Ultrasonic Versus Standard Electric Dissection in Laparoscopic Cholecystectomy in Patients with Acute Calculous Cholecystitis, Complicated by Peritonitis: Influence on the Postoperative Systemic Inflammation and Immune Response. A Prospective Randomized Study

Use of High Energy Devices (HEDs) versus electrocautery for laparoscopic cholecystectomy: a systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

According to the literature, there is no clear definition of a High Energy Devices (HEDs), and their proper indications for use are also unclear. Nevertheless, the flourishing market of HEDs could make their choice in daily clinical practice arduous, possibly increasing the risk of improper use for a lack of specific training. At the same time, the diffusion of HEDs impacts the economic asset of the healthcare systems. This study aims to assess the efficacy and safety of HEDs compared to electrocautery devices while performing laparoscopic cholecystectomy (LC).

MATERIALS AND METHODS

On behalf of the Italian Society of Endoscopic Surgery and New Technologies, experts performed a systematic review and meta-analysis and synthesised the evidence assessing the efficacy and safety of HEDs compared to electrocautery devices while performing laparoscopic cholecystectomy (LC). Only randomised controlled trials (RCTs) and comparative observational studies were included. Outcomes were: operating time, bleeding, intra-operative and post-operative complications, length of hospital stay, costs, and exposition to surgical smoke. The review was registered on PROSPERO (CRD42021250447).

RESULTS

Twenty-six studies were included: 21 RCTs, one prospective parallel arm comparative non-RCT, and one retrospective cohort study, while three were prospective comparative studies. Most of the studies included laparoscopic cholecystectomy performed in an elective setting. All the studies but three analysed the outcomes deriving from the utilisation of US sources of energy compared to electrocautery. Operative time was significantly shorter in the HED group compared to the electrocautery group (15 studies, 1938 patients; SMD - 1.33; 95% CI - 1.89 to 0.78; I2 = 97%, Random-effect). No other statistically significant differences were found in the other examined variables.

CONCLUSIONS

HEDs seem to have a superiority over Electrocautery while performing LC in terms of operative time, while no difference was observed in terms of length of hospitalisation and blood loss. No concerns about safety were raised.

Ultrasonic versus electrosurgical device for laparoscopic cholecystectomy: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Ultrasonic and electrosurgical energy dissectors are main dissecting devices widely used for the laparoscopic cholecystectomy. Trial sequential analyses can establish whether firm evidence favoring a specific device has been reached from accumulated literature. To explore this, we performed a meta-analysis and trial sequential analyses.

METHODS

PubMed, Embase, and the Cochrane Library were searched from inception to October 2016. The primary outcome was operative time. The secondary outcomes included adverse events during operation, postoperative complications, intra-abdominal collection, hospital stay, hospital costs, and sick leave or time to full recovery. Relative risks (RRs) were calculated for dichotomous outcomes and mean differences (MDs) for continuous outcomes. Finally, we calculated numbers needed to treat to examine benefits of the ultrasonic device.

RESULTS

We identified 19 studies. Compared with the electrosurgical device, the ultrasonic device led to shorter operative time (MD, -14.86; 95% confidence interval (CI), -21.45 to -8.27; P < 0.00001), less blood loss (MD, -47.24; 95% CI, -79.57 to -14.90; P = 0.004), fewer gallbladder perforations (RR, 0.45; 95% CI, 0.35 to 0.57; P < 0.00001), shorter hospital stay (MD, -0.37; 95% CI, -0.61 to -0.14; P = 0.002), and fewer abdominal pains (MD, -0.95; 95% CI, -1.40 to -0.50; P < 0.0001). The trial sequential analysis demonstrated that the cumulative z-curve crossed the trial sequential monitoring and reached the required information size of the operative time. The numbers needed to treat to avoid one gallbladder perforation and postoperative nausea, respectively, were 7 and 15.

CONCLUSIONS

Compared with the electrosurgery device, the ultrasonic device could be superior with more clinical effectiveness. The trial sequential analysis demonstrated that further studies about the operative time were not needed.

[Types of immune response in advanced suppurative peritonitis]

AIM

to assess types of immune response in patients with advanced suppurative peritonitis and course of disease.

MATERIAL AND METHODS

We examined 79 patients with acute surgical abdominal diseases and injuries complicated by advanced suppurative peritonitis. Blood immunological parameters were estimated using flowing cytometry and enzyme immunoassay.

RESULTS

It was concluded that functional parameters of immune system are very various in patients with advanced suppurative peritonitis. Cluster analysis defined 4 immune types which are determined by different state of congenital and acquired immunity. Immunodeficient and unreactive immune types are unfavorable. Immune types with activation of congenital and acquired immunity are the most favourable. This stratification personifies diagnosis and treatment of immune disorders in patients with advanced suppurative peritonitis.

Cholecystectomy is associated with higher risk of early recurrence and poorer survival after curative resection for early stage hepatocellular carcinoma

Although cholecystectomy has been reported to be associated with increased risk of developing hepatocellular carcinoma (HCC), the association between cholecystectomy and prognosis of HCC patients underwent curative resection has never been examined. Through retrospective analysis of the data of 3933 patients underwent curative resection for HCC, we found that cholecystectomy was an independent prognostic factor for recurrence-free survival (RFS) of patients at early stage (BCLC stage 0/A) (p = 0.020, HR: 1.29, 95% CI: 1.04-1.59), and the 1-, 3-, 5-year RFS rates for patients at early stage were significantly worse in cholecystectomy group than in non-cholecystectomy group (80.5%, 61.8%, 52.0% vs 88.2%, 68.8%, 56.8%, p = 0.033). The early recurrence rate of cholecystectomy group was significantly higher than that of non-cholecystectomy group for patients at early stage (59/47 vs 236/333, p = 0.007), but not for patients at advanced stage (BCLC stage C) (p = 0.194). Multivariate analyses showed that cholecystectomy was an independent risk factor for early recurrence (p = 0.005, HR: 1.52, 95% CI: 1.13-2.03) of early stage HCC, but not for late recurrence (p = 0.959). In conclusion, cholecystectomy is an independent predictor for early recurrence and is associated with poorer RFS of early stage HCC. Removal of normal gallbladder during HCC resection may be avoided for early stage patients.