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Kurauchi N, Mori Y, Nakamura Y, Tokumura H. Gallbladder and common bile duct. Asian J Endosc Surg 2024; 17:e13369. [PMID: 39278638 DOI: 10.1111/ases.13369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 07/20/2024] [Indexed: 09/18/2024]
Affiliation(s)
- Nobuaki Kurauchi
- Department of Surgery, Kutchan-Kosei General Hospital, Hokkaido, Japan
| | - Yasuhisa Mori
- Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyusyu, Japan
| | - Yoshiharu Nakamura
- Department of Surgery, Nippon Medical School, Chiba Hokusoh Hospital, Chiba, Japan
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Laudari U, Acharya S, Malla BR. Liver pucker sign: predictor of difficult laparoscopic cholecystectomy: a case series. Ann Med Surg (Lond) 2024; 86:2442-2445. [PMID: 38694274 PMCID: PMC11060316 DOI: 10.1097/ms9.0000000000002017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 03/16/2024] [Indexed: 05/04/2024] Open
Abstract
Introduction Pucker sign is the depression of the liver in the region of the gallbladder due to a high degree of chronic contractive inflammation of the gallbladder. It usually develops in patients who have a delayed cholecystectomy after acute cholecystitis due to a high degree of chronic contractive inflammation of the gallbladder and contraction of the cystic plate. It is an essential finding either preoperatively or intraoperatively as it can act as a stopping rule during cholecystectomy (act as a guide that cholecystectomy will be difficult). Case series The authors here report three cases of pucker sign that were incidentally discovered during laparoscopy. Discussion Chronic cholecystitis is a prolonged, subacute condition caused by inflammation of the gallbladder, which mostly occurs in the setting of cholelithiasis. Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. Hence, it would be beneficial to be aware of reliable signs that predict difficult Laparoscopic cholecystectomy. Pucker sign usually predicts increased operative difficulty as there is an operative danger of biliary or vascular injury. Conclusion The pucker sign is a novel indicator of significant persistent inflammation and heightened difficulty during surgery. It might establish a halting rule that modifies the procedure's management and raises its level of safety.
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Affiliation(s)
- Uttam Laudari
- Department of Surgery, Kathmandu University School of Medical Sciences
| | - Suyash Acharya
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel, Nepal
| | - Bala Ram Malla
- Department of Surgery, Kathmandu University School of Medical Sciences
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Hemmila MR, Neiman PU, Hoppe BL, Gerhardinger L, Kramer KA, Jakubus JL, Mikhail JN, Yang AY, Lindsey HJ, Golden RJ, Mitchell EJ, Scott JW, Napolitano LM. Improving outcomes in emergency general surgery: Construct of a collaborative quality initiative. J Trauma Acute Care Surg 2024; 96:715-726. [PMID: 38189669 PMCID: PMC11042990 DOI: 10.1097/ta.0000000000004248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Emergency general surgery conditions are common, costly, and highly morbid. The proportion of excess morbidity due to variation in health systems and processes of care is poorly understood. We constructed a collaborative quality initiative for emergency general surgery to investigate the emergency general surgery care provided and guide process improvements. METHODS We collected data at 10 hospitals from July 2019 to December 2022. Five cohorts were defined: acute appendicitis, acute gallbladder disease, small bowel obstruction, emergency laparotomy, and overall aggregate. Processes and inpatient outcomes investigated included operative versus nonoperative management, mortality, morbidity (mortality and/or complication), readmissions, and length of stay. Multivariable risk adjustment accounted for variations in demographic, comorbid, anatomic, and disease traits. RESULTS Of the 19,956 emergency general surgery patients, 56.8% were female and 82.8% were White, and the mean (SD) age was 53.3 (20.8) years. After accounting for patient and disease factors, the adjusted aggregate mortality rate was 3.5% (95% confidence interval [CI], 3.2-3.7), morbidity rate was 27.6% (95% CI, 27.0-28.3), and the readmission rate was 15.1% (95% CI, 14.6-15.6). Operative management varied between hospitals from 70.9% to 96.9% for acute appendicitis and 19.8% to 79.4% for small bowel obstruction. Significant differences in outcomes between hospitals were observed with high- and low-outlier performers identified after risk adjustment in the overall cohort for mortality, morbidity, and readmissions. The use of a Gastrografin challenge in patients with a small bowel obstruction ranged from 10.7% to 61.4% of patients. In patients who underwent initial nonoperative management of acute cholecystitis, 51.5% had a cholecystostomy tube placed. The cholecystostomy tube placement rate ranged from 23.5% to 62.1% across hospitals. CONCLUSION A multihospital emergency general surgery collaborative reveals high morbidity with substantial variability in processes and outcomes among hospitals. A targeted collaborative quality improvement effort can identify outliers in emergency general surgery care and may provide a mechanism to optimize outcomes. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Mark R. Hemmila
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Pooja U. Neiman
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- National Clinical Scholars Program, University of Michigan, Ann Arbor, MI
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Beckie L. Hoppe
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Laura Gerhardinger
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Kim A. Kramer
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Jill L. Jakubus
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Judy N. Mikhail
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Amanda Y. Yang
- Department of Surgery, Corewell Health, Grand Rapids, MI
| | | | - Roy J. Golden
- Department of Surgery, Trinity Health Ann Arbor, Ann Arbor, MI
| | - Eric J. Mitchell
- Department of Surgery, University of Michigan Health - West, Wyoming, MI
| | - John W. Scott
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Lena M. Napolitano
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
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Zhang C, Guo D, Lv G, Lin F, Wang Q, Lin J, Xiao D, Wang R, Gong Q. Application of 3-Step Laparoscopic Cholecystectomy in Acute Difficult Cholecystitis. Surg Laparosc Endosc Percutan Tech 2024; 34:201-205. [PMID: 38571322 DOI: 10.1097/sle.0000000000001272] [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: 06/14/2023] [Accepted: 11/09/2023] [Indexed: 04/05/2024]
Abstract
BACKGROUND With the aging of the global population, the incidence rate of acute cholecystitis is increasing. Laparoscopic cholecystectomy is considered as the first choice to treat acute cholecystitis. How to effectively avoid serious intraoperative complications such as bile duct and blood vessel injury is still a difficult problem that puzzles surgeons. This paper introduces the application of laparoscopic cholecystectomy, a new surgical concept, in acute difficult cholecystitis. METHODS This retrospective analysis was carried out from January 2019 to January 2021. A total of 36 patients with acute difficult cholecystitis underwent 3-step laparoscopic cholecystectomy. The general information, clinical features, surgical methods, surgical results, and postoperative complications of the patients were analyzed. RESULTS All patients successfully completed the surgery, one of them was converted to laparotomy, and the other 35 cases were treated with 3-step laparoscopic cholecystectomy. Postoperative bile leakage occurred in 2 cases (5.56%), secondary choledocholithiasis in 1 case (2.78%), and hepatic effusion in 1 case (2.78%). No postoperative bleeding, septal infection, and other complications occurred, and no postoperative colon injury, gastroduodenal injury, liver injury, bile duct injury, vascular injury, and other surgery-related complications occurred. All 36 patients were discharged from hospital after successful recovery. No one died 30 days after surgery, and there was no abnormality in outpatient follow-up for 3 months after surgery. CONCLUSIONS Three-step laparoscopic cholecystectomy seems to be safer and more feasible for acute difficult cholecystitis patients. Compared with traditional laparoscopic cholecystectomy or partial cholecystectomy, 3-step laparoscopic cholecystectomy has the advantages of safe surgery and less complications, which is worth trying by clinicians.
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Affiliation(s)
- Chun Zhang
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
- Shengli Clinical Medical College of Fujian Medical University
| | - Dengfang Guo
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Guifang Lv
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Feng Lin
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Qinglin Wang
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Jianyuan Lin
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Dexian Xiao
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Ruotao Wang
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
| | - Qingquan Gong
- Department of General Surgery, Mindong Hospital Affiliated to Fujian Medical University, Ningde
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Lee KJ, Park SW, Park DH, Cha HW, Choi A, Koh DH, Lee J, Lee JM, Park CH. Gallbladder perforation in acute acalculous vs. calculous cholecystitis: a retrospective comparative cohort study with 10-year single-center experience. Int J Surg 2024; 110:1383-1391. [PMID: 38079596 PMCID: PMC10942242 DOI: 10.1097/js9.0000000000000994] [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] [Received: 09/04/2023] [Accepted: 11/27/2023] [Indexed: 03/16/2024]
Abstract
BACKGROUND Gallstones are a well-known risk factor for acute cholecystitis. However, their role as a risk factor for gallbladder perforation (GBP) remains unclear. Therefore, this study aimed to determine the effect of gallstones on the development of GBP. MATERIALS AND METHODS This large-scale retrospective cohort study enroled consecutive patients who underwent cholecystectomy for acute cholecystitis. The primary endpoint was the role of gallstones as a risk factor for developing GBP. Secondary endpoints included the clinical characteristics of GBP, other risk factors for GBP, differences in clinical outcomes between patients with acalculous cholecystitis (AC) and calculous cholecystitis (CC), and the influence of cholecystectomy timing. RESULTS A total of 4497 patients were included in this study. The incidence of GBP was significantly higher in the AC group compared to the CC group (5.6% vs. 1.0%, P <0.001). However, there were no differences in ICU admission and hospital stay durations. The incidence of overall complications was significantly higher in the AC group than in the CC group (2.2% vs. 1.0%, P <0.001). Patients with AC had a higher risk of developing GBP than those with CC (odds ratio, 5.00; 95% CI, 2.94-8.33). In addition, older age (≥60 years), male sex, comorbidities, poor performance status, and concomitant acute cholangitis were associated with the development of GBP. Furthermore, the incidence of GBP was significantly higher in the delayed cholecystectomy group than in the early cholecystectomy group (2.0% vs. 0.9%, P <0.001). CONCLUSIONS AC is a significant risk factor for GBP. Furthermore, early cholecystectomy can significantly reduce GBP-related morbidity and mortality.
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Affiliation(s)
| | | | | | | | | | | | - Jin Lee
- Department of Internal Medicine
| | - Jung Min Lee
- Department of Surgery, Hallym University Dongtan Sacred Heart Hospital, Hallym University, Hwaseong
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University, Guri, Republic of Korea
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Mishima K, Fujiyama Y, Wakabayashi T, Tsutsui A, Okamoto N, Marescaux J, Kitagawa Y, Wakabayashi G. Combining preoperative C-reactive protein values with the Tokyo Guidelines 2018 grading criteria can enhance the prediction of surgical difficulty in early laparoscopic cholecystectomy for acute cholecystitis. HPB (Oxford) 2024; 26:426-435. [PMID: 38135551 DOI: 10.1016/j.hpb.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/23/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Early laparoscopic cholecystectomy (ELC) is the standard treatment for acute cholecystitis (AC). However, predicting the difficulty of this procedure remains challenging. The present study aimed to develop an improved prediction model for surgical difficulty during ELC, surpassing the current Tokyo Guidelines 2018 (TG18) grading system. METHODS We analyzed data from 201 consecutive patients who underwent ELC for AC between 2019 and 2021. Surgical difficulty was defined as the failure to achieve the critical view of safety (non-CVS). We developed a scoring system by conducting multivariate analysis on demographics, symptoms, laboratory data, and radiographic findings. The predictive accuracy of our scoring system was compared to that of the TG18 grading system (Grade I vs. Grade II/III). RESULTS Through multivariate logistic regression analysis, a novel scoring system was formulated. This system incorporated preoperative C-reactive protein (CRP) values (≥5: 1 pt, ≥10: 2 pts, ≥15: 3 pts) and TG18 grading score (duration >72 h: 1 pt, image criteria for Grade II AC: 1 pt). Our model, a cutoff score of ≥3, exhibited a significantly elevated area under the curve (AUC) of 0.721 compared to the TG18 grading system alone (AUC 0.609) (p = 0.001). CONCLUSION Combining preoperative CRP values with TG18 grading criteria can enhance the accuracy of predicting intraoperative difficulty in ELC for AC.
