Gallstones in cirrhotics revisited by a laparoscopic view

Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study

With improved laparoscopic techniques, experience, and availability of newer tools and instruments like ultrasonic shears; laparoscopic cholecystectomy (LC) became a feasible option in cirrhotic patients, the aim of this study was to analyze the outcome of LC in cirrhotic patients.

METHODS

We retrospectively analyzed 213 cirrhotic patients underwent LC, in the period from 2011 to 2019; the overall male/female ratio was 114/99.

RESULTS

The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities.

CONCLUSION

LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.

Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study

With improved laparoscopic techniques, experience, and availability of newer tools and instruments like ultrasonic shears; laparoscopic cholecystectomy (LC) became a feasible option in cirrhotic patients, the aim of this study was to analyze the outcome of LC in cirrhotic patients.

METHODS

We retrospectively analyzed 213 cirrhotic patients underwent LC, in the period from 2011 to 2019; the overall male/female ratio was 114/99.

RESULTS

The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities.

CONCLUSION

LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.

Laparoscopic cholecystectomy in cirrhotics

BACKGROUND AND OBJECTIVES

Due to the concern of risk of intra- and postoperative complications and associated morbidity, cirrhosis of the liver is often considered a contraindication for laparoscopic cholecystectomy (LC). This article intends to review the literature and underline the various approaches to dealing with this technically challenging procedure.

METHODS

A Medline search of major articles in the English literature on LC in cirrhotic patients over a 16-y period from 1994 to 2011 was reviewed and the findings analyzed. A total of 1310 cases were identified.

RESULTS

Most the patients who underwent LC were in Child-Pugh class A, followed by Child-Pugh classes B and C, respectively. The overall conversion rate was 4.58%, and morbidity was 17% and mortality 0.45%. Among the patients who died, most were in Child-Pugh class C, with a small number in classes B and A. The cause of death included, postoperative bleeding, liver failure, sepsis, duodenal perforation, and myocardial infarction. A meta-analysis of 400 patients in the literature, comparing outcomes of patients undergoing LC with and without cirrhosis, revealed higher conversion rate, longer operative time, higher bleeding complications, and overall increased morbidity in patients with cirrhosis. Safe LC was facilitated by measures that included the use of ultrasonic shears and other hemostatic measures and using subtotal cholecystectomy in patients with difficult hilum and gallbladder bed.

CONCLUSIONS

Laparoscopic cholecystectomy can be safely performed in cirrhotic patients, within Child-Pugh classes A and B, with acceptable morbidity and conversion rate.

Laparoscopic cholecystectomy in the cirrhotic patient: predictors of outcome

BACKGROUND

We sought to determine the outcome predictors of 94 cirrhotic patients undergoing laparoscopic cholecystectomy (LC).

METHODS

We performed a single-center, retrospective review of cirrhotic patients undergoing LC for symptomatic gallbladder disease. Statistical analysis was completed using the Chi-square, Wilcoxon rank-sum, and Student t tests as appropriate.

RESULTS

Ninety-four procedures were completed. The median Child-Turcotte-Pugh (CTP) score was 6 (range, 5-12), and the average Model for End-Stage Liver Disease (MELD) score was 11 ± 5. Hepatitis C was the most common etiology of liver disease (50%) followed by Laennec's cirrhosis (22%). The average length of stay was 2.6 ± 4.3 days; 21% were outpatient procedures. The conversion rate was 11%. Conversion risk factors were decreased serum albumin, increased MELD score, and blood loss. Morbidity occurred in 32 patients. Predictors of morbidity were decreases in serum albumin, increases in International Normalized Ratio (INR) and CTP score, and the number of intraoperative red blood cell transfusions. Mortality occurred in 4 patients. Increased INR, CTP score, CTP class, the number of intraoperative blood and platelet transfusions were predictors of mortality.

CONCLUSION

LC can be safely performed in cirrhotic patients with appropriate patient selection. Liver synthetic function, operative blood loss, transfusion requirement, CTP, and MELD scores may be used to predict outcomes in these patients.

