Does gender affect laparoscopic cholecystectomy?

Statistical Insight into China's Indigenous Diagnosis-Related-Group System Evolution

The use of Diagnosis-Related Groups (DRG) is a prevalent payment system employed to control hospitalization costs and improve medical efficiency. China has developed an indigenized DRG payment system including Single Disease Payment (SDP), DRGs, and Big Data Diagnosis-Intervention Packet (DIP). In this study, we took cholecystitis as an example, drawing on both primary and secondary data to verify the effectiveness of China's indigenized DRG system and to introduce the evolution of DRGs in China. Primary data were gathered from Qilu Hospital in 2019-2021. Secondary data were collected from published literature from 2004-2016. Only studies with both pre-SDP/DRG and post-SDP/DRG groups were included. Among the studies included, 92.9% (13/14) reported a significant reduction in hospitalization costs after the implementation of SDP while other studies identified length of stay (LOS) and age as the most significant influential factors in SDP. Furthermore, we elaborated the efficiency of DRGs using data from 2738 inpatients in Qilu hospital. Moreover, 60% (6/10) of the studies from the databases also showed the efficiency of DRGs in different regions. SDP is efficient in saving hospitalization costs, but its implementation is limited. DRGs have a broader scope of application, but their effectiveness remains to be validated. DIP is a brand new concept in China, and more data are needed to assess its efficiency.

Rare or Overlooked Cases of Acute Acalculous Cholecystitis in Young Patients with Central Nervous System Lesion

This case series presents two cases of acute acalculous cholecystitis (AAC)-a rare condition-in young women with central nervous system (CNS) lesions. Both patients had significant neurologic deficits and no well-known risk factors or presence of comorbidities (such as diabetes or a history of cardiovascular or cerebrovascular disease). Early diagnosis is important in cases of AAC owing to its high mortality rate; however, due to neurological deficits in our cases, accurate medical and physical examinations were limited, thereby leading to a delay in the diagnosis. The first case was of a 33-year-old woman with multiple fractures and hypovolemic shock due to a traumatic accident; she was diagnosed with hypoxic brain injury. The second case was of a 32-year-old woman with bipolar disorder and early-onset cerebellar ataxia who developed symptoms of impaired cognition and psychosis; she was later diagnosed with autoimmune encephalopathy. In the first case, the duration between symptom onset and diagnosis was 1 day, but in the second case, it was 4 days from diagnosis based on the occurrence of high fever. We emphasize that if a young woman presents with high fever, the possibility of AAC should be considered, particularly if a CNS lesion is present because it may pose difficulty in the evaluation of typical symptoms of AAC. Careful attention is thus required in such cases.

A POPULATION STUDY ON GENDER AND ETHNICITY DIFFERENCES