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Affiliation(s)
- Kohei Mishima
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan; Department of Surgery, Keio University School of Medicine, Tokyo, Japan; Research Institute against Digestive Cancer (IRCAD), Strasbourg, France.
| | - Yoshiki Fujiyama
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Taiga Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Atsuko Tsutsui
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Nobuhiko Okamoto
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Jacques Marescaux
- Research Institute against Digestive Cancer (IRCAD), Strasbourg, France
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
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Woong Choi JD, John Fong M, Shanmugalingam A, Aslam A, Aqeel Abbas Kazmi S, Kulkarni R, James Curran R. Safe postoperative outcomes following early cholecystectomy for acute calculus cholecystitis regardless of symptom onset. Turk J Surg 2023; 39:321-327. [PMID: 38694534 PMCID: PMC11057926 DOI: 10.47717/turkjsurg.2023.6165] [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: 07/05/2023] [Accepted: 12/06/2023] [Indexed: 05/04/2024]
Abstract
Objectives There is growing evidence for reduced post-operative complications, and lower hospital costs associated with early cholecystectomy for acute calculus cholecystitis (AC) compared to delayed surgery. Limited high-quality evidence exists for how early, if at all, should surgeons be operating emergently for AC based on symptom onset. Material and Methods Seven hundred seventy-four patients who had cholecystectomy performed by a single surgeon between January 2015-October 2022 were retrospectively reviewed. Five hundred fourty-one patients were analysed. Patients were divided into three groups based on symptom onset: Group 1: 0-72 hours (n= 305), Group 2: 72 hrs-1 week (n= 154) and Group 3: >1 week (n= 82). Results Median operative time was most prolonged in Group 2 (96.5 minutes), and had the greatest proportion of reconstituting 95% cholecystectomies (n= 22/154, 14.29%) compared to Group 1 (p> 0.05). The conversion to open was between 0.65-1.64% in all groups. The greatest proportion of bile leak occurred in Group 1 (n= 7/305, 2.3%) followed by Group 3 (n= 1/82, 1.22%) (p> 0.05). All were successfully managed with ERCP and biliary stent. Median hospital stay was significantly prolonged in Group 2 (2.3 days) compared to Group 1 (2 days) (p= 0.03). The proportion of 95% cholecystectomies in Group 2 and 3 were not significant compared to Group 1. Conclusion Early cholecystectomy for calculus cholecystitis, irrespective of the timing of symptoms appears to have safe postoperative outcomes. Surgeons do not necessarily need to limit early cholecystectomy for within 72 hours of symptom onset.
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Affiliation(s)
- Joseph Do Woong Choi
- Department of Surgery, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia
- Discipline of Surgery, University of Sydney Faculty of Medicine and Health, New South Wales, Australia
| | - Matthew John Fong
- Department of Surgery, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia
| | - Aswin Shanmugalingam
- Department of Surgery, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia
| | - Anoosha Aslam
- Department of Surgery, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia
| | - Syed Aqeel Abbas Kazmi
- Department of Surgery, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia
| | - Rukmini Kulkarni
- Department of Surgery, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia
| | - Richard James Curran
- Department of Surgery, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia
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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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Nve E, Badia JM, Amillo-Zaragüeta M, Juvany M, Mourelo-Fariña M, Jorba R. Early Management of Severe Biliary Infection in the Era of the Tokyo Guidelines. J Clin Med 2023; 12:4711. [PMID: 37510826 PMCID: PMC10380792 DOI: 10.3390/jcm12144711] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 06/28/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
Sepsis of biliary origin is increasing worldwide and has become one of the leading causes of emergency department admissions. The presence of multi-resistant bacteria (MRB) is increasing, and mortality rates may reach 20%. This review focuses on the changes induced by the Tokyo guidelines and new concepts related to the early treatment of severe biliary disease. If cholecystitis or cholangitis is suspected, ultrasound is the imaging test of choice. Appropriate empirical antibiotic treatment should be initiated promptly, and selection should be performed while bearing in mind the severity and risk factors for MRB. In acute cholecystitis, laparoscopic cholecystectomy is the main therapeutic intervention. In patients not suitable for surgery, percutaneous cholecystostomy is a valid alternative for controlling the infection. Treatment of severe acute cholangitis is based on endoscopic or transhepatic bile duct drainage and antibiotic therapy. Endoscopic ultrasound and other new endoscopic techniques have been added to the arsenal as novel alternatives in high-risk patients. However, biliary infections remain serious conditions that can lead to sepsis and death. The introduction of internationally accepted guidelines, based on clinical presentation, laboratory tests, and imaging, provides a framework for their rapid diagnosis and treatment. Prompt assessment of patient severity, timely initiation of antimicrobials, and early control of the source of infection are essential to reduce morbidity and mortality rates.
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Affiliation(s)
- Esther Nve
- Department of Surgery, Hospital Universitari Mútua de Terrassa, 08221 Barcelona, Spain;
- School of Medicine, Universitat Rovira i Virgili, 43003 Tarragona, Spain;
| | - Josep M. Badia
- Department of Surgery, Hospital General Granollers, School of Medicine, Universitat Internacional de Catalunya, Av Francesc Ribas 1, 08402 Granollers, Spain; (M.A.-Z.); (M.J.)
| | - Mireia Amillo-Zaragüeta
- Department of Surgery, Hospital General Granollers, School of Medicine, Universitat Internacional de Catalunya, Av Francesc Ribas 1, 08402 Granollers, Spain; (M.A.-Z.); (M.J.)
| | - Montserrat Juvany
- Department of Surgery, Hospital General Granollers, School of Medicine, Universitat Internacional de Catalunya, Av Francesc Ribas 1, 08402 Granollers, Spain; (M.A.-Z.); (M.J.)
| | - Mónica Mourelo-Fariña
- Intensive Care Unit, Complexo Hospitalario Universitario A Coruña, 15006 A Coruña, Spain;
| | - Rosa Jorba
- School of Medicine, Universitat Rovira i Virgili, 43003 Tarragona, Spain;
- Department of Surgery, Hospital Universitari de Tarragona Joan XXIII, 43005 Tarragona, Spain
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10
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Popowicz A, Enochsson L, Sandblom G. Timing of Elective Cholecystectomy After Acute Cholecystitis: A Population-based Register Study. World J Surg 2023; 47:152-161. [PMID: 36280615 PMCID: PMC9726773 DOI: 10.1007/s00268-022-06772-x] [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: 08/19/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute cholecystectomy is standard treatment for acute cholecystitis. However, many patients are still treated conservatively and undergo delayed elective surgery. The aim of this study was to determine the ideal time to perform an elective cholecystectomy after acute cholecystitis. METHODS All patients treated for acute cholecystitis in Sweden between 2006 and 2013 were identified through the Swedish Patient Register. This cohort was cross-linked with the Swedish Register for Gallstone Surgery, GallRiks, where information on surgical outcome was retrieved. The impact of the time interval after discharge from hospital to elective surgery was analysed by multivariate logistic regression adjusting for gender and age. RESULTS After exclusion of patients not subjected to surgery, not registered in GallRiks and patients treated with acute cholecystectomy, 8532 remained. This cohort was divided into six-time categories. Using the first time interval < 11 days from discharge to elective surgery as the reference category the chance of completing surgery with a minimally invasive technique was increased for all categories (p < 0.05). The risk for perioperative complication and cystic duct leakage was reduced if surgery was undertaken > 30 days after discharge (both p < 0.05). The risk for bile duct injury was significantly increased if the procedure was undertaken > 365 days after discharge (p = 0.030). The chance of completing the procedure within 100 min was not affected by time. CONCLUSION For patients undergoing elective cholecystectomy after acute cholecystitis, the safety of the procedure increases if surgery is performed more than 30 days after discharge from the primary admission.
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Affiliation(s)
- Agnieszka Popowicz
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Trauma and Emergency Surgery, Karolinska Institute, Karolinska University Hospital, SE-141 52, Solna, Stockholm, Sweden.
| | - Lars Enochsson
- grid.12650.300000 0001 1034 3451Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Gabriel Sandblom
- grid.4714.60000 0004 1937 0626Department of Clinical Science and Education, Department of Surgery, Södersjukhuset, Karolinska Institute, Stockholm, Solna, Stockholm Sweden
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11
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Hamid M, Khalid A, Parmar J. Does percutaneous cholecystostomy timing in high anaesthetic-risk patients impact on outcome? Updates Surg 2023; 75:133-140. [PMID: 36333564 DOI: 10.1007/s13304-022-01405-3] [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: 06/30/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
The optimal timing for percutaneous cholecystostomy (PCT) in patients with acute biliary sepsis, who are high-risk for cholecystectomy, requires further investigation. We aimed to study local factors influencing the timing to PCT placement, and investigate patient outcomes in early (≤ 48 h) vs. delayed PCT over a six-year period. A retrospective observational study investigating patients who required a PCT at a single hospital in the UK between January 2014 and December 2019. Placement of a PCT was at the discretion of the on-call surgical consultant according to their own personal experience and not based on a standard local protocol. Clinical outcomes, hospital statistics and details of any subsequent bridging surgery were analysed using multivariate logistic regression models adjusting for age, sex, Charlson Comorbidity Index (CCI) and American Society of Anaesthesiologists (ASA) grade. There were 72 patients with 35/72 (48.6%) classed as TG18 AC grade 3; 26/72 (36.1%) had an early PCT placed and 46/72 (63.9%) delayed. Median age was 76 (65-83) years, 52.8% were female, and 51.4% were classed ASA ≥ 3 with 94.0% scoring CCI > 2. Trial on antibiotic therapy was the primary reason for delayed PCT. In adjusted models, early PCT was associated with a shorter length in hospital stay (OR 3.02, p = 0.044), successful definitive treatment (OR 6.26, p = 0.009); and reduced likelihood for catheter dislodgment (OR 0.12, p = 0.004) with fewer patients bridging to later emergency open surgery (OR 0.19, p = 0.024). Clinical outcomes may be superior in urgent or early PCT for high anaesthetic-risk patients following acute biliary sepsis.
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Affiliation(s)
- Mohammed Hamid
- University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TH, UK. .,Department of Upper Gastrointestinal Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK.
| | - Ayesha Khalid
- University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TH, UK.,Department of Upper Gastrointestinal Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK
| | - Jitesh Parmar
- University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TH, UK.,Department of Upper Gastrointestinal Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK
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12
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Evaluation of early versus delayed laparoscopic cholecystectomy in acute calculous cholecystitis: a prospective, randomized study. JOURNAL OF MINIMALLY INVASIVE SURGERY 2022; 25:139-144. [PMID: 36601493 PMCID: PMC9763484 DOI: 10.7602/jmis.2022.25.4.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 12/04/2022] [Indexed: 12/23/2022]
Abstract
Purpose Uncertainty exists about whether early laparoscopic cholecystectomy (LC) is an appropriate surgical treatment for acute calculous cholecystitis. This study aimed to compare early vs. late LC for acute calculous cholecystitis regarding intraoperative difficulty and postoperative outcomes. Methods This was a prospective randomized study carried out between December 2015 and June 2017; 60 patients with acute calculous cholecystitis were divided into two groups (early and delayed groups), each comprising 30 patients. Thirty patients treated with LC within 3 to 5 days of arrival at the hospital were assigned to the early group. The other 30 patients were placed in the delayed group, first treated conservatively, and followed by LC 3 to 6 weeks later. Results The conversion rates in both groups were 6.7% and 0%, respectively (p = 0.143). The operating time was 56.67 ± 11.70 minutes in the early group and 75.67 ± 20.52 minutes in the delayed group (p = 0.001), and both groups observed equal levels of postoperative complications. Early LC patients, on the other hand, required much fewer postoperative hospital stay (3.40 ± 1.99 vs. 6.27 ± 2.90 days, p = 0.006). Conclusion Considering shorter operative time and hospital stay without significant increase of open conversion rates, early LC might have benefits over late LC.
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13
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Devas N, Guenthart A, Nie L, Joshi I, Yang J, Morris-Stiff G, Pryor A. Timing is everything: outcomes of 30,259 delayed cholecystectomies in New York State. Surg Endosc 2022; 36:9390-9397. [PMID: 35768738 DOI: 10.1007/s00464-022-09251-5] [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] [Received: 08/20/2021] [Accepted: 04/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The timing of cholecystectomy in relation to outcomes has been debated. To our knowledge, there are no large population-based studies looking at outcomes and complications of delayed cholecystectomy [DC] (> 72 h after presentation). This study utilizes a statewide database to determine whether there are differences in patient outcomes for DC performed at 3-4 days, 5-6 days, and ≥ 7 days after presentation. METHODS The New York SPARCS database was used to identify adult patients presenting with a diagnosis of acute cholecystitis from 2005 to 2017. Patients aged < 18, those with missing identifier or procedure-date information, those who underwent early cholecystectomy < 72 h or upon readmission, were excluded. Patients undergoing DC at 3-4 days, 5-6 days, and ≥ 7 days were compared in terms of overall complications, hospital length of stay (LOS), 30-day readmissions/emergency department (ED) visits, and 30-day mortality. RESULTS 30,259 patients were identified. DCs were performed within 3-4 days (n = 19,845, 65.6%), 5-6 days (n = 6432, 21.3%), and ≥ 7 days (n = 3982, 13.2%). There was a stepwise deterioration in outcomes with increased delay to surgery (Fig. 1). When comparing 3-4 and ≥ 7 days, overall complications (OR = 0.418, 95% CI: 0.387-0.452), 30-day readmissions (OR = 0.609, 95% CI: 0.549-0.674), 30-day ED visits (OR = 0.697, 95% CI: 0.637-0.763), 30-day mortality (OR = 0.601, 95% CI: 0.400-0.904), and LOS (OR = 0.729, 95% CI: 0.710-0.748) were lower in the 3-4 day cohort. CONCLUSIONS DC within 3-4 days is associated with fewer complications, readmissions and ED visits, and reduced LOS compared to DC at 5-6 or ≥ 7 days after presentation. In addition, 30-day mortality was also significantly different comparing 3-4 with ≥ 7-day cohorts. These data are important for guiding patients in the consent process and may point to choosing an earlier interval cholecystectomy for high-risk patients.