Laparoscopic cholecystectomy is the preferred approach in cirrhosis: a nationwide, population-based study

BACKGROUND/AIM

To assess the impact of open versus laparoscopic surgery in cirrhotic patients undergoing a cholecystectomy using the Nationwide Inpatient Sample (NIS).

METHODS

All patients with cirrhosis who underwent a cholecystectomy (open or laparoscopic) between 2003 and 2006 were queried from the NIS. Associated complications including infection, transfusion, reoperation, liver failure and mortality were determined.

RESULTS

A total of 3240 patients with cirrhosis underwent a cholecystectomy: 383 patients underwent an open cholecystectomy (OC) whereas 2857 patients underwent a laparoscopic cholecystectomy (LC), which included 412 patients converted (LCC) from a LC to an OC. Post-operative infection was higher in OC as opposed to a laparoscopic cholecystectomy (TLC) or LCC (3.5% versus 0.7% versus 0.2%, P < 0.0001). The need for a blood transfusion was significantly higher in the OC and LCC groups as compared with the TLC group (19.2% versus 14.4% versus 6.2%, P < 0.0001). Reoperation was more frequent after OC or LCC versus TLC (1.5% versus 2.5% versus 0.8%, P = 0.007). In-hospital mortality was higher after OC as compared with TLC and LCC (8.3% versus 1.3% versus 1.4%, P < 0.0001).

CONCLUSION

Patients with cirrhosis have increased in-hospital morbidity and mortality after an open as opposed to a laparoscopic or conversion to an open cholecystectomy. LC should be the preferred initial approach in cirrhotic patients.

Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials

BACKGROUND

Cholecystectomy is associated with increased risks in patients with cirrhosis. The well-established advantages of laparoscopic surgery may be offset by the increased risk for complications relating particularly to portal hypertension and coagulopathy.

METHODS

A systematic search was undertaken to identify studies comparing open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) in patients with cirrhosis. A meta-analysis was performed of the available randomized controlled trials (RCTs).

RESULTS

Forty-four studies were analysed. These included a total of 2005 patients with cirrhosis who underwent laparoscopic (n= 1756) or open (n= 249) cholecystectomy, with mortality rates of 0.74% and 2.00%, respectively. A meta-analysis of three RCTs involving a total of 220 patients was conducted. There was a reduction in the overall incidences of postoperative complications and infectious complications and a shorter length of hospital stay in LC. However, frequencies of postoperative hepatic insufficiency did not differ significantly.

CONCLUSIONS

There are few RCTs comparing OC and LC in patients with cirrhosis. These studies are small, heterogeneous in design and include almost exclusively patients with Child-Pugh class A and B disease. However, LC appears to be associated with shorter operative time, reduced complication rates and reduced length of hospital stay.

Laparoscopic cholecystectomy and liver cirrhosis

INTRODUCTION

Historically the presence of liver cirrhosis has been an absolute or relative contraindication to laparoscopic cholecystectomy (LC). Accumulating experience in LC has resulted in an increasing number of investigators reporting that LC can be safely performed in cirrhotic patients. The aim of this study was to report the efficacy and safety of LC in the treatment of symptomatic cholelithiasis in cirrhotic patients, and a review of the literature in the matter.

METHODS

Between January 2006 and July 2010, from 503 patients under LC, we reviewed 43 cirrhotic patients of Child-Pugh Classification A, B, and C, with symptomatic gallstones.

RESULTS

Conversion to an open procedure was necessary in 5 patients due to multiple factors. The mean operative time and length of hospital stay were significantly longer and higher in cirrhotic group (P<0.05). Postoperative complications were observed in 37.2% of patients. Trocar site hematoma (P=0.02), wound complications (P=0.02), and intra-abdominal collection (P=0.01) occurred more frequently in patients with cirrhosis (Child B and C class) than in patients without cirrhosis. One case of continuing hemorrhage from the gallbladder bed required a reoperation for hemostasis. Two patients with Child-Pugh class C and 1 patient with class B cirrhosis developed ascites after surgery; 1 patient with Child-Pugh class A had bile leakage. No deaths occurred.

