 72 hr and within 7 days of index admission with a diagnosis of Acute cholecystitis between Aug 2009 and Apr 2014 were retrospectively analyzed. Patients were classified according Tokyo 2013 guideline criteria. RESULTS The median age of the study group was 52 yr. The rates of open and laparoscopic cholecystectomies was 53.5% and 33.1%, respectively. Conversion to open cholecystectomy was performed in 19 patients (13.4 %). The median length of hospital stay was 7 days. Eighty-four patients (59.2%) met the criteria for a definite diagnosis of Acute cholecystitis according to Tokyo 2013 guideline. Longer postoperative and total length of hospital stay was determined in patients with a definite diagnosis. CONCLUSION Increased severity grading is correlated with longer pre- and post-operative hospital stay. Early cholecystectomy in Acute cholecystitis performed by experienced surgeons after 72 hr of admission and within 7 days maybe a feasible and safe procedure.
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Affiliation(s)
- İsmail Sert
- Clinic of General Surgery and Transplantation, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Fuat İpekci
- Clinic of General Surgery, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Ömer Engin
- Clinic of General Surgery, Buca Seyfi Demirsoy State Hospital, İzmir, Turkey
| | - Muharrem Karaoğlan
- Clinic of General Surgery, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Özhan Çetindağ
- Clinic of General Surgery, Tepecik Training and Research Hospital, İzmir, Turkey
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Bouassida M, Chtourou MF, Charrada H, Zribi S, Hamzaoui L, Mighri MM, Touinsi H. The severity grading of acute cholecystitis following the Tokyo Guidelines is the most powerful predictive factor for conversion from laparoscopic cholecystectomy to open cholecystectomy. J Visc Surg 2017; 154:239-243. [PMID: 28709978 DOI: 10.1016/j.jviscsurg.2016.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND The relationship between the severity assessment of acute cholecystitis based on the Tokyo Guidelines and the risk for conversion from laparoscopic surgery to open surgery has been assessed in few previous reports, with conflicting results. METHODS A retrospective review of patients with acute cholecystitis within a single system from 2010 to 2013 was performed. The diagnosis and severity of acute cholecystitis were assigned by the Tokyo Guidelines 2013 (TG13). The primary outcome measure was conversion to open cholecystectomy. RESULTS During the period of study, 493 patients were operated by laparoscopy for acute cholecystitis. Laparoscopic cholecystectomy was intraoperatively converted to open surgery in 56 cases (11.4%). The multivariate analysis showed that the risk factors for conversion to open surgery included male gender (OR: 2.15; IC95% [1.18-3.9]), diabetes (OR: 2.22; IC95% [1.13-4.33]), total bilirubin levels (OR: 1.02; IC95% [1-1.05]), and the TG13 severity classification (OR: 4.44; IC95% [2.25-8.75]). CONCLUSIONS The independent risk factors for conversion to open surgery included male sex, diabetes mellitus, total bilirubin level, and TG13 grade. TG13 grade was found to be the most powerful predictive factor for conversion as it had the highest OR.
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Affiliation(s)
- M Bouassida
- Department of Surgery, Mohamed Tahar Maamouri Hospital, 8000 Nabeul, Tunisia.
| | - M F Chtourou
- Department of Surgery, Mohamed Tahar Maamouri Hospital, 8000 Nabeul, Tunisia
| | - H Charrada
- Department of Surgery, Mohamed Tahar Maamouri Hospital, 8000 Nabeul, Tunisia
| | - S Zribi
- Department of Surgery, Mohamed Tahar Maamouri Hospital, 8000 Nabeul, Tunisia
| | - L Hamzaoui
- Department of Gastroenterology, Mohamed Tahar Maamouri Hospital, 8000 Nabeul, Tunisia
| | - M M Mighri
- Department of Surgery, Mohamed Tahar Maamouri Hospital, 8000 Nabeul, Tunisia
| | - H Touinsi
- Department of Surgery, Mohamed Tahar Maamouri Hospital, 8000 Nabeul, Tunisia
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