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Affiliation(s)
- Nina Devas
- Department of Surgery, Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY, 11794, USA
| | - Andrew Guenthart
- Department of Surgery, Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY, 11794, USA.
| | - Lizhou Nie
- Department of Biostatistics, Stony Brook School of Medicine, Stony Brook, USA
| | - Isha Joshi
- Department of Surgery, Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY, 11794, USA
| | - Jie Yang
- Department of Biostatistics, Stony Brook School of Medicine, Stony Brook, USA
| | | | - Aurora Pryor
- Department of Surgery, Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY, 11794, USA
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Fujinaga A, Hirashita T, Iwashita Y, Kawamura M, Nakanuma H, Kawasaki T, Kawano Y, Masuda T, Endo Y, Ohta M, Inomata M. An additional port in difficult laparoscopic cholecystectomy for surgical safety. Asian J Endosc Surg 2022; 15:737-744. [PMID: 35505453 DOI: 10.1111/ases.13073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/20/2022] [Accepted: 04/15/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Tokyo Guidelines 2018, clinical practice guidelines for acute cholangitis and cholecystitis, recommend bailout procedures to prevent bile duct injury (BDI) during laparoscopic cholecystectomy (LC) for difficult gallbladder. We first insert an additional port (AP) for difficult gallbladder that may require bailout procedures. Because the usefulness of an AP during LC is unclear, we therefore examined the efficacy of the AP during LC in this study. METHODS Data were collected from 115 patients who underwent LC for acute cholecystitis in our department. The indications for AP were excessive bleeding, scarring, and poor visual field around Calot's triangle. AP was inserted into the right middle abdomen so as not to interfere with other trocars and was used by the assistant. Surgical outcomes were evaluated based on AP use during LC. RESULTS AP was inserted in 19 patients during LC (AP group). The indications for AP were excessive bleeding in nine patients, scarring around Calot's triangle in seven patients, and poor visual field around Calot's triangle in three patients. Open conversion was performed in two patients in the non-AP group. BDI occurred in one patient in the non-AP group. In patients with Difficulty Score 3, operation time was significantly shorter (P = .038) and Critical View of Safety (CVS) score was significantly higher in the AP group (P = .046). CONCLUSION AP is useful in patients with excessive bleeding to shorten operation time and increase the CVS score. AP may be one useful option for difficult gallbladder.
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Affiliation(s)
- Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yukio Iwashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masahiro Kawamura
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Hiroaki Nakanuma
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takahide Kawasaki
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yoko Kawano
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takashi Masuda
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masayuki Ohta
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
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15
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Kurata Y, Hayano K, Imai Y, Ichinose M, Hirata A, Mizumachi R, Hirasawa S, Yonemoto S, Sasaki T, Kainuma S, Takahashi Y, Ohira G, Matsubara H. Apparent diffusion coefficient by magnetic resonance cholangiopancreatography is useful for grading cholecystitis and surgery planning. Asian J Endosc Surg 2022; 16:173-180. [PMID: 36180045 DOI: 10.1111/ases.13128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/18/2022] [Accepted: 09/09/2022] [Indexed: 12/07/2022]
Abstract
INTRODUCTION Laparoscopic cholecystectomy is a standard procedure for treating cholescytitis, but severe inflammation may cause complications. Our previous study showed that the apparent diffusion coefficient (ADC) values could predict difficult surgery. In the present study, relevance of ADC values in grading the severity of cholecystitis was pathologically investigated. METHODS We retrospectively analyzed a total of 50 patients who underwent laparoscopic cholecystectomy or laparotomic cholecystectomy/choledocholithotomy. The degree of inflammation in the neck of the gall bladder was pathologically graded into three tiers (grade 1, mild; grade 2, moderate; grade 3, severe), and ulceration, lymphoid follicle formation, and wall thickness of the gallbladder neck were recorded. All factors were statistically compared with the measured ADC values. RESULTS The ADC value was significantly lower in the severe inflammation group ( grade 3) than in the weak inflammation group (grades 1 and 2) (1.93 ± 0.22 vs 2.38 ± 0.67, respectively; P = .02). Ulceration and wall thickness in the gallbladder neck were significantly correlated with ADC values (P = .04 and .006, respectively), and lymphoid follicle formation was marginally correlated with ADC values (P = .06). The diagnostic utility of the ADC values decreased as the interval between imaging and cholecystectomy increased. [Correction added on 19 October 2022, after first online publication: [On the first sentence of the Results section, (grades 2 and 3) for weak inflammation group has been changed to (grades 1 and 2).] CONCLUSION: ADC values were inversely associated with the pathologic intensity of cholecystitis. We recommend that the ADC value be measured before surgery, so that the procedure can be accordingly planned.
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Affiliation(s)
- Yoshihiro Kurata
- Department of Digestive Surgery, International University of Health and Welfare Shioya Hospital, Tochigi, Japan.,Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Koichi Hayano
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasuo Imai
- Department of Diagnostic Pathology, Ota Memorial Hospital, SUBARU Health Insurance Society, Ota, Japan
| | - Masanori Ichinose
- Department of Digestive Surgery, International University of Health and Welfare Shioya Hospital, Tochigi, Japan
| | - Atsushi Hirata
- Department of Digestive Surgery, International University of Health and Welfare Shioya Hospital, Tochigi, Japan.,Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ryoya Mizumachi
- Department of Digestive Surgery, International University of Health and Welfare Shioya Hospital, Tochigi, Japan.,Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Soichiro Hirasawa
- Department of Digestive Surgery, International University of Health and Welfare Shioya Hospital, Tochigi, Japan.,Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shohei Yonemoto
- Department of Digestive Surgery, International University of Health and Welfare Shioya Hospital, Tochigi, Japan.,Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takuma Sasaki
- Department of Digestive Surgery, International University of Health and Welfare Shioya Hospital, Tochigi, Japan.,Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shunsuke Kainuma
- Department of Digestive Surgery, International University of Health and Welfare Shioya Hospital, Tochigi, Japan.,Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yumiko Takahashi
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Gaku Ohira
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hisahiro Matsubara
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Nantais J, Mansour M, de Mestral C, Jayaraman S, Gomez D. Administrative codes may have limited utility in diagnosing biliary colic in emergency department visits: A validation study. Ann Hepatobiliary Pancreat Surg 2022; 26:277-280. [PMID: 35851329 PMCID: PMC9428434 DOI: 10.14701/ahbps.21-171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/03/2022] [Accepted: 03/03/2022] [Indexed: 12/07/2022] Open
Abstract
Backgrounds/Aims Biliary colic is a common cause of emergency department (ED) visits; however, the natural history of the disease and thus the indications for urgent or scheduled surgery remain unclear. Limitations of previous attempts to elucidate this natural history at a population level are based on the reliance on the identification of biliary colic via administrative codes in isolation. The purpose of our study was to validate the use of International Statistical Classification of Diseases and Related Health Problems codes, 10th Revision, Canadian modification (ICD-10-CA) from ED visits in adequately differentiating patients with biliary colic from those with other biliary diagnoses such as cholecystitis or common bile duct stones. Methods We performed a retrospective validation study using administrative data from two large academic hospitals in Toronto. We assessed all the patients presenting to the ED between January 1, 2012 and December 31, 2018, assigned ICD-10-CA codes in keeping with uncomplicated biliary colic. The codes were compared to the individually abstracted charts to assess diagnostic agreement. Results Among the 991 patient charts abstracted, 26.5% were misclassified, corresponding to a positive predictive value of 73% (95% confidence interval 73%–74%). The most frequent reasons for inaccurate diagnoses were a lack of gallstones (49.8%) and acute cholecystitis (27.8%). Conclusions Our findings suggest that the use of ICD-10 codes as the sole means of identifying biliary colic to the exclusion of other biliary pathologies is prone to moderate inaccuracy. Previous investigations of biliary colic utilizing administrative codes for diagnosis may therefore be prone to unforeseen bias.
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Affiliation(s)
- Jordan Nantais
- Division of General Surgery, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Muhammad Mansour
- Division of General Surgery, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Surgery A, Galilee Medical Center, Faculty of Medicine of the Galilee, Bar-Ilan University, Nahariya, Israel
| | - Charles de Mestral
- Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Shiva Jayaraman
- Division of General Surgery, St. Joseph’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - David Gomez
- Division of General Surgery, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
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17
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Ouni A, Khosla AA, Gómez V. Perception of Bariatric Surgery and Endoscopic Bariatric Therapies Among Primary Care Physicians. Obes Surg 2022; 32:3384-3389. [PMID: 35931932 DOI: 10.1007/s11695-022-06231-5] [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: 04/13/2022] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In the USA, less than 1% of eligible patients who qualify for bariatric surgery ultimately undergo surgery. Perceptions of endoscopic bariatric therapies (EBTs) for weight management remain unknown. METHODS A 22-question survey was distributed to primary care physicians (PCPs) across the Mayo Clinic healthcare system. Survey invitations were sent via email, and all surveys were unanimously conducted electronically. RESULTS A total of 130 PCPs participated in the survey (40% response rate). Twenty-four PCPs were between 20 and 24 years out of training (18.5%), and 71 (54.6%) were female. Most providers had a body mass index (BMI) between 18.5 and 24.9 kg/m2 (n = 62, 47.7%). Among the weight loss options discussed during clinic visits, PCPs discussed lifestyle modification including diet and exercise (n = 129; 99.2%), and 68 PCPs (52.3%) were not aware of EBTs as weight loss interventions. While 46.2% of the PCPs agreed that a bariatric endoscopy is an effective option for weight loss, only 24.6% of PCPs were familiar with the indications for EBTs. Most of the cohort (n = 69, 53.1%) experienced barriers in referring their patients. Moreover, most of the patients referred to bariatric clinics were from PCPs who had a BMI between 18.5 and 24.9 kg/m2 (n = 62, 47.7%) as compared to PCPs with a BMI of 40 kg/m2 and greater (n = 5, 3.8%). CONCLUSIONS Due to the rise of bariatric therapies in recent years, PCPs are increasingly involved in the referral and management of patients with obesity and obesity-related comorbidities. However, knowledge gaps regarding weight loss options, including EBTs, could limit optimal care to patients desiring medically monitored weight loss.
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Affiliation(s)
- Ahmed Ouni
- Department of Gastroenterology and Hepatology, Mayo Clinic in Florida, Jacksonville, FL, 32224, USA.
| | - Atulya Aman Khosla
- Department of Gastroenterology and Hepatology, Mayo Clinic in Florida, Jacksonville, FL, 32224, USA
| | - Victoria Gómez
- Department of Gastroenterology and Hepatology, Mayo Clinic in Florida, Jacksonville, FL, 32224, USA
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18
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Van Roekel D, LeBedis C, Santos J, Paul D, Qureshi M, Kasotakis G, Gupta A. Cholecystitis: association between ultrasound findings and surgical outcomes. Clin Radiol 2022; 77:360-367. [DOI: 10.1016/j.crad.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 02/01/2022] [Indexed: 12/07/2022]
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19
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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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20
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Cecire J, Sutherland A, Das KK. Gallbladder Torsion Masking as Acalculus Cholecystitis: A Review of Two Cases Including Unsuccessful Management With Percutaneous Cholecystostomy. J Med Cases 2021; 12:223-225. [PMID: 34434462 PMCID: PMC8383507 DOI: 10.14740/jmc3683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/02/2021] [Indexed: 11/30/2022] Open
Abstract
Gallbladder torsion is a rare cause of abdominal pain; however, it is important to diagnose pre-operatively. We report two cases of gallbladder torsion, both of which were not recognized until the time of surgery. Both patients were elderly thin females, presenting with right upper quadrant pain, and on examination had a positive Murphy’s sign, and pre-operative imaging was suggestive of acalculus cholecystitis. One patient was initially managed by percutaneous insertion of a cholecystostomy tube, with progression to a laparoscopic cholecystectomy after a failure of resolution of symptoms. The second patient was taken to theater shortly after presentation, with the gallbladder torsion recognized intra-operatively. In both cases, the gallbladder was distorted and a routine laparoscopic cholecystectomy was performed with good recovery following. These two cases highlight the need for gallbladder torsion to be considered as a diagnostic possibility in those presenting with right upper quadrant pain, particularly those groups at most risk, including elderly thin females. Whilst other causes of cholecystitis can be managed non-operatively, at least in the acute phase, gallbladder torsion requires urgent operative intervention.