CONCLUSIONS

LC is an effective and safe procedure and should be the treatment of choice for symptomatic cholelithiasis or cholecystitis in patients with compensated cirrhosis.

Laparoscopic cholecystectomy in cirrhotic patients

BACKGROUND AND OBJECTIVES

Gallstones are twice as common in cirrhotic patients as in the general population. Although laparoscopic cholecystectomy (LC) has become the gold standard for symptomatic gallstones, cirrhosis has been considered an absolute or relative contraindication. Many authors have reported on the safety of LC in cirrhotic patients. We reviewed our patients retrospectively and assessed the safety of LC in cirrhotic patients at a tertiary care hospital in Pakistan.

METHODS

From January 2003 to December 2005, a retrospective study was conducted at SU IV, Liaquat University of Medical & Health Sciences Jamshoro. All the cirrhotic patients with Child-Pugh class A and B cirrhosis undergoing LC were included in the study. Cirrhosis was diagnosed based on clinical, biochemical, ultrasonography, and intraoperative findings of the nodular liver and histopathological study.

RESULTS

Of 250 patients undergoing laparoscopic cholecystectomy, 20 (12.5%) were cirrhotic. Of these 20, 12 (60%) were Childs group A and 8 (40%) were group B. Thirty percent were hepatitis B positive, and 70% were hepatitis C positive. Preoperative diagnosis of cirrhosis was possible in 80% of cases, and 20% were diagnosed during surgery. Morbidity rate was 15% and mortality rate was 0%. Two patients developed postoperative ascites, and mean hospital stay was 2.8+/-0.1 days. Of the 20 cases, 2 (10%) were converted to open cholecystectomy. The mean operation time was 70.2+/-32.54 minutes.

CONCLUSION

Laparoscopic cholecystectomy is an effective and safe treatment for symptomatic gallstone disease in select patients with Child-Pugh A and B cirrhosis. The advantages over open cholecystectomy are the lower morbidity rate and reduced hospital stay.

Clipless laparoscopic cholecystectomy using the Harmonic scalpel for cirrhotic patients: a prospective randomized study

BACKGROUND

Improved laparoscopic experiences have made laparoscopic cholecystectomy (LC) feasible options for cirrhotic patients. This study aimed to compare the traditional method for LC with LC using the Harmonic scalpel in terms of safety and efficacy for cirrhotic patients.

METHODS

In this study, group A (60 patients) underwent LC by the traditional method (TM) with clipping of both the cystic duct and artery and dissection of the gallbladder by diathermy, and group B (60 patients) had LC performed using Harmonic scalpel (HS) closure and division of both the cystic duct and artery with dissection of the gallbladder by the HS. The perioperative data were recorded.

RESULTS

The operation with the Harmonic scalpel was performed in less time than TM (45.17 ± 10.54 vs. 69.71 ± 13.01 min; p = 0.0001). The intraoperative blood loss was significantly more with TM (133 ± 131.13 l vs. 70.13 ± 80.79 ml; p = 0.002). The conversion rate was 5% with TM and 3.3% with HS (p = 0.65). The incidence of gallbladder peroration was lower in the HS group (10% vs. 18.3%; p = 0.03). Bile leak was encountered in 1.7% with HS and 3.3% with TM (p = 0.45). The visual analog scale (VAS) for pain with HS on postoperative day 1 was (3.07 ± 2.02 vs. 4.4 ± 2.11 (p = 0.001).

CONCLUSION

For cirrhotic patients, LC still is more complicated and difficult than for patients without cirrhosis. The Harmonic scalpel provides complete hemobiliary stasis and is a safe alternative to the standard clipping of the cystic duct and artery for cirrhotic patients. It offers a shorter operative duration and less blood loss.

Laparoscopic cholecystectomy in patients with cirrhosis of the liver and symptomatic cholelithiasis

BACKGROUND

The indications and benefits of laparoscopic cholecystectomy (LC) in patients with liver cirrhosis and symptomatic cholelithiasis have not been satisfactorily documented. The aim of this study was to investigate its efficacy and safety in such patients.

