Contemporary minimally invasive approaches to the management of acute cholecystitis: a review and appraisal

Early laparoscopic cholecystectomy in severely comorbid patients with acute cholecystitis: results of a monocentric study

Aim: The aim is to evaluate laparoscopic cholecystectomy safety based on American Society of Anesthesiologists score for acute cholecystitis in patients with comorbidities. Patients & methods: This is retrospective study of patients who underwent laparoscopic cholecystectomy for acute cholecystitis between 2003 and 2021. According to their respective ASA-score, patients were divided into group 1: ASA1-2 and group 2: ASA3-4. Results: We collected 578 patients. Even though the gangrenous forms were more frequent and the operative time was longer in group 2, laparoscopic cholecystectomy seems safe and effective. We didn't observe any differences in terms of intraoperative incidents, open conversion rate, or postoperative complications compared with other patients. Conclusion: ASA3-4 patients with acute cholecystitis don't face elevated risks of complications or mortality during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy in the treatment of acute cholecystitis: comparison of results between early and late cholecystectomy

Introduction

Laparoscopic cholecystectomy has become the gold standard in the treatment of symptomatic gallstones. The common opinion about treatment of acute cholecystitis is initially conservative treatment due to preventing complications of inflamation and following laparoscopic cholecystectomy after 6- 8 weeks. However with the increase of laparoscopic experience in recent years, early laparoscopic cholecystectomy has become more common.

Methods

We aimed to compare the outcomes of the patients to whom we applied early or late cholecystectomy after hospitalization from the emergency department with the diagnosis of AC between March 2012-2015.

Results

We retrospectively reviewed the files of totally 66 patients in whom we performed early cholecystectomy (within the first 24 hours) (n: 33) and to whom we firstly administered conservative therapy and performed late cholecystectomy (after 6 to 8 weeks) (n: 33) after hospitalization from the emergency department with the diagnosis of acute cholecystitis. The groups were made up of patients who had similar clinical and demographic characteristics. While there were no statistically significant differences between the durations of operation, the durations of hospitalization were longer in those who underwent early cholecystectomy. Moreover, more complications were seen in the patients who underwent early cholecystectomy although the difference was not statistically significant.

Conclusion

Early cholecystectomy is known to significantly reduce the costs in patients with acute cholecystitis. However, switching to open surgery as well as increase of complications in patients who admitted with severe inflammation attack and who have high comorbidity, caution should be exercised when selecting patients for early operation.

Evaluation of Early versus Delayed Laparoscopic Cholecystectomy in Acute Cholecystitis

Background. The role of early laparoscopic cholecystectomy for acute cholecystitis with cholelithiasis is not yet established. The aim of our prospective randomized study was to evaluate the safety and feasibility of early LC for acute cholecystitis and to compare the results with delayed LC. Methods. Between March 2007 to December 2008, 50 patients with diagnosis of acute cholecystitis were assigned randomly to early group, n = 25 (LC within 24 hrs of admission), and delayed group, n = 25 (initial conservative treatment followed by delayed LC, 6-8 weeks later). Results. We found in our study that the conversion rate in early LC and delayed LC was 16% and 8%, respectively, Operation time for early LC was 69.4 min versus 66.4 min for delayed LC, postoperative complications for early LC were 24% versus 8% for delayed LC, and blood loss was 159.6 mL early group versus 146.8 mL for delayed group. However early LC had significantly shorter hospital stay (4.1 days versus 8.6 days). Conclusions. Early LC for acute cholecystitis with cholelithiasis is safe and feasible, offering the additional benefit of shorter hospital stay. It should be offered to the patients with acute cholecystitis, provided that the surgery is performed within 96 hrs of acute symptoms by an experienced surgeon.

Evaluation of affecting factors for conversion to open cholecystectomy in acute cholecystitis

INTRODUCTION

Laparoscopic cholecystectomy has become the gold standard for the surgical treatment of gallbladder disease. Severe inflammation makes laparoscopic dissection technically more demanding in acute cholecystitis. Conversion to open cholecystectomy due to adverse conditions is still required in some patients.

AIM

To evaluate predictive risk factors associated with conversion to open cholecystectomy in acute cholecystitis.

MATERIAL AND METHODS

A retrospective analysis was performed on 165 patients who underwent a laparoscopic cholecystectomy for acute cholecystitis in our clinic. Patients who completed laparoscopic cholecystectomy and required conversion to open cholecystectomy were compared in terms of age, sex, fever, laboratory and USG findings, operation timing, complications, and duration of hospital stay.