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Affiliation(s)
- Jack Cecire
- Department of Surgery, Coffs Harbour Health Campus, Coffs Harbour, NSW, Australia
| | - Andrew Sutherland
- Department of Surgery, Coffs Harbour Health Campus, Coffs Harbour, NSW, Australia
| | - Kamala Kanta Das
- Department of Surgery, Coffs Harbour Health Campus, Coffs Harbour, NSW, Australia
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21
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The Importance of Early Management of Severe Biliary Infection: Current Concepts. Int Surg 2021. [DOI: 10.9738/intsurg-d-20-00046.1] [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
Background
The incidence of biliary infections is rising worldwide and has become one of the main reasons for emergency admissions.
Methods
This is a narrative review of the literature emphasizing news concepts related to the early management of biliary diseases.
Results
The bacteriology is frequently polymicrobial, with a progressive increase of multidrug resistant bacteria. The form of presentation is variable, and the mortality rate may reach 20%. When cholecystitis or cholangitis is suspected, ultrasound is the gold standard imaging test. Depending on the severity of presentation, local resistances, and risk factors for multiresistant organisms, the most appropriate empirical antibiotic treatment must be initiated. In acute cholecystitis, cholecystectomy plays the main therapeutic role. In patients not suitable for surgery, percutaneous cholecystostomy is a valid alternative for source control. Treatment of severe cholangitis is based on the drainage of the bile duct and antibiotic therapy.
Conclusions
Biliary infections are serious conditions that can lead to sepsis and death. The introduction of new internationally accepted guidelines, based on clinical presentation, laboratory tests, and imaging, provides a platform for their timely diagnosis and management. Early severity assessment, initiation of intravenous antibiotics, and source control are fundamental to improving morbidity and mortality.
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22
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de'Angelis N, Catena F, Memeo R, Coccolini F, Martínez-Pérez A, Romeo OM, De Simone B, Di Saverio S, Brustia R, Rhaiem R, Piardi T, Conticchio M, Marchegiani F, Beghdadi N, Abu-Zidan FM, Alikhanov R, Allard MA, Allievi N, Amaddeo G, Ansaloni L, Andersson R, Andolfi E, Azfar M, Bala M, Benkabbou A, Ben-Ishay O, Bianchi G, Biffl WL, Brunetti F, Carra MC, Casanova D, Celentano V, Ceresoli M, Chiara O, Cimbanassi S, Bini R, Coimbra R, Luigi de'Angelis G, Decembrino F, De Palma A, de Reuver PR, Domingo C, Cotsoglou C, Ferrero A, Fraga GP, Gaiani F, Gheza F, Gurrado A, Harrison E, Henriquez A, Hofmeyr S, Iadarola R, Kashuk JL, Kianmanesh R, Kirkpatrick AW, Kluger Y, Landi F, Langella S, Lapointe R, Le Roy B, Luciani A, Machado F, Maggi U, Maier RV, Mefire AC, Hiramatsu K, Ordoñez C, Patrizi F, Planells M, Peitzman AB, Pekolj J, Perdigao F, Pereira BM, Pessaux P, Pisano M, Puyana JC, Rizoli S, Portigliotti L, Romito R, Sakakushev B, Sanei B, Scatton O, Serradilla-Martin M, Schneck AS, Sissoko ML, Sobhani I, Ten Broek RP, Testini M, Valinas R, Veloudis G, Vitali GC, Weber D, Zorcolo L, Giuliante F, Gavriilidis P, Fuks D, Sommacale D. 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg 2021; 16:30. [PMID: 34112197 PMCID: PMC8190978 DOI: 10.1186/s13017-021-00369-w] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/18/2021] [Indexed: 12/16/2022] Open
Abstract
Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.
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Affiliation(s)
- Nicola de'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, General Regional Hospital "F. Miulli", Strada Prov. 127 Acquaviva - Santeramo Km. 4, 70021 Acquaviva delle Fonti BA, Bari, Italy. .,Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France.
| | - Fausto Catena
- Department of Emergency and Trauma Surgery of the University Hospital of Parma, Parma, Italy
| | - Riccardo Memeo
- Department of Hepato-Pancreatic-Biliary Surgery, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Aleix Martínez-Pérez
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Oreste M Romeo
- Trauma, Burn, and Surgical Care Program, Bronson Methodist Hospital, Kalamazoo, Michigan, USA
| | - Belinda De Simone
- Service de Chirurgie Générale, Digestive, et Métabolique, Centre hospitalier de Poissy/Saint Germain en Laye, Saint Germain en Laye, France
| | - Salomone Di Saverio
- Department of Surgery, Cambridge University Hospital, NHS Foundation Trust, Cambridge, UK
| | - Raffaele Brustia
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Rami Rhaiem
- Department of HBP and Digestive Oncologic Surgery, Robert Debré University Hospital, Reims, France
| | - Tullio Piardi
- Department of HBP and Digestive Oncologic Surgery, Robert Debré University Hospital, Reims, France.,Department of Surgery, HPB Unit, Troyes Hospital, Troyes, France
| | - Maria Conticchio
- Department of Hepato-Pancreatic-Biliary Surgery, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Francesco Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Nassiba Beghdadi
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Ruslan Alikhanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Shosse Enthusiastov, 86, 111123, Moscow, Russia
| | | | - Niccolò Allievi
- 1st Surgical Unit, Department of Emergency, Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Giuliana Amaddeo
- Service d'Hepatologie, APHP, Henri Mondor University Hospital, Creteil, and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Luca Ansaloni
- General Surgery, San Matteo University Hospital, Pavia, Italy
| | | | - Enrico Andolfi
- Department of Surgery, Division of General Surgery, San Donato Hospital, 52100, Arezzo, Italy
| | - Mohammad Azfar
- Department of Surgery, Al Rahba Hospital, Abu Dhabi, UAE
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Amine Benkabbou
- Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco
| | - Offir Ben-Ishay
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Giorgio Bianchi
- Unit of Minimally Invasive and Robotic Digestive Surgery, General Regional Hospital "F. Miulli", Strada Prov. 127 Acquaviva - Santeramo Km. 4, 70021 Acquaviva delle Fonti BA, Bari, Italy
| | - Walter L Biffl
- Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Francesco Brunetti
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | | | - Daniel Casanova
- Hospital Universitario Marqués de Valdecilla, University of Cantabria, Santander, Spain
| | - Valerio Celentano
- Colorectal Unit, Chelsea and Westminster Hospital, NHS Foundation Trust, London, UK
| | - Marco Ceresoli
- Emergency and General Surgery Department, University of Milan Bicocca, Milan, Italy
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Roberto Bini
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC and Loma Linda University School of Medicine, Loma Linda, USA
| | - Gian Luigi de'Angelis
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Decembrino
- Gastroenterology and Endoscopy Unit, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Andrea De Palma
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Carlos Domingo
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | | | - Alessandro Ferrero
- Department of General and Oncological Surgery, Azienda Ospedaliera Ordine Mauriziano "Umberto I", Turin, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Federica Gaiani
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Federico Gheza
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Gurrado
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Ewen Harrison
- Department of Clinical Surgery and Centre for Medical Informatics, Usher Institute, University of Edinburgh, Little France Crescent, Edinburgh, UK
| | | | - Stefan Hofmeyr
- Division of Surgery, Surgical Gastroenterology Unit, Tygerberg Academic Hospital, University of Stellenbosch Faculty of Medicine and Health Sciences, Stellenbosch, South Africa
| | - Roberta Iadarola
- Department of Emergency and Trauma Surgery of the University Hospital of Parma, Parma, Italy
| | - Jeffry L Kashuk
- Department of Surgery, Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel
| | - Reza Kianmanesh
- Department of HBP and Digestive Oncologic Surgery, Robert Debré University Hospital, Reims, France
| | - Andrew W Kirkpatrick
- Department of Surgery, Critical Care Medicine and the Regional Trauma Service, Foothills Medical Center, Calgari, Alberta, Canada
| | - Yoram Kluger
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Filippo Landi
- Department of HPB and Transplant Surgery, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain
| | - Serena Langella
- Department of General and Oncological Surgery, Azienda Ospedaliera Ordine Mauriziano "Umberto I", Turin, Italy
| | - Real Lapointe
- Department of HBP Surgery and Liver Transplantation, Department of Surgery, Centre Hospitalier de l'Université de Montreal, Montreal, QC, Canada
| | - Bertrand Le Roy
- Department of Digestive Surgery, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Alain Luciani
- Unit of Radiology, Henri Mondor University Hospital (AP-HP), Creteil, and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Fernando Machado
- Department of Emergency Surgery, Hospital de Clínicas, School of Medicine UDELAR, Montevideo, Uruguay
| | - Umberto Maggi
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Alain Chichom Mefire
- Department of Surgery and Obstetrics/Gynecologic, Regional Hospital, Limbe, Cameroon
| | - Kazuhiro Hiramatsu
- Department of General Surgery, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan
| | - Carlos Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Universidad del Valle Cali, Cali, Colombia
| | - Franca Patrizi
- Unit of Gastroenterology and Endoscopy, Maggiore Hospital, Bologna, Italy
| | - Manuel Planells
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Andrew B Peitzman
- Department of Surgery, UPMC, University of Pittsburg, School of Medicine, Pittsburg, USA
| | - Juan Pekolj
- General Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fabiano Perdigao
- Liver Transplant Unit, APHP, Unité de Chirurgie Hépatobiliaire et Transplantation hépatique, Hôpital Pitié Salpêtrière, Paris, France
| | - Bruno M Pereira
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Patrick Pessaux
- Hepatobiliary and Pancreatic Surgical Unit, Visceral and Digestive Surgery, IHU mix-surg, Institute for Minimally Invasive Image-Guided Surgery, University of Strasbourg, Strasbourg, France
| | - Michele Pisano
- 1st Surgical Unit, Department of Emergency, Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Juan Carlos Puyana
- Trauma & Acute Care Surgery - Global Health, University of Pittsburgh, Pittsburgh, USA
| | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael's Hospital, Toronto, ON, Canada
| | - Luca Portigliotti
- Chirurgia Epato-Gastro-Pancreatica, Azienda Ospedaliera-Universitaria Maggiore della Carità, Novara, Italy
| | - Raffaele Romito
- Chirurgia Epato-Gastro-Pancreatica, Azienda Ospedaliera-Universitaria Maggiore della Carità, Novara, Italy
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Behnam Sanei
- Department of Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Olivier Scatton
- Liver Transplant Unit, APHP, Unité de Chirurgie Hépatobiliaire et Transplantation hépatique, Hôpital Pitié Salpêtrière, Paris, France
| | - Mario Serradilla-Martin
- Instituto de Investigación Sanitaria Aragón, Department of Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Anne-Sophie Schneck
- Digestive Surgery Unit, Centre Hospitalier Universitaire de Guadeloupe, Pointe-À-Pitre, Les Avymes, Guadeloupe, France
| | - Mohammed Lamine Sissoko
- Service de Chirurgie, Hôpital National Blaise Compaoré de Ouagadougou, Ouagadougou, Burkina Faso
| | - Iradj Sobhani
- Department of Gastroenterology and Digestive Endoscopy, Henri Mondor Hospital, AP-HP, Creteil, and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Richard P Ten Broek
- Department of Surgery, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Mario Testini
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Roberto Valinas
- Department of Surgery "F", Faculty of Medicine, Clinic Hospital "Dr. Manuel Quintela", Montevideo, Uruguay
| | | | - Giulio Cesare Vitali
- Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Dieter Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Luigi Zorcolo
- Department of Surgery, Colorectal Surgery Unit, University of Cagliari, Cagliari, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Foundation "Policlinico Universitario A. Gemelli", IRCCS, Rome, Italy
| | - Paschalis Gavriilidis
- Division of Gastrointestinal and HBP Surgery, Imperial College HealthCare, NHS Trust, Hammersmith Hospital, London, UK
| | - David Fuks
- Institut Mutualiste Montsouris, Paris, France
| | - Daniele Sommacale
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
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23
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Eryigit Ö, van de Graaf FW, Nieuwenhuijs VB, Sosef MN, de Graaf EJR, Menon AG, Lange MM, Lange JF. Association of Video Completed by Audio in Laparoscopic Cholecystectomy With Improvements in Operative Reporting. JAMA Surg 2021; 155:617-623. [PMID: 32432660 DOI: 10.1001/jamasurg.2020.0741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance All events that transpire during laparoscopic cholecystectomy (LC) cannot be adequately reproduced in the operative note. Video recording is already known to add important information regarding this operation. Objective It is hypothesized that additional audio recordings can provide an even better procedural understanding by capturing the surgeons' considerations. Design, Setting, and Participants The Simultaneous Video and Audio Recording of Laparoscopic Cholecystectomy Procedures (SONAR) trial is a multicenter prospective observational trial conducted in the Netherlands in which operators were requested to dictate essential steps of LC. Elective LCs of patients 18 years and older were eligible for inclusion. Data collection occurred from September 18, 2018, to November 13, 2018. Main Outcomes and Measures Adequacy rates for video recordings and operative note were compared. Adequacy was defined as the competent depiction of a surgical step and expressed as the number of adequate steps divided by the total applicable steps for all cases. In case of discrepancies, in which a step was adequately observed in the video recording but inadequately reported in the operative note, an expert panel analyzed the added value of the audio recording to resolve the discrepancy. Results A total of 79 patients (49 women [62.0%]; mean [SD] age, 54.3 [15.9] years) were included. Video recordings resulted in higher adequacy for the inspection of the gallbladder (note, 39 of 79 cases [49.4%] vs video, 79 of 79 cases [100%]; P < .001), the inspection of the liver condition (note, 17 of 79 [21.5%] vs video, 78 of 79 cases [98.7%]; P < .001), and the circumferential dissection of the cystic duct and the cystic artery (note, 25 of 77 [32.5%] vs video, 62 of 77 [80.5%]; P < .001). The total adequacy was higher for the video recordings (note, 849 of 1089 observations [78.0%] vs video, 1005 of 1089 observations [92.3%]; P < .001). In the cases of discrepancies between video and note, additional audio recordings lowered discrepancy rates for the inspection of the gallbladder (without audio, 40 of 79 cases [50.6%] vs with audio, 17 of 79 cases [21.5%]; P < .001), the inspection of the liver condition (without audio, 61 of 79 [77.2%] vs with audio, 37 of 79 [46.8%]; P < .001), the circumferential dissection of the cystic duct and the cystic artery (without audio, 43 of 77 cases [55.8%] vs with audio, 17 of 77 cases [22.1%]; P < .001), and similarly for the removal of the first accessory trocar (without audio, 27 of 79 [34.2%] vs with audio, 16 of 79 [20.3%]; P = .02), the second accessory trocar (without audio, 24 of 79 [30.4%] vs with audio, 11 of 79 [13.9%]; P < .001), and the third accessory trocar (without audio, 27 of 79 [34.2%] vs with audio, 14 of 79 [17.7%]; P < .001). The total discrepancy was lower with audio adjustment (without audio, 254 of 1089 observations [23.3%] vs with audio, 128 of 1089 observations [11.8%]; P < .001). Conclusions and Relevance Audio recording during LC significantly improves the adequacy of depicting essential surgical steps and exhibits lower discrepancies between video and operative note.