METHODS

Medical records of 38 patients with liver cirrhosis (stages Child-Pugh A and B) who underwent LC were retrospectively reviewed. Demographic characteristics and other parameters including initial presentation, conversion rate, complication rate, mortality, and duration of hospital stay were investigated and compared with noncirrhotic patients' parameters in our database.

RESULTS

Cirrhotic patients who underwent LC were older than noncirrhotic patients (P=0.021). Both the conversion rate (15.78%) and the duration of hospital stay were increased in the cirrhotic group, but without significant differences. Major complications occurred more often in the cirrhotic group (P=0.027), increasing morbidity; however, the mortality was zero.

CONCLUSIONS

LC can be safely performed in Child-Pugh A and B cirrhotic patients with symptomatic gallstone disease, with acceptable complication and conversion rates. The increased risk for a major complication, however, demands more attention than usual.

Laparoscopic cholecystectomy in cirrhotic patients: the value of MELD score and Child-Pugh classification in predicting outcome

BACKGROUND

Laparoscopic cholecystectomy is a challenging procedure in patients with cirrhosis. This study aims to evaluate the safety and outcome of laparoscopic cholecystectomy in patients with cirrhosis and examines the value of model for end-stage liver disease (MELD) score and Child-Pugh classification in predicting morbidity.

MATERIALS AND METHODS

From January 1995 to July 2008, 220 laparoscopic cholecystectomies were performed in cirrhotic, Child-Pugh class A and B patients. Indications included symptomatic gallbladder disease and cholecystitis. MELD score ranged between 8 and 27. Child-Pugh class and MELD score were preoperatively calculated and associated with postoperative results. Data regarding patients and surgical outcome were retrospectively analyzed.

RESULTS

No deaths occurred. Postoperative morbidity occurred in 19% of the patients and included hemorrhage, wound complications, and intra-abdominal collections controlled conservatively. Intraoperative difficulty due to liver bed bleeding was experienced in 19 patients. Conversion to open cholecystectomy was necessary in 12 cases. Median operative time was 95 min. Median hospital stay was 4 days. Patients with preoperative MELD score above 13 showed a tendency for higher complication rate postoperatively. Child-Pugh classification did not seem to predict morbidity effectively.

CONCLUSION

Laparoscopic cholecystectomy can be performed safely in selected patients with cirrhosis Child-Pugh A and B and symptomatic cholelithiasis with acceptable morbidity. Some of its advantages are shorter operative time and reduced hospital stay. MELD score seems to predict morbidity more accurately than Child-Pugh classification system.

Laparoscopic cholecystectomy in patients with mild cirrhosis and symptomatic cholelithiasis

BACKGROUND

Our goal was to support the emerging opinion that laparoscopic cholecystectomy is safe and well tolerated in selected cirrhotic patients with indications for surgery. We present our experience with 50 laparoscopic cholecystectomies performed on patients with mild cirrhosis.

METHODS

We retrospectively reviewed and analyzed the outcomes of 50 laparoscopic cholecystectomies performed between January 1995 and May 2006 in patients with Child-Pugh A and B cirrhosis.

RESULTS

Laparoscopic cholecystectomy was uneventful for 35 cirrhotic patients. Conversion to an open procedure was necessary in two Child-Pugh B patients with chronic cholelcystitis. One Child-Pugh B cirrhotic patient required blood transfusion. Postoperative complications occurred in 12 patients, including hemorrhage, wound infection, intra-abdominal collection, and cardiopulmonary complications. The mean postoperative stay was 5 days (range, 3 to 13). No deaths occurred.

CONCLUSIONS

Laparoscopic cholecystectomy is a safe procedure in well-selected Child-Pugh A and B cirrhotic patients and should be the gold standard for patients with mild cirrhosis and symptomatic cholelithiasis.

Updates in biliary endoscopy 2006

PURPOSE OF REVIEW

Endoscopic retrograde cholangiopancreatography is reserved primarily for therapeutic reasons. Recent literature continues to support therapeutic uses of the technique. This review addresses the literature in the field of biliary endoscopy for the year 2006 and is intended to assist gastroenterologists and gastrointestinal surgeons in everyday practice.