RESULTS

There were 53 (32%) male and 112 (68%) female patients; the mean age was 52.4 ±12.5 years. Forty-six (27.9%) of the 165 patients were converted to open cholecystectomy. Male sex of the patients who underwent conversion (47.1%) was found to be statistically significant (p < 0.001). Preoperative white blood count, blood glucose and amylase values, morbidity rate, and hospital stay were raised in patients who underwent conversion, and all were found to be statistically significant (p < 0.05).

CONCLUSIONS

Male sex, blood leucocyte, glucose, and raised amylase emerged as the effective factors for conversion cholecystectomy in our study. These factors should help the clinical decision-making process when planning laparoscopic cholecystectomy in acute cholecystitis. By predicting these risk factors for conversion, preoperative patient counselling can be improved.

Determination of optimal operation time for the management of acute cholecystitis: a clinical trial

INTRODUCTION

Although all studies have reported that laparoscopic cholecystectomy (LC) is a safe and effective treatment for acute cholecystitis, the optimal timing for the procedure is still the subject of some debate.

AIM

This retrospective analysis of a prospective database was aimed at comparing early with delayed LC for acute cholecystitis.

MATERIAL AND METHODS

The LC was performed in 165 patients, of whom 83 were operated within 72 h of admission (group 1) and 82 patients after 72 h (group 2) with acute cholecystitis between January 2012 and August 2013. All data were collected prospectively and both groups compared in terms of age, sex, fever, white blood count count, ultrasound findings, operation time, conversion to open surgery, complications and mean hospital stay.

RESULTS

The study included 165 patients, 53 men and 112 women, who had median age 54 (20-85) years. The overall conversion rate was 27.9%. There was no significant difference in conversion rates (21% vs. 34%) between groups (p = 0.08). The operation time (116 min vs. 102 min, p = 0.02) was significantly increased in group 1. The complication rates (9% vs. 18%, p = 0.03) and total hospital stay (3.8 days vs. 7.9 days, p = 0.001) were significantly reduced in group 1.

CONCLUSIONS

Early LC within 72 h of admission reduces complications and hospital stay and is the preferred approach for acute cholecystitis.

Determination of optimal operation time for the management of acute cholecystitis: a clinical trial

Introduction

Although all studies have reported that laparoscopic cholecystectomy (LC) is a safe and effective treatment for acute cholecystitis, the optimal timing for the procedure is still the subject of some debate.

Aim

This retrospective analysis of a prospective database was aimed at comparing early with delayed LC for acute cholecystitis.

Material and methods

The LC was performed in 165 patients, of whom 83 were operated within 72 h of admission (group 1) and 82 patients after 72 h (group 2) with acute cholecystitis between January 2012 and August 2013. All data were collected prospectively and both groups compared in terms of age, sex, fever, white blood count count, ultrasound findings, operation time, conversion to open surgery, complications and mean hospital stay.

Results

The study included 165 patients, 53 men and 112 women, who had median age 54 (20–85) years. The overall conversion rate was 27.9%. There was no significant difference in conversion rates (21% vs. 34%) between groups (p = 0.08). The operation time (116 min vs. 102 min, p = 0.02) was significantly increased in group 1. The complication rates (9% vs. 18%, p = 0.03) and total hospital stay (3.8 days vs. 7.9 days, p = 0.001) were significantly reduced in group 1.

Conclusions

Early LC within 72 h of admission reduces complications and hospital stay and is the preferred approach for acute cholecystitis.

Management of acute cholecystitis: prevalence of percutaneous cholecystostomy and delayed cholecystectomy in the elderly

BACKGROUND

Published guidelines recommend early cholecystectomy for acute cholecystitis in the elderly. Alternatively, percutaneous cholecystostomy can be used in compromised patients.

METHODS

We reviewed 806 elderly patients diagnosed with biliary disease retrospectively identified through billing and diagnosis codes. Two hundred sixty-five patients with histologically documented acute cholecystitis were selected.

RESULTS

Initially, 75 patients had percutaneous cholecystostomy (Group 1), 64 (24 % underwent interval cholecystectomy, 74 (28 %) early (Group 2), and 127 (48 %) delayed cholecystectomy (Group 3). Group 1 was more likely to have American Society of Anesthesiologists (ASA) scores of 4 when compared to those in Groups 2 and 3 (p = 0.04). No difference existed among the groups when patients with an ASA of 4 were excluded: conversion rates (11 %), biliary leak, bowel injury, need for reoperation, or 30 days mortality. Patients in Group 1 and in Group 3 were five times (p = 0.04) and four times (p = 0.06) more likely, respectively, than those in Group 2 to have recurrent episodes of pancreatitis, cholecystitis, and cholangitis.