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Affiliation(s)
- Özgür Eryigit
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Floyd W van de Graaf
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Meindert N Sosef
- Department of Surgery, Zuyderland Medical Center, Sittard-Geleen and Heerlen, the Netherlands
| | | | - Anand G Menon
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marilyne M Lange
- Department of Pathology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
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24
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Kurata M, Iwashita Y, Ohyama T, Endo I, Hibi T, Umezawa A, Suzuki K, Watanabe M, Asai K, Mori Y, Higashida M, Kumamoto Y, Shindoh J, Yoshida M, Honda G, Misawa T, Abe Y, Nagakawa Y, Toyota N, Yamada S, Norimizu S, Matsumura N, Sata N, Sunagawa H, Ito M, Takeda Y, Nakamura Y, Rikiyama T, Higuchi R, Gocho T, Ueno K, Kumagai Y, Kanaji S, Takada T, Yamamoto M. Assembling a library of typical surgery video clips to construct a system for assessing the surgical difficulty of laparoscopic cholecystectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:255-262. [PMID: 33260262 DOI: 10.1002/jhbp.871] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/08/2020] [Accepted: 11/18/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND To explore best practices for acute cholecystitis, it is necessary to construct a system to assess the difficulty of laparoscopic cholecystectomy (LC) based on intraoperative findings. In this study, multiple evaluators assessed videos of LC to assemble a library of typical video clips for 25 intraoperative findings. METHODS We have previously identified 25 items that contribute to surgical difficulty in LC. For each item, roughly 30-second video clips were submitted from videos of LC performed at member institutions. We then selected one typical video from the collected clips based on simple tabulation of the instances of agreement. Inter-rater agreement was assessed with Fleiss's κ and Gwet's agreement coefficient (AC). RESULTS Except in the case of two assessment items ("edematous change" and "easy bleeding"), κ or AC significantly exceeded 0.5 and the typical videos were judged to be applicable. For the two remaining items, the evaluation was repeated after clarifying the definitions of positive and negative findings. Eventually, they were recognized as typical. The completed video clip library contains 31 clips and is divided into five categories (http://www.jshbps.jp/modules/project/index.php?content_id=13). CONCLUSIONS This clip library may be highly useful in clinical settings as a more objective standard for assessing surgical difficulty in LC.
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Affiliation(s)
- Masanao Kurata
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yukio Iwashita
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | | | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Akiko Umezawa
- Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Kenji Suzuki
- Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Manabu Watanabe
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Koji Asai
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yasuhisa Mori
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masaharu Higashida
- Department of Digestive Surgery, Kawasaki Medical School, Okayama, Japan
| | - Yusuke Kumamoto
- Department of General, Pediatric and Hepatobiliary-Pancreatic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Junichi Shindoh
- Hepato-Biliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
| | - Goro Honda
- Department of Gastroenterological Surgery, New Tokyo Hospital, Matsudo, Japan
| | - Takeyuki Misawa
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Naoyuki Toyota
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan.,Department of Surgery, Sainokuni Higashiomiya Medical Center, Saitama, Japan
| | | | - Shinji Norimizu
- Department of Surgery, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | | | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Tochigi, Japan
| | | | - Masahiro Ito
- Department of Gastroenterological Surgery, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Yutaka Takeda
- Department of Suregery, Kansai Rosai Hospital, Amagasaki, Japan
| | - Yoshiharu Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Takeshi Gocho
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kimihiko Ueno
- Department of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.,Department of Surgery, Kobe Medical Center, Kobe, Japan
| | - Yuko Kumagai
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Tochigi, Japan
| | - Shingo Kanaji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
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25
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Zevin B, Martin M, Dalgarno N, Chan L, Sivapalan N, Houlden R, Birtwhistle R, Smith K, Barber D. Survey of perceptions and educational needs of primary care providers regarding management of patients with class II and III obesity in Ontario, Canada. BMC FAMILY PRACTICE 2021; 22:14. [PMID: 33422014 PMCID: PMC7797146 DOI: 10.1186/s12875-020-01356-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary care providers (PCPs) are typically the primary contact for patients with obesity seeking medical and surgical weight loss interventions; however, previous studies suggest that fewer than 7% of eligible adult patients are referred to publically funded medical and surgical weight loss interventions (MSWLI). METHODS We performed an anonymous survey study between October 2017 and June 2018 to explore the knowledge, experiences, perceptions, and educational needs of PCPs in Southeastern Ontario in managing patients with class II and III obesity. RESULTS Surveys were distributed to 591 PCPs (n = 538 family physicians; n = 53 nurse practitioners) identified as practicing in the Southeastern Ontario and 92 (15.6%) participated. PCPs serving a rural population estimated that 14.2 ± 10.9% of patients would qualify for MSWLI compared to 9.9 ± 8.5% of patients of PCPs serving an urban population (p = .049). Overall, 57.5% of respondents did not feel competent prescribing MSWLI to patients with class II/III obesity, while 69.8% stated they had 'good' knowledge of the referral criteria for MSWLI. 22.2% of respondents were hesitant to refer patients for bariatric surgery (BS) due to concerns about postoperative surgical complications and risks associated with surgery. Only 25% of respondents were comfortable providing long-term follow up after BS, and only 39.1% had participated in continuing education on management of patients with class II/III obesity in the past 5 years. CONCLUSION The majority of PCPs believe there is a need for additional education about MSWLI for patients with class II/III obesity. Future studies are needed to develop and compare the effectiveness of additional education and professional development around risks of contemporary BS, indications to consider referral for MSWLI, management and long-term follow-up of patients after BS.
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Affiliation(s)
- Boris Zevin
- Department of Surgery, Queen's University, Kingston, ON, Canada.
| | - Mary Martin
- Department of Family Medicine, Queen's University, Kingston, ON, Canada
| | - Nancy Dalgarno
- Office of Professional Development and Educational Scholarship, Queen's University, Kingston, ON, Canada
| | - Linda Chan
- Office of Professional Development and Educational Scholarship, Queen's University, Kingston, ON, Canada
| | | | - Robyn Houlden
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Richard Birtwhistle
- Office of Professional Development and Educational Scholarship, Queen's University, Kingston, ON, Canada
| | - Karen Smith
- Department of Physical Medicine and Rehabilitation, Queen's University, Kingston, ON, Canada
| | - David Barber
- Department of Family Medicine, Queen's University, Kingston, ON, Canada
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26
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Schuster KM, O'Connor R, Cripps M, Kuhlenschmidt K, Taveras L, Kaafarani HM, El Hechi M, Puri R, Mull J, Schroeppel TJ, Rodriquez J, Cullinane DC, Cullinane LM, Enniss TM, Sensenig R, Zilberman B, Crandall M. Multicenter validation of the American Association for the Surgery of Trauma grading scale for acute cholecystitis. J Trauma Acute Care Surg 2021; 90:87-96. [PMID: 33332782 DOI: 10.1097/ta.0000000000002901] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) patient assessment committee has created grading systems for emergency general surgery diseases to assist with clinical decision making and risk adjustment during research. Single-institution studies have validated the cholecystitis grading system as associated with patient outcomes. Our aim was to validate the grading system in a multi-institutional fashion and compare it with the Parkland grade and Tokyo Guidelines for acute cholecystitis. METHODS Patients presenting with acute cholecystitis to 1 of 8 institutions were enrolled. Discrete data to assign the AAST grade were collected. The Parkland grade was collected prospectively from the operative surgeon from four institutions. Parkland grade, Tokyo Guidelines, AAST grade, and the AAST preoperative grade (clinical and imaging subscales) were compared using linear and logistic regression to the need for surgical "bailout" (subtotal or fenestrated cholecystectomy, or cholecystostomy), conversion to open, surgical complications (bile leak, surgical site infection, bile duct injury), all complications, and operative time. RESULTS Of 861 patients, 781 underwent cholecystectomy. Mean (SD) age was 51.1 (18.6), and 62.7% were female. There were six deaths. Median AAST grade was 2 (interquartile range [IQR], 1-2), and median Parkland grade was 3 (interquartile range [IQR], 2-4). Median AAST clinical and imaging grades were 2 (IQR, 2-2) and 1 (IQR, 0-1), respectively. Higher grades were associated with longer operative times, and worse outcomes although few were significant. The Parkland grade outperformed the AAST grade based on area under the receiver operating characteristic curve. CONCLUSION The AAST cholecystitis grading schema has modest discriminatory power similar to the Tokyo Guidelines, but generally lower than the Parkland grade, and should be modified before widespread use. LEVEL OF EVIDENCE Diagnostic study, level IV.
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Affiliation(s)
- Kevin M Schuster
- From the Department of Surgery (K.M.S., R.O.), Yale School of Medicine, New Haven, CT; Department of Surgery (M. Cripps, K.K., L.T.), University of Texas Southwestern School of Medicine, Dallas, TX; Department of Surgery (H.M.K., M.E.), Massachusetts General Hospital, Boston, MA; Department of Surgery (R.P., M. Crandall, J.M.), College of Medicine - Jacksonville, University of Florida, Jacksonville, FL; Department of Surgery (T.J.S., J.R.), UC Health, Colorado Springs, CO; Department of Surgery (D.C.C., L.M.C.), Marshfield Clinic, Marshfield, WI; Department of Surgery (T.M.E.), School of Medicine, University of Utah, Salt Lake City, UT; and Department of Surgery (R.S., B.Z.), Cooper Medical School of Rowan University, Camden, NJ
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Macdonald N, Clements C, Sobti A, Rossiter D, Unnithan A, Bosanquet N. Tackling the elective case backlog generated by Covid-19: the scale of the problem and solutions. J Public Health (Oxf) 2021; 42:712-716. [PMID: 32930797 PMCID: PMC7543523 DOI: 10.1093/pubmed/fdaa155] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/08/2020] [Accepted: 08/10/2020] [Indexed: 12/02/2022] Open
Abstract
Background In April 2020, Covid-19 brought NHS elective procedures to a halt. The aim of this paper is to produce accurate forecasts on the building backlog, highlight the state of waiting lists currently and propose solutions required to prevent a public health crisis. Method Using data published by NHS digital and NHS England on previous years, we have analysed and used this to produce estimates of cancellations and missed cases. We also analyse government data on waiting lists and show compliance or lack of with these. Results We show that compliance with waiting list times pre pandemic was falling year on year (83.2% in 2020 down from 87% in 2019). Every month that passes we estimate that 400 000 cases are not being performed. This may include urgent cancer care work in some trusts. Conclusions Waiting lists have been governed by strict rules since 2004. Given falling compliance with 18-week intention to treat we believe the scale of the backlog combined with NHS capacity diminished due to Covid-19 precautions is a public health crisis waiting to occur. We identify difficulties in resuming elective work and suggest strategies that could be employed to avoid a public health crisis.