RECENT FINDINGS

Endoscopic management of choledocholithiasis in gallstone pancreatitis, a newer approach in the endoscopic management of malignant biliary strictures, the broadening therapeutic indications including the use of gallbladder stenting and the performance of endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y gastric bypass are discussed. Safety of the technique continues to be addressed. The risks of pancreatitis after endoscopic retrograde cholangiopancreatography as well as morbidity in the elderly are addressed.

SUMMARY

Major updates in the management of biliary tract disease using biliary endoscopy are discussed over a broad range of biliary tract diseases. The literature emphasizes the broadening therapeutic role of endoscopic retrograde cholangiopancreatography as well as improvements in our understanding of risk factors for complications and the potential for their prevention.

Endoscopic gallbladder stent placement for treatment of symptomatic cholelithiasis in patients with end-stage liver disease

OBJECTIVES

Symptomatic cholelithiasis is a common disease in the general population with an increased prevalence in patients with cirrhosis. While cholecystectomy is the procedure of choice for the treatment of symptomatic cholelithiasis, cirrhotics have an increased risk of complications associated with this therapy. We have found that placement of an endoscopic gallbladder stent is an alternative, less invasive treatment for cirrhotic patients with symptomatic gallbladder disease and describe our experience here.

METHODS

A retrospective medical record review of 23 patients with cirrhosis who underwent endoscopic retrograde cholangiography with gallbladder stent placement for symptomatic gallbladder disease from July 1994 to August 2004.

RESULTS

Indications for stent placement included recurrent biliary colic (56.5%), acute calculous cholecystitis (39%), acalculous cholecystitis (8.6%), and gallstone pancreatitis (8.6%). All patients experienced resolution of their symptoms following stent placement. Twenty patients (87%) were asymptomatic from 5 days to 3 years post-procedure until transplantation, death, or end of study period. Nine patients (39%) underwent liver transplantation, 5 days to 34 months after the procedure. Eleven patients are well, with ten patients awaiting liver transplantation. Three patients developed late complications and were treated successfully with antibiotics.

CONCLUSION

Endoscopic stenting of the gallbladder may be a potential treatment for symptomatic gallbladder disease in patients with cirrhosis awaiting liver transplantation, considered to be high-risk for cholecystectomy.

Cirrhosis is not a contraindication to laparoscopic surgery

BACKGROUND

Cirrhosis of the liver contributes significantly to morbidity and mortality in abdominal surgery. The proven benefits of laparoscopy seem especially applicable to patients with this complex disease. This study evaluates the safety and efficacy of laparoscopic procedures in a series of consecutively treated patients with biopsy-proven cirrhosis.

METHODS

The medical records of all patients with biopsy-proven cirrhosis undergoing laparoscopic surgery at the authors' medical center between January 2000 and December 2003 were retrospectively reviewed.

RESULTS

A total of 50 patients (27 men and 23 women) underwent 52 laparoscopic procedures. Among these 50 patients were 39 patients with Child-Pugh classification A cirrhosis, 10 with classification B, and 1 with classification C, who underwent a variety of laparoscopic procedures including cholecystectomy (n = 22), splenectomy (n = 18), colectomy (n = 4), diagnostic laparoscopy (n = 3), ventral hernia repair (n = 1), Nissen fundoplication (n = 1), Heller myotomy (n = 1), Roux-en-Y gastric bypass (n = 1), and radical nephrectomy (n = 1). There were two conversions (4%) to an open procedure. The mean operative time was 155 min. Estimated blood loss averaged 124 ml for all procedures, and 20 patients (40%) required perioperative transfusion of blood products. One patient required a single blood transfusion postoperatively because of anemia. No one experienced hepatic decompensation. Overall morbidity was 16%. There were no deaths. The mean length of hospitalization was 3 days.

CONCLUSIONS

Although technically challenging because portal hypertension, varices, and thrombocytopenia frequently coexist, basic and advanced laparoscopic procedures are safe for patients with mild to moderate cirrhosis of the liver.