CONCLUSION

Patients were more likely to have delayed cholecystectomy after initial antibiotic therapy or cholecystostomy without the benefit of a lower conversion rate when compared to the early group, but they had higher recurrent episodes of cholecystitis/pancreatitis or cholangitis.

Advantages of early cholecystectomy in clinical practice of a terciary care center

BACKGROUND

Despite a number of studies show the superiority of early over delayed cholecystectomy in the treatment of acute cholecystitis, there is still controversy over the time for intervention. This study aimed to assess the use of early versus delayed cholecystectomy for the treatment of acute cholecystitis in terms of complications, conversion to open surgery and mean hospital stay.

METHOD

We collected patients with acute cholecystitis treated at a referral center for a year, and retrospectively analyzed the chosen therapeutic approach, the percentage of conversion of early cholecystectomy to open surgery, appearance of surgical complications, and mean hospital stay.

RESULTS

The study included 117 patients, 44 women and 73 men, who had a mean age of 67.36+/-15.74 years. Early cholecystectomy was chosen in 31 (26.5%) and delayed cholecystectomy in 74 patients (63.2%). Of the 74 patients, 28 (37.8%) required emergency performance of delayed cholecystectomy, and 19 (25.7%) had not undergone surgery by the end of the study. While no differences were observed between early and delayed cholecystectomy in terms of surgical complications and conversion to open surgery, mean hospital stay was nevertheless significantly shorter in the early versus the delayed cholecystectomy group (8.32+/-4.98 vs 15.96+/-8.89 days).

CONCLUSION

Under the routine working conditions of a hospital that is neither specially dedicated to the surgical treatment of acute cholecystitis nor provided with specific management guidelines, early cholecystectomy can reduce the hospital stay without increase of the conversion rate or complications.

Laparoscopic Treatment for Esophageal Achalasia and Gastro-Esophago-reflex Disease Using Radius Surgical System

Radius surgical system (RSS) is a manual manipulator to enhance the surgeon's dexterity and ergonomy achieving more degrees of freedom, and it enables us easy to perform intracorporeal suturing in laparoscopic surgery. We successfully performed laparoscopic treatment including intracorporeal suturing in cases of esophageal achalasia and gastroesophageal reflux disease using RSS. RSS may facilitate of intracorporeal suturing and knotting in complex laparoscopic procedures.

Open cholecystectomy in the laparoscopic era

INTRODUCTION

As techniques in laparoscopic cholecystectomy have improved, surgeon experience of open cholecystectomy may be limited. This study examined the current indications for and techniques used in primary open cholecystectomy.

METHODS

Some 3100 consecutive patients undergoing elective or emergency cholecystectomy over a 5-year interval were identified from a prospective surgical audit database. Demographic, diagnostic and procedural data were examined.

RESULTS

There were 123 (4.0 per cent) primary and 219 (7.4 per cent) converted open cholecystectomies. Some 48.0 and 45.6 per cent of patients in the primary open cholecystectomy and converted groups respectively were men, compared with 24.0 per cent of 2758 who had a successful laparoscopic procedure. Primary open cholecystectomy was employed principally for previous upper abdominal open surgery (22.7 per cent) and emergency operation for general peritonitis (19.5 per cent). The fundus-first approach was employed in 53.7 per cent of primary open procedures and 53.0 per cent of conversions, with subtotal excision in 4.9 and 13.2 per cent respectively.

CONCLUSION

Primary open cholecystectomy remains a common procedure in the treatment of gallbladder disease despite the success of laparoscopic cholecystectomy. Successful outcome in difficult cases requires familiarity with specific techniques, exposure to which may be limited in current training programmes.