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Affiliation(s)
| | - Caterina Clements
- General Surgery, Kingston Hospital NHS trust, Kingston upon Thames, UK
| | - Anshul Sobti
- Orthopaedics, Ashford and St Peters NHS Trust, Ashford, UK
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28
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Fujinaga A, Iwashita Y, Tada K, Watanabe K, Kawasaki T, Masuda T, Hirashita T, Endo Y, Ohta M, Inomata M. Efficacy of releasing impacted gallstones after percutaneous transhepatic gallbladder drainage for acute cholecystitis and consideration of the surgical difficulty during laparoscopic cholecystectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:993-999. [PMID: 33128850 DOI: 10.1002/jhbp.857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/01/2020] [Accepted: 10/07/2020] [Indexed: 12/07/2022]
Abstract
INTRODUCTION Laparoscopic cholecystectomy (LC) is considered difficult in patients with an impacted gallstone (IG). We examined the efficacy of releasing an IG after percutaneous transhepatic gallbladder drainage (PTGBD) for acute cholecystitis (AC) and the usefulness of the Difficulty Score (DS) proposed in the Tokyo Guidelines 2018. METHODS Data were collected from 28 patients who underwent LC after PTGBD for AC caused by an IG in our department. The IG was released by flushing the gallbladder with saline or performing cholecystography. Release of the IG was evaluated based on cholecystography or drainage findings. Surgical outcomes were evaluated by comparing whether the IG could be released. RESULTS Nine patients had an IG (IG group) and 19 had a released IG at the time of surgery. Operation time was significantly longer (P = .008), Critical View of Safety score was significantly lower (P = .019), and DS was significantly higher (P < .001) in the IG group. In multivariate analysis, DS was the only independent factor for operation time (odds ratio = 8.943, 95% confidence interval 1.179-167.032; P = .033). CONCLUSION Releasing an IG may reduce surgical difficulty and maintain surgical safety. DS can be useful in predicting surgical outcomes.
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Affiliation(s)
- Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yukio Iwashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Kazuhiro Tada
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Kiminori Watanabe
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takahide Kawasaki
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takashi Masuda
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masayuki Ohta
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
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Sapmaz A, Karaca AS. Risk factors for conversion to open surgery in laparoscopic cholecystectomy: A single center experience. Turk J Surg 2020; 37:28-32. [PMID: 34585091 DOI: 10.47717/turkjsurg.2020.4734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/01/2020] [Indexed: 01/10/2023]
Abstract
Objectives This study aimed to demonstrate the demographic characteristics for laparoscopic cholecystectomy surgeries performed in the general surgery clinics of our hospital and to identify the rate of conversion to open surgery and the main reasons for convert to open surgery. Material and Methods Medical records of a total of 1.294 patients who underwent laparoscopic cholecystectomy in our hospital between October 2013 and May 2017 were retrospectively reviewed, and the rates of conversion to open surgery based on age groups were recorded. Results Of these patients, 1191 were females (92.0%) and 103 (7.9%) were males. Mean age was 48.6 ± 13.2 (range: 18 to 89) years. Indications for surgery were cholelithiasis in 1195 patients (92.4%), acute cholecystitis in 56 patients (4.4%), and gallbladder polyps in 43 patients (3.3%). The procedure was conversion to open surgery in 41 patients (3.16%), while 12 (0.9%) developed intraoperative complications. There was no mortality. Mean length of hospital stay was 1.2 (range: 1 to 6) days. The main reasons for conversation to open surgery were as follows: adhesions in the Calot's triangle (n= 3), acute cholecystitis (n= 29), choledocholithiasis (n= 2), adhesions due to previous surgery (n= 1), dissection difficulty (n= 2), organ damage (n= 2), anatomic variation (n= 1), and stone expulsion (n= 1). Conclusion Acute cholecystitis appears to be the significant factor increasing the rate of conversation to open surgery during LC procedures. Male sex and older age are the other factors increasing the risk of con- vert to open surgery. However, LC should be still the first choice of intervention.
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Affiliation(s)
- Ali Sapmaz
- Clinic of General Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ahmet Serdar Karaca
- Department of General Surgery, Baskent University İstanbul Hospital, İstanbul, Turkey
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30
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Bourgouin S, Monchal T, Julien C, d'Argouges F, Balandraud P. Early versus delayed cholecystectomy for cholecystitis at high risk of operative difficulties: A propensity score-matching analysis. Am J Surg 2020; 221:1061-1068. [PMID: 33066954 DOI: 10.1016/j.amjsurg.2020.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/07/2020] [Accepted: 09/15/2020] [Indexed: 12/07/2022]
Abstract
BACKGROUND Numerous studies have demonstrated the superiority of early (EC) over delayed (DC) cholecystectomy for acute cholecystitis (AC). However, none have assessed the effect of operative difficulty when reporting on treatment outcomes. METHODS Outcomes of patients who underwent EC or DC between 2010 and 2019 were compared taking into account the operative difficulty evaluated by the Difficult Laparoscopic Cholecystectomy score (DiLC). For each patient, the DiLC score was retrospectively calculated and corresponded to the foreseeable operative difficulty measured on admission for AC. A propensity score was used to account for confounders. Primary endpoints were the length of stay (LOS) and the occurrence of a serious operative/post-operative event (SOE). RESULTS DC in patients with DiLC≥10 reduced the risk of SOE without increasing the LOS. Conversely, DC in patients with DiLC<10 increased the LOS without improving outcomes. Multivariate analysis found EC in patients with DiLC≥10 as the main independent predictor of SOE. CONCLUSIONS Provided prospective validation, DC for AC in patients with DiLC≥10 seems safer than EC and is not hospital-stay consuming.
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Affiliation(s)
- Stéphane Bourgouin
- Sainte Anne Military Teaching Hospital, Department of Oncologic and Digestive Surgery, Toulon, France.
| | - Tristan Monchal
- Sainte Anne Military Teaching Hospital, Department of Oncologic and Digestive Surgery, Toulon, France
| | - Clément Julien
- Sainte Anne Military Teaching Hospital, Department of Oncologic and Digestive Surgery, Toulon, France
| | - Florent d'Argouges
- Sainte Anne Military Teaching Hospital, Department of Oncologic and Digestive Surgery, Toulon, France
| | - Paul Balandraud
- Sainte Anne Military Teaching Hospital, Department of Oncologic and Digestive Surgery, Toulon, France; French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
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Biliary Enteric Reconstruction After Biliary Injury: Delayed Repair Is More Costly Than Early Repair. J Surg Res 2020; 257:349-355. [PMID: 32892130 DOI: 10.1016/j.jss.2020.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/28/2020] [Accepted: 08/02/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Bile duct injury (BDI) during cholecystectomy requiring biliary enteric reconstruction (BER) is associated with increased risk of postoperative mortality and substantive increases in costs of care. The impact of the timing of repair on overall costs of care is poorly understood. MATERIALS AND METHODS The Healthcare Cost and Utilization Project Florida State databases (2006-2015) were queried to identify patients undergoing BER within 1-y of cholecystectomy performed for benign biliary disease. Patients were then categorized by the time interval between cholecystectomy to BER: early (≤3 d), intermediate (4 d to 6 wk), or delayed (>6 wk). By repair timing strategy, 1-y outcomes were aggregated, including charges, inpatient costs, aggregate length of stay, and inpatient mortality. RESULTS Of 563,887 patients undergoing cholecystectomy, 1168 required a BER (0.21%) within 1-y of cholecystectomy. Early BER was performed in 560 patients (47.9%), intermediate BER in 439 patients (37.6%), and delayed BER in 169 (14.5%) patients. On multivariable analysis adjusting for patient, procedure, and facility factors, intermediate BER demonstrated an increased risk of mortality (odds ratio 2.04, 95% confidence interval [CI]: 1.16-3.56) and increased aggregate inpatient cost (+$12,472; 95% CI: $6421-$18,524) relative to early BER. There was no notable difference in adjusted risk of inpatient mortality between the early and delayed BER cohorts (odds ratio 0.90; 95% CI: 0.32-1.25), but delayed BER was associated with increased aggregate inpatient costs (+$45,111; 95% CI: $36,813-$53,409). CONCLUSIONS When compared with delayed BER, early repair was associated with shorter aggregate inpatient hospitalization without increased postoperative mortality. Intermediate timing of repair is associated with increased costs and risk of mortality.
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32
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Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy. Ann Surg 2020; 272:3-23. [PMID: 32404658 DOI: 10.1097/sla.0000000000003791] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI. METHODS Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus. RESULTS Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team. CONCLUSIONS These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.
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33
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Argiriov Y, Dani M, Tsironis C, Koizia LJ. Cholecystectomy for Complicated Gallbladder and Common Biliary Duct Stones: Current Surgical Management. Front Surg 2020; 7:42. [PMID: 32793627 PMCID: PMC7385246 DOI: 10.3389/fsurg.2020.00042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/08/2020] [Indexed: 12/12/2022] Open
Abstract
Gallstone disease accounts for the vast majority of acute surgical admissions in the UK, with a major treatment being cholecystectomy. Practice varies significantly as to whether surgery is performed during the acute symptomatic phase, or after a period of recovery. Differences in practice relate to operative factors, patient factors, surgeon factors and hospital and trust wide policies. In this review we summarize recent evidence on management of gallstone disease, particularly with respect to whether cholecystectomy should occur during index presentation or following recovery. We highlight morbidity and mortality studies, cost, and patient reported outcomes. We speculate on barriers to change in service delivery. Finally, we propose potential solutions to optimize care.
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Affiliation(s)
- Yanna Argiriov
- Cutrale Perioperative and Ageing Research Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Melanie Dani
- Cutrale Perioperative and Ageing Research Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Christos Tsironis
- Department of Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Louis J Koizia
- Cutrale Perioperative and Ageing Research Group, Department of Bioengineering, Imperial College London, London, United Kingdom
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34
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Bedada AG, Hsiao M, Azzie G. Sustaining a laparoscopic program in resource-limited environments: results and lessons learned over 13 years in Botswana. Surg Endosc 2020; 35:3716-3722. [PMID: 32748266 DOI: 10.1007/s00464-020-07854-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Metrics of sustainability and frank descriptions of the unique challenges, successes, failures, and lessons learned from a longitudinal laparoscopic program in resource-limited environments are lacking. We set out to evaluate the safety and sustainability of the laparoscopic cholecystectomy program at Princess Marina Hospital, the largest tertiary and teaching hospital in Botswana. METHODS We assessed the clinical outcomes of patients who underwent laparoscopic cholecystectomy, comparing them with patients who underwent open cholecystectomy from January 2013 to December 2018. Technical independence and sustainability factors were measured and discussed. RESULTS Two hundred and twenty-six laparoscopic cholecystectomies (LC) and 39 open cholecystectomies (OC) were performed. Four surgeons who trained as part of the inaugural laparoscopic program performed 48.2% of LC. Eleven surgeons who trained elsewhere performed the remainder. Overall, 94.2% of LC were performed without expatriate surgeons. The conversion rate was 25/226 (11.1%). There were 3 bile duct injuries in the LC group (3/226, 1.3%) and none in the OC group. There was one mortality in the OC group (1/39, 2.6%) and none in the LC group. Fostering a trusting relationship among all stakeholder was identified as the major key to success, while the development of a system-based strategy was identified as the most significant ongoing challenge. CONCLUSION The laparoscopic cholecystectomy program in Botswana initially established between 2006 and 2012 has moved into its sustainability phase, characterized by increased usage of laparoscopy and greater independent operating by local surgeons, all while maintaining patient safety. Sustaining a laparoscopic program in resource-limited environments has particular challenges which may differ from country to country.