Does the Complication Rate Increase in Laparoscopic Cholecystectomy for Acute Cholecystitis?

BACKGROUND

Laparoscopic cholecystectomy (LC) has replaced open cholecystectomy for the treatment of gallbladder disease. Despite the well-accepted success of LC in chronic cholecystitis, the efficacy of this technique has been subject to some debate in acute cholecystitis (AC). This study was designed to evaluate our institution's experience with LC for AC and chronic symptomatic calculous cholecystitis (CC), based on complication and conversion rates to open surgery.

PATIENTS AND METHODS

The records of 1158 patients with LC from September 1991 to December 2001 were analyzed. The parameters of age, gender, early and late complication rates, and conversion rates from LC to open cholecystectomy were compared in patients with AC and CC.

RESULTS

During the study period, LC was performed in 1158 patients. Of these, 162 patients had AC (group 1) and 996 patients had CC (group 2). The conversion rates were 4.3% (7/162) in group 1 and 2.4% (24/996) in group 2. The complication rates were not significantly different (5.6% in group 1, 5.1% in group 2, P > 0.05). Difficulty in dissection around Calot's triangle and obscure anatomy were the main reasons for conversion to conventional open surgery. The mortality rate was 1.2% in group 1 and 0.01% in group 2.

CONCLUSION

LC appears to be a reliable, safe, and effective treatment modality for AC and CC. The surgical approach should be performed carefully because of the spectrum of potential hazards of the laparoscopic procedure. Conversion and complication rates are similar in both AC and CC groups, and improve as surgeons gain experience.

A metaanalysis of laparoscopic cholecystectomy in patients with cirrhosis

BACKGROUND

Few articles address the issue of LC in patients with cirrhosis. Existing articles are retrospective and with small sample sizes, which makes it difficult to draw conclusions about indications and complications with LC in this setting.

STUDY DESIGN

An extensive search of the Medline, Embase, and Cochrane databases using the terms "laparoscopic cholecystectomy" and "cirrhosis" or "cirrhotic" was conducted. The data from each study were extracted, combined with those of similar studies, and analyzed.

RESULTS

Twenty-five publications (400 patients with cirrhosis undergoing LC) from 1993 to 2001 were identified. Four articles compared LC with open cholecystectomy in patients with cirrhosis, and six compared patients with cirrhosis to patients without cirrhosis. Patients were primarily in Child-Pugh class A or B, with only six patients in Child-Pugh class C. Compared with patients without cirrhosis, patients with cirrhosis had higher conversion rates (7.06% versus 3.64%, p = 0.024), operative times (98.2 minutes versus 70 minutes, p = 0.005), bleeding complications (26.4% versus 3.1%, p < 0.001), and overall morbidity (20.86% versus 7.99%, p < 0.001). Acute cholecystitis was evident in 47% of patients with cirrhosis versus 14.7% of patients without cirrhosis (p < 0.001). When LC was compared with open cholecystectomy in patients with cirrhosis, LC was associated with less operative blood loss (113 mL versus 425.2 mL, p = 0.015), operative time (123.3 minutes versus 150.2 minutes, p < 0.042), and length of hospital stay (6 days versus 12.2 days, p < 0.001).

CONCLUSIONS

Patients with cirrhosis undergo cholecystectomies for more emergent reasons and have higher morbidity. The laparoscopic approach offers advantages of less blood loss, shorter operative time, and shorter length of hospitalization in patients with cirrhosis. Prospective studies will establish which factors affect outcomes and determine the appropriateness of LC in Child's-Pugh class C cirrhosis.

Laparoscopic cholecystectomy in cirrhotic patients

BACKGROUND

This study aimed to evaluate the safety of laparoscopic cholecystectomy for patients with cirrhosis.

METHODS

The records of 22 laparoscopic cholecystectomies performed in patients with cirrhosis Child-Pugh A and B, from January 1995 to July 2001 were retrospectively reviewed.