Perioperative fluorocholangiography with routine indication versus selective indication in laparoscopic cholecystectomy

BACKGROUND: The use of routine or selective peroperatory cholangiography in cholecystectomy is a matter of controversy in literature. AIM: To compare the efficacy of selective or routine fluorocholangiography in diagnostic of common bile duct stone in patients underwent to laparoscopic cholecystectomy based on selective indication criteria. METHOD: Two hundred and fifty four patients with cholelithiasis were prospectively studied. The patients were divided in two groups: to the first 127 patients perioperative fluorocholangiography was indicated as routine (group 1), and to the other 127 patients perioperative fluorocholangiography indication followed clinical criteria (jaundice, choluria, fecal acholia and history of pancreatitis), laboratory criteria (increase in seric alkaline phosphatase, bilirubins, amylase) or ultra-sonographyc criteria (less than 6 mm diameter calculi, common bile duct stone, common bile duct diameter more than 6 mm). A comparative assessment of the difference in common bile duct stone diagnosis, fluorocholangiography success index and reliability of the selective criteria of indication for perioperative fluorocholangiography was compared between the two groups. RESULTS: Perioperative fluorocholangiography was successfully performed in 102 of the 127 patients from group 1 (a rate of 80.3%), and in 59 of the 71 patients from group 2 (a rate of 83.1%). In the 102 patients of group 1 who underwent perioperative fluorocholangiography, 11 (10.8%) presented common bile duct stone, 4 (3.9%) presented common bile duct dilatation, and 1 (1%) had a false-positive image. In the 59 patients from group 2, 7 (11.7%) presented common bile duct stone and one (1.7%) presented a common bile duct diatation. In another situation, when application of selective indication criteria to perioperative fluorocholangiography was simulated in group 1 patients, we observed that only in one patient with common bile duct stone the diagnostic would not have been made. Fluorocholangiography selective indication criteria presented sensitivity of 90.9% and specificity of 46.2%. The main causes of fluorocholangiography failure were biliary pedicle inflammation and cystic duct size and caliber variations. CONCLUSION: There was not a significant difference in common bile duct stone diagnostic through perioperative fluorocholangiography between the groups of patients with selective and routine indication, validating the examination selective indication criteria, with a sensitivity of 90.9%, despite the specificity of 46.2 % - 43 patients were selected to the flourocholangiography and common bile duct stone was not diagnosed.

Routine early laparoscopic cholecystectomy for acute cholecystitis after conclusion of a randomized controlled trial

Background

The aim of this retrospective review was to assess the clinical outcomes of laparoscopic cholecystectomy for acute cholecystitis since the conclusion of a randomized controlled trial in 1997.

Methods

Records of all patients admitted for acute cholecystitis in whom early laparoscopic cholecystectomy was attempted between July 1997 and December 2004 were reviewed.

Results

A total of 209 patients were recruited to this study. Forty-three surgeons performed the procedures. The conversion rate increased significantly in the early period after the trial from 21 per cent to 42 per cent (39 of 92 patients) and decreased significantly to 24 per cent (13 of 54 patients) in the later period. The proportion of operations performed by higher surgical trainees increased significantly from 17 per cent in the early period to 56 per cent in the later period. This increase was associated with a fall in conversion rate without any significant increase in duration of operation or complication rate.

Conclusion

This study has demonstrated that the results achieved in a randomized trial can be translated into clinical practice by the entire surgical unit. A structured training programme with the inclusion of an experienced surgeon assisting both trainees and specialists should minimize this learning curve.

The safety of a laparoscopic cholecystectomy in acute cholecystitis in high-risk patients older than sixty with stratification based on ASA score

The purpose of this study was to evaluate the safety of a laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) in patients older than sixty years of age, with stratification based on the ASA (American Society of Anesthesiologists) score. For five years, 137 patients older than sixty, who had undergone a LC for AC, were classified into three groups; ASA 1 (n = 33), ASA 2 (n = 79) and ASA 3 (n = 25). Preoperative percutaneous gallbladder drainage was performed in eight of the 137 cases (5.8%). All except one underwent one-stage management and 19.7% patients underwent emergency surgery within 24 hours of the index admission of AC. The preoperative hospital stay for ASA 3 (8.8 days) was longer than that for ASA 1 (5.6 days). There was a higher proportion of complicated cholecystitis and a longer operating time in ASA 2 (50.6%, 111 min.) and 3 (66.7 %, 114 min.) than in ASA 1 (24.2%, 85 min.) (p<0.05). Morbidity was more frequent in ASA 3 (20.0%) than in ASA 1 (9.1%). However, the open conversion rate, time to diet, and postoperative hospital stay were similar in the three groups (p>0.05). We conclude that a LC for AC may be an effective treatment option in elderly-high risk patients.

Laparoscopy for abdominal emergencies

BACKGROUND

Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment.

METHODS

A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain.

RECOMMENDATIONS

Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen.

CONCLUSIONS

Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.