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Affiliation(s)
- Alemayehu Ginbo Bedada
- Department of Surgery, Faculty of Medicine, Princess Marina Hospital, University of Botswana, River Walk, Village, PO Box 45759, Gaborone, Botswana.
| | - Marvin Hsiao
- Division of General Surgery, Royal Columbian Hospital, Vancouver, BC, Canada
| | - Georges Azzie
- Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Canada
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35
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Macdonald N, Clements C, Sobti A, Rossiter D, Unnithan A, Bosanquet N. The building backlog of NHS elective cases post Covid-19. Br J Surg 2020; 107:e377-e378. [PMID: 32779749 PMCID: PMC7405047 DOI: 10.1002/bjs.11817] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 05/26/2020] [Indexed: 11/05/2022]
Affiliation(s)
- N Macdonald
- NJM - Registrar, Orthopaedics, Ashford and St Peters NHS Trust, England
| | - C Clements
- CDMC- Registrar, General Surgery, Kingston Hospital NHS trust, England
| | - A Sobti
- AS- Senior Fellow, Orthopaedics Ashford and St Peters NHS Trust, England
| | - D Rossiter
- DR -Registrar, Orthopaedics, Ashford and St Peters NHS Trust, England
| | - A Unnithan
- AU-Consultant, Orthopaedics, Ashford and St Peters NHS Trust, England
| | - N Bosanquet
- NB-Prof. Health Policy, Imperial College London, England
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36
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Patients with acute cholecystitis should be admitted to a surgical service. J Trauma Acute Care Surg 2020; 87:870-875. [PMID: 31233439 DOI: 10.1097/ta.0000000000002415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In bowel obstruction and biliary pancreatitis, patients receive more expedient surgical care when admitted to surgical compared with medical services. This has not been studied in acute cholecystitis. METHODS Retrospective analysis of clinical and cost data from July 2013 to September 2015 for patients with cholecystitis who underwent laparoscopic cholecystectomy in a tertiary care inpatient hospital. One hundred ninety lower-risk (Charlson-Deyo) patients were included. We assessed admitting service, length of stay (LOS), time from admission to surgery, time from surgery to discharge, number of imaging studies, and total cost. RESULTS Patients admitted to surgical (n = 106) versus medical (n = 84) service had shorter mean LOS (1.4 days vs. 2.6 days), shorter time from admission to surgery (0.4 days vs. 0.8 days), and shorter time from surgery to discharge (0.8 days vs. 1.1 days). Surgical service patients had fewer CT (38% vs. 56%) and magnetic resonance imaging (MRI) (5% vs. 16%) studies. Cholangiography (30% vs. 25%) and endoscopic retrograde cholangiopancreatography (ERCP) (3 vs. 8%) rates were similar. Surgical service patients had 39% lower median total costs (US $7787 vs. US $12572). CONCLUSION Nonsurgical admissions of patients with cholecystitis are common, even among lower-risk patients. Routine admission to the surgical service should decrease LOS, resource utilization and costs. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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37
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Cheng X, Cheng P, Xu P, Hu P, Zhao G, Tao K, Wang G, Shuai X, Zhang J. Safety and feasibility of prolonged versus early laparoscopic cholecystectomy for acute cholecystitis: a single-center retrospective study. Surg Endosc 2020; 35:2297-2305. [PMID: 32444970 PMCID: PMC8057981 DOI: 10.1007/s00464-020-07643-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 05/13/2020] [Indexed: 01/08/2023]
Abstract
Background Laparoscopic cholecystectomy (LC) is the standard treatment for acute cholecystitis (AC), and it should be performed within 72 h of symptoms onset if possible. In many undesired situations, LC was performed beyond the golden 72 h. However, the safety and feasibility of prolonged LC (i.e., performed more than 72 h after symptoms onset) are largely unknown, and therefore were investigated in this study. Methods We retrospectively enrolled the adult patients who were diagnosed as AC and were treated with LC at the same admission between January 2015 and October 2018 in an emergency department of a tertiary academic medical center in China. The primary outcome was the rate and severity of adverse events, while the secondary outcomes were length of hospital stay and costs. Results Among the 104 qualified patients, 70 (67.3%) underwent prolonged LC and 34 (32.7%) underwent early LC (< 72 h of symptom onset). There were no differences between the two groups in mortality rate (none for both), conversion rates (prolonged LC 5.4%, and early LC 8.8%, P = 0.68), intraoperative and postoperative complications (prolonged LC 5.7% and early LC 2.9%, P ≥ 0.99), operation time (prolonged LC 193.5 min and early LC 198.0 min, P = 0.81), and operation costs (prolonged LC 8,700 Yuan, and early LC 8,500 Yuan, P = 0.86). However, the prolonged LC was associated with longer postoperative hospitalization (7.0 days versus 6.0 days, P = 0.03), longer total hospital stay (11.0 days versus 8.0 days, P < 0.01), and subsequently higher total costs (40,400 Yuan versus 31,100 Yuan, P < 0.01). Conclusions Prolonged LC is safe and feasible for patients with AC for having similar rates and severity of adverse events as early LC, but it is also associated with longer hospital stay and subsequently higher total cost.
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Affiliation(s)
- Xing Cheng
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, People's Republic of China
| | - Ping Cheng
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, People's Republic of China
| | - Peng Xu
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, People's Republic of China
| | - Ping Hu
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, People's Republic of China
| | - Gang Zhao
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, People's Republic of China
| | - Kaixiong Tao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, People's Republic of China
| | - Guobin Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, People's Republic of China
| | - Xiaoming Shuai
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, People's Republic of China
| | - Jinxiang Zhang
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, People's Republic of China.
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Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy. Surg Endosc 2020; 34:2827-2855. [PMID: 32399938 DOI: 10.1007/s00464-020-07568-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/10/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI. METHODS Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidence-based recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus. RESULTS Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team. CONCLUSION These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.
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Purzner RH, Ho KB, Al-Sukhni E, Jayaraman S. Safe laparoscopic subtotal cholecystectomy in the face of severe inflammation in the cystohepatic triangle: a retrospective review and proposed management strategy for the difficult gallbladder. Can J Surg 2020; 62:402-411. [PMID: 31782296 DOI: 10.1503/cjs.014617] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Laparoscopic subtotal cholecystectomy (LSC) can be employed when extensive fibrosis or inflammation of the cystohepatic triangle prohibits safe dissection of the cystic duct and artery. The purpose of this study was to compare postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy (LC) or LSC. Methods In this retrospective study, we compared the postoperative outcomes of patients with severe cholecystitis who underwent LC or LSC between July 2010 and July 2016 at St. Joseph’s Health Centre, Toronto. We further stratified LSC cases on the basis of the extent of gallbladder (GB) dissection and GB remnant closure. Results A total of 105 patients who underwent LC and 46 who underwent LSC were included in the study. There were 4 bile duct injuries in the LC group and 0 in the LSC group. Bile leaks (relative risk [RR] 3.4, 95% confidence interval [CI] 1.01–11.5) and subphrenic collections (RR 3.1, 95% CI 1.3–8.0) were more common in the LSC group. Overall postoperative morbidity did not differ significantly between the 2 groups. Postoperative endoscopic retrograde cholangiopancreatography (ERCP) (RR 3.2, 95% CI 1.1–9.5) and biliary stent insertion (RR 4.6, 95% CI 1.2–17.5) were more common in the LSC group. Bile leaks appeared to be more prominent with open GB remnants but all cases of leak were successfully managed with ERCP and biliary stenting. Conclusion LSC may mitigate the risk of bile duct injury when dissection into the cystohepatic triangle is unsafe. There were more bile leaks in patients who underwent LSC; however, they were readily managed with endoscopic stents. Long-term biliary fistulae were not observed. LSC should be considered early as a means of completing difficult cholecystectomies safely without the need for cholecystostomy tube or conversion to laparotomy.
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Affiliation(s)
- Roderick H. Purzner
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Purzner, Ho, Al-Sukhni, Jayaraman); and the Hepatopancreatobiliary Surgery Service, St. Joseph’s Health Centre, Toronto, Ont. (Al-Sukhni, Jayaraman)
| | - Karen B. Ho
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Purzner, Ho, Al-Sukhni, Jayaraman); and the Hepatopancreatobiliary Surgery Service, St. Joseph’s Health Centre, Toronto, Ont. (Al-Sukhni, Jayaraman)
| | - Eisar Al-Sukhni
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Purzner, Ho, Al-Sukhni, Jayaraman); and the Hepatopancreatobiliary Surgery Service, St. Joseph’s Health Centre, Toronto, Ont. (Al-Sukhni, Jayaraman)
| | - Shiva Jayaraman
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Purzner, Ho, Al-Sukhni, Jayaraman); and the Hepatopancreatobiliary Surgery Service, St. Joseph’s Health Centre, Toronto, Ont. (Al-Sukhni, Jayaraman)
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Gustafsson C, Dahlberg M, Sondén A, Järnbert-Pettersson H, Sandblom G. Is out-of-hours cholecystectomy for acute cholecystitis associated with complications? Br J Surg 2020; 107:1313-1323. [DOI: 10.1002/bjs.11633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/24/2020] [Accepted: 03/23/2020] [Indexed: 12/24/2022]
Abstract
Abstract
Background
Existing data on the safety of out-of-hours cholecystectomy are conflicting. The aim of this study was to investigate whether out-of-hours cholecystectomy for acute cholecystitis is associated with a higher risk for complications compared with surgery during office hours.
Methods
This was a population-based cohort study. The Swedish Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography Register (GallRiks) was used to investigate the association between out-of-hours cholecystectomy for acute cholecystitis and complications developing within 30 days. Data from patients who underwent cholecystectomy between 2006 and 2017 were collected. Out-of-hours surgery was defined as surgery commencing between 19.00 and 07.00 hours on weekdays, or any time at weekends (Friday 19.00 hours to Monday 07.00 hours). Multivariable logistic regression analysis was used to assess the risk of complications, with time of procedure as independent variable. The proportion of open procedures and proportion of procedures exceeding 120 min were also analysed. Adjustments were made for sex, age, ASA grade, time between admission and surgery, and hospital-specific features.
Results
Of 11 153 procedures included, complications occurred within 30 days in 1573 patients (14·1 per cent). The adjusted odds ratio (OR) for complications for out-of-hours versus office-hours surgery was 1·12 (95 per cent c.i. 0·99 to 1·28). The adjusted OR for procedures completed as open surgery was 1·39 (1·25 to 1·54), and that for operating time exceeding 120 min was 0·63 (0·58 to 0·69).
Conclusion
Out-of-hours complications may relate to patient factors and the higher proportion of open procedures.
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Affiliation(s)
- C Gustafsson
- Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, Sjukhusbacken 10, S-118 83, Stockholm, Sweden
| | - M Dahlberg
- Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, Sjukhusbacken 10, S-118 83, Stockholm, Sweden
| | - A Sondén
- Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, Sjukhusbacken 10, S-118 83, Stockholm, Sweden
| | - H Järnbert-Pettersson
- Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, Sjukhusbacken 10, S-118 83, Stockholm, Sweden
| | - G Sandblom
- Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, Sjukhusbacken 10, S-118 83, Stockholm, Sweden
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41
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Janjic G, Simatovic M, Skrbic V, Karabeg R, Radulj D. Early vs. Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis - Single Center Experience. Med Arch 2020; 74:34-38. [PMID: 32317832 PMCID: PMC7164737 DOI: 10.5455/medarh.2020.74.34-37] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction: Laparoscopic cholecystectomy is now considered the procedure of choice that achieves a shorter recovery period after the surgery and reduction in the cost of treatment. Aim: The aim of the study is to prove which method: early or delayed laparoscopic cholecystectomy is the method of choice in the treatment of acute cholecystitis by examining: duration of hospitalization, conversion rate, duration of surgery, postoperative complications, and total cost. Methods: The study was conducted at the University Clinical Center of Republika Srpska as a retrospective-prospective study from May 1st 2013 until December 31st 2019. Patients diagnosed with acute cholecystitis were divided into two groups: Patients designated for early laparoscopic cholecystectomy within 72 hours of admission (group A–42 patients), Patients designated for initial conservative treatment followed by a delayed interval of 6-12 weeks until surgery (group B-42 patients). Results: In both groups, there were statistically significantly more female respondents. The results showed that the average cost of treatment in the early treated group was statistically significantly lower than the cost of treatment in the delayed treatment group. The patients in the early group had shorter hospitalization times (an average of 2.8 days and 5.6 days in the delayed group of patients), a smaller percentage of conversions (4.8% in the early and 16.7 in the delayed group of patients), the total cost of in the early group it was 1300.83 KM, while in the delayed group it was 1645.43 KM. Conclusion: Early laparoscopic cholecystectomy is a method to be preferred in surgical treatment.