RESULTS

No deaths occurred. Conversion to open cholecystectomy was necessary in two cases. The average operative time was 115 min, which was significantly shorter than that for patients undergoing open cholecystectomy. None of the patients required blood transfusion. Intraoperative problems occurred in two patients who experienced liver bed bleeding. Postoperative morbidity occurred in 36% of the patients and included hemorrhage, wound complications, intraabdominal collections, and cardiopulmonary complications, but all were controlled. The patients were dismissed after an average of 4 days.

CONCLUSION

The authors believe laparoscopic cholecystectomy can be performed safely in selected patients with cirrhosis Child-Pugh A and B who manifest indication for surgery. Laparoscopic cholecystectomy offers several advantages over open cholecystectomy: lower morbidity, shorter operative time, and reduced hospital stay.

Surgery in the patient with liver disease

Management of the surgical patient with liver disease begins with a careful preoperative assessment (Fig. 1). Any clues to liver disease on history and physical examination should be investigated to ascertain the cause of the clinical finding. More data on surgical patients with unexpected liver disease are now available. Patients undergoing emergent surgery are at significant risk of developing liver dysfunction. Child's class still correlates strongly to postoperative complications. Cornerstones of perioperative management in these patients are medical treatment of complications of chronic liver disease, such as ascites; coagulopathy; prevention of encephalopathy; and rapid treatment of dangerous postoperative complications, such as acute acalculous cholecystitis. Evolving knowledge of the effects of anesthesia, improving surgical techniques, and use of better diagnostic tests will help in the reduction of perioperative complications in these patients.

Laparoscopic cholecystectomy in cirrhotic patients

Since 1992, laparoscopic cholecystectomy has been the treatment of choice for symptomatic gallstones. The advantages of laparoscopic cholecystectomy for most patients have been extensively published. However, its benefits and successful use in patients with cirrhosis are less well documented. The aim of this study was to determine the efficacy and safety of laparoscopic cholecystectomy in cirrhotic patients. We did a retrospective review of the records of 26 consecutive laparoscopic cholecystectomy procedures performed on cirrhotic patients between January 1992 and September 2000. Twenty-two patients were classified as having Child's class A cirrhosis, and 4 patients were classified as having Child's class B. No patients were classified as having Child's class C cirrhosis. There were 20 men and 6 women, with a mean age of 57 years (range, 37-76). All procedures were completed laparoscopically. There was histologic confirmation of cirrhosis in all patients. The mean operative time was 126 minutes (range, 60-184). The mean estimated blood loss was 110 mL (range, 40-380). Complications occurred in 7 patients (27%). No operative mortality occurred in this study. The mean length of hospital stay was 5 days (range, 3-14). Our results and the results of others show that laparoscopic cholecystectomy in cirrhotic patients seems to be safe in selected Child-Pugh class A and B patients with compensated cirrhosis. Cholecystectomy remains a high-risk procedure in cirrhotic patients, and indications for cholecystectomy should be evaluated carefully. Controlled trials are required to confirm the safety of this procedure, and further studies are also required to evaluate the management of gallbladder disease in patients with Child-Pugh class C cirrhosis.

Laparoscopic cholecystectomy in cirrhosis: contraindication or privileged indication?

Until recently, cirrhosis has been considered to be an absolute or relative contraindication of laparoscopic cholecystectomy. An evaluation of benefits and risks of laparoscopic cholecystectomy in the treatment of gall bladder lithiasis in cirrhotic patients is presented. Thirty-three consecutive laparoscopic cholecystectomies in patients with cirrhosis were performed between March 1990 and March 1997. During the same period, no open cholecystectomy was performed in patients with cirrhosis. There was no morbidity or mortality; the conversion rate was 6% (2/33). No patient received blood transfusion, and the mean hospital stay was 2.8 days. These results favorably compare with the results of open cholecystectomy. Specific advantages of laparoscopic cholecystectomy in patients with cirrhosis include the absence of wound infection and a lower rate of postoperative hepatic failure. Finally, laparoscopic surgery reduces the risk of viral contamination (the hepatitis B virus, the hepatitis C virus, or the human immunodeficiency virus) of the surgical staff.