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Affiliation(s)
- Goran Janjic
- Clinic for General and Abdominal Surgery, University Clinical Center Republic Srpska, Banja Luka, Bosna i Hercegovina
| | - Milan Simatovic
- Clinic for General and Abdominal Surgery, University Clinical Center Republic Srpska, Banja Luka, Bosna i Hercegovina
| | - Velimir Skrbic
- Clinic for General and Abdominal Surgery, University Clinical Center Republic Srpska, Banja Luka, Bosna i Hercegovina
| | - Reuf Karabeg
- Private Clinic "Karabeg",Sarajevo, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Dragan Radulj
- Clinic for General and Abdominal Surgery, University Clinical Center Republic Srpska, Banja Luka, Bosna i Hercegovina
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Slim K, Veziant J. [Urgent digestive surgery, a collateral victim of the Covid-19 crisis?]. ACTA ACUST UNITED AC 2020; 157:S4-S5. [PMID: 32292533 PMCID: PMC7144856 DOI: 10.1016/j.jchirv.2020.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- K Slim
- Service de chirurgie digestive, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand, France.,Groupe francophone de réhabilitation améliorée après chirurgie (GRACE), allée du Riboulet, 63110 Beaumont France
| | - J Veziant
- Service de chirurgie digestive, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand, France
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Affiliation(s)
- K Slim
- Department of Digestive Surgery, Clermont-Ferrand Teaching Hospital, Clermont-Ferrand, France.
| | - J Veziant
- Department of Digestive Surgery, Clermont-Ferrand Teaching Hospital, Clermont-Ferrand, France
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44
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Karvellas CJ, Dong V, Abraldes JG, Lester EL, Kumar A. The impact of delayed source control and antimicrobial therapy in 196 patients with cholecystitis-associated septic shock: a cohort analysis. Can J Surg 2020; 62:189-198. [PMID: 31134783 DOI: 10.1503/cjs.009418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Cholecystitis-associated septic shock carries a significant mortality. Our aim was to determine whether timing of source control affects survival in cholecystitis patients with septic shock. Methods We conducted a nested cohort study of all patients with cholecystitis-associated septic shock from an international, multicentre database (1996–2015). Multivariable logistic regression was performed to determine associations between clinical factors and in-hospital mortality. The results were used to inform a classification and regression tree (CART) analysis that modelled the association between disease severity (APACHE II), time to source control and survival. Results Among 196 patients with cholecystitis-associated septic shock, overall mortality was 37%. Compared with nonsurvivors (n = 72), survivors (n = 124) had lower mean admission APACHE II scores (21 v. 27, p < 0.001) and lower median admission serum lactate (2.4 v. 6.8 μmol/L, p < 0.001). Survivors were more likely to receive appropriate antimicrobial therapy earlier (median 2.8 v. 6.1 h from shock, p = 0.012). Survivors were also more likely to undergo successful source control earlier (median 9.8 v. 24.7 h from shock, p < 0.001). Adjusting for covariates, APACHE II (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.06–1.21 per increment) and delayed source control > 16 h (OR 4.45, 95% CI 1.88–10.70) were independently associated with increased mortality (all p < 0.001). The CART analysis showed that patients with APACHE II scores of 15–26 benefitted most from source control within 16 h (p < 0.0001). Conclusion In patients with cholecystitis-associated septic shock, admission APACHE II score and delay in source control (cholecystectomy or percutaneous cholecystostomy drainage) significantly affected hospital outcomes.
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Affiliation(s)
- Constantine J. Karvellas
- From the Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, Alta. (Karvellas); the Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alta. (Karvellas, Dong, Abraldes); the Division of General Surgery, University of Alberta, Edmonton, Alta. (Lester); the Section of Critical Care Medicine, University of Manitoba, Winnipeg, Man. (Kumar); and the Section of Infectious Diseases, University of Manitoba, Winnipeg, Man. (Kumar)
| | - Victor Dong
- From the Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, Alta. (Karvellas); the Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alta. (Karvellas, Dong, Abraldes); the Division of General Surgery, University of Alberta, Edmonton, Alta. (Lester); the Section of Critical Care Medicine, University of Manitoba, Winnipeg, Man. (Kumar); and the Section of Infectious Diseases, University of Manitoba, Winnipeg, Man. (Kumar)
| | - Juan G. Abraldes
- From the Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, Alta. (Karvellas); the Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alta. (Karvellas, Dong, Abraldes); the Division of General Surgery, University of Alberta, Edmonton, Alta. (Lester); the Section of Critical Care Medicine, University of Manitoba, Winnipeg, Man. (Kumar); and the Section of Infectious Diseases, University of Manitoba, Winnipeg, Man. (Kumar)
| | - Erica L.W. Lester
- From the Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, Alta. (Karvellas); the Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alta. (Karvellas, Dong, Abraldes); the Division of General Surgery, University of Alberta, Edmonton, Alta. (Lester); the Section of Critical Care Medicine, University of Manitoba, Winnipeg, Man. (Kumar); and the Section of Infectious Diseases, University of Manitoba, Winnipeg, Man. (Kumar)
| | - Anand Kumar
- From the Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, Alta. (Karvellas); the Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alta. (Karvellas, Dong, Abraldes); the Division of General Surgery, University of Alberta, Edmonton, Alta. (Lester); the Section of Critical Care Medicine, University of Manitoba, Winnipeg, Man. (Kumar); and the Section of Infectious Diseases, University of Manitoba, Winnipeg, Man. (Kumar)
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45
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AbdelDayem M, Osgood L, Escofet X, Farag M. A New Preoperative Scoring System to Predict Difficulty of Laparoscopic Cholecystectomy and Risk of Conversion to Open Surgery. Indian J Surg 2019. [DOI: 10.1007/s12262-019-02033-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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46
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Alore EA, Ward JL, Todd SR, Wilson CT, Gordy SD, Hoffman MK, Suliburk JW. Ideal timing of early cholecystectomy for acute cholecystitis: An ACS-NSQIP review. Am J Surg 2019; 218:1084-1089. [DOI: 10.1016/j.amjsurg.2019.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/09/2019] [Accepted: 08/10/2019] [Indexed: 01/25/2023]
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47
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Bleszynski MS, DeGirolamo KM, Meneghetti AT, Chiu CJ, Panton ON. Fluorescent Cholangiography in Laparoscopic Cholecystectomy: An Updated Canadian Experience. Surg Innov 2019; 27:38-43. [PMID: 31744398 DOI: 10.1177/1553350619885792] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background. Laparoscopic cholecystectomy (LC) is one of the most common general surgery procedures in Canada with approximately 100 000 cases performed per year. Bile duct injury remains a morbid complication with an incidence rate of 0.3% to 0.5%. Indocyanine green (ICG) fluorescent cholangiography is a noninvasive technology aiding in real-time identification of biliary structures for safe dissection within Calot's triangle. The objectives were to provide an update to our initial experience with ICG aiding in the identification of biliary structures and ensuring that no adverse patient reactions occurred with ICG administration. Methods. Prospective case series from 2016 to 2018 for elective LC with ICG technology performed at a single academic teaching institution. Patient demographics, indications for operation, biliary structures visualized, amount of ICG used, operative times, and complications were recorded. Results. One hundred eight cases were included for review. The cystic duct, common hepatic duct, and common bile duct were identified with ICG in 90%, 48%, and 84% of cases, respectively. ICG simultaneously visualized at least 2 of 3 biliary structures 83.4% of the time. Only 1 biliary structure was identified in 10% of cases. No biliary structures were identified in 6% of cases. Mean initial ICG dose given was 1.65 mL. No adverse patient reactions to ICG were noted. Conclusions. This updated series illustrates that administration of ICG enhances visualization of the biliary system during outpatient LC. ICG is safe and its application should be further studied in early LC for acute cholecystitis.
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Affiliation(s)
| | | | | | - C Jack Chiu
- University of British Columbia, Vancouver, British Columbia, Canada
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48
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Wennmacker SZ, Bhimani N, van Dijk AH, Hugh TJ, de Reuver PR. Predicting operative difficulty of laparoscopic cholecystectomy in patients with acute biliary presentations. ANZ J Surg 2019; 89:1451-1456. [PMID: 31642165 PMCID: PMC6899702 DOI: 10.1111/ans.15493] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/30/2019] [Accepted: 09/15/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Early laparoscopic cholecystectomy (LC) is advocated in patients with an acute biliary presentation but may require some precaution. We aimed to assess the intra-operative difficulty of cholecystectomy in patients who underwent early intervention, and to establish a prediction model for a 'complicated' LC. METHODS Retrospective analysis of prospectively collected data from patients presenting to the emergency department with acute biliary symptoms, and who subsequently underwent early LC between 2015 and 2018. Operative difficulty was assessed by standardized grading of intra-operative findings (grades 1-4). Pre-operative predictors for a 'complicated' LC (grades 3/4) were assessed using univariable and multivariable logistic regression analysis. A prediction model was created using variable regression coefficients. Cut-off and accuracy of the model were assessed using a receiver operating characteristic curve. RESULTS A total of 185 patients were included and 59% presented with acute cholecystitis. In this cohort 113 (61%) patients underwent a 'complicated' LC. A prediction model for a 'complicated' LC (0-4.5 points) included: clinical diagnosis of acute cholecystitis (2 points), C-reactive protein >10.5 mg/L (1.5 points) and pericholecystic fluid on pre-operative imaging (1 point). A score ≥2.5 had a sensitivity of 77.7%, specificity of 81.7% and positive and negative predictive values of 87.0% and 69.9%, respectively. CONCLUSION Early LC may be 'complicated' in up to 60% of cases. The presented prediction model uses readily available information in the emergency department and is a simple but accurate way to predict a likely 'complicated' LC in patients with acute biliary presentations.
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Affiliation(s)
- Sarah Z Wennmacker
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Nazim Bhimani
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Aafke H van Dijk
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Thomas J Hugh
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Discipline of Surgery, The University of Sydney, Sydney, New South Wales, Australia
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Long-term Outcomes of Carotid Endarterectomy Versus Stenting in a Multicenter Population-based Canadian Study. Ann Surg 2019; 268:364-373. [PMID: 28498234 DOI: 10.1097/sla.0000000000002301] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To compare the long-term outcomes of patients treated with carotid endarterectomy and carotid-artery stenting. BACKGROUND Evidence for the long-term safety and efficacy of carotid-artery stenting compared with endarterectomy is accumulating from randomized trials. However, comparative data on the long-term outcomes of carotid revascularization strategies in real world practice are lacking. METHODS We conducted a population-based, multicenter, observational cohort study using validated linked databases from Ontario, Canada. We identified all individuals treated with carotid endarterectomy and stenting (2002-2014), and followed them up to 2015. We compared long-term (up to 13 years) and 30-day outcomes of each strategy using multilevel multivariable Cox proportional-hazards models, and conducted confirmatory analyses using propensity-score matching methods. RESULTS In all, 15,525 patients received carotid-artery revascularization. Rate of the primary composite outcome of 30-day death, stroke, or myocardial infarction plus any stroke during 13-year follow-up was higher with stenting (16.3%) compared with endarterectomy (9.7%) [adjusted hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.43-1.73, P < 0.001). The increased risk with stenting was observed regardless of age, sex, intervention year, carotid-artery symptoms, or diabetes. The primary outcome was driven by higher rates of 30-day stroke (adjusted HR 1.59, 95% CI 1.29-1.95), 30-day death (adjusted HR 2.62, 95% CI 2.20-3.13), and long-term stroke >30 days after the procedure (adjusted HR 1.47, 95% CI 1.36-1.59) with stenting; 30-day myocardial infarction was lower with stenting (adjusted HR 0.70, 95% CI 0.57-0.86). These results were confirmed with 1:2 propensity-score matching (HR for primary composite outcome with stenting 1.55, 95% CI 1.31-1.83, P < 0.001). CONCLUSIONS Compared with carotid endarterectomy, stenting was associated with an early and sustained approximately 55% increased hazard for major adverse events over long-term follow-up. Although nonrandomized, these results raise potential concerns about the interchangeability of carotid endarterectomy and stenting in the context of actual clinical practice.
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50
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Gregory GC, Kuzman M, Sivaraj J, Navarro AP, Cameron IC, Irving G, Gomez D. C-reactive Protein is an Independent Predictor of Difficult Emergency Cholecystectomy. Cureus 2019; 11:e4573. [PMID: 31281756 PMCID: PMC6605972 DOI: 10.7759/cureus.4573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose The objective of this study was to identify variables that predict a difficult laparoscopic cholecystectomy performed in an emergency setting. The secondary aim was to devise a pathway for patients admitted acutely that required a cholecystectomy. Methods Patients admitted to the Emergency General Surgery Department at Nottingham, the United Kingdom that had an emergency cholecystectomy performed during the one-year period from May 2016 to June 2017 were identified. Collected data included patient demographics, clinical presentation, biochemical analysis, radiological findings, subsequent interventions, surgical data, and clinical outcome. A difficult cholecystectomy was defined as operative time >60 minutes, conversion to an open procedure, or sub-total cholecystectomy performed. Results A total of 149 patients were included. Cholecystitis was the most common diagnosis (n = 86, 57.7%), followed by acute pancreatitis (n = 36, 24.1%). Fifty-five (36.9%) patients had an elevated C-reactive protein (CRP) >100 mg/dL. One hundred and twenty-one (81.2%) patients who had an emergency cholecystectomy were defined as “difficult”. The overall morbidity rate was 15.4% (n = 23), and there was no post-operative in-hospital mortality. Univariate analysis showed that age >60 years (p = 0.012), underlying diagnosis (p = 0.010), presence of heart rate >90 (p = 0.027), and an elevated pre-surgery CRP >100 (p < 0.001) was associated with a difficult emergency cholecystectomy. Multi-variate analysis demonstrated that an elevated pre-surgery CRP >100 was an independent predictor of a difficult emergency cholecystectomy (p = 0.041). Conclusions An elevated pre-operative CRP is an independent predictor of a technically more difficult cholecystectomy in the emergency setting.
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Affiliation(s)
- Gordon C Gregory
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
| | - Matta Kuzman
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
| | - Jayaram Sivaraj
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
| | - Alex P Navarro
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
| | - Iain C Cameron
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
| | - Glen Irving
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
| | - Dhanwant Gomez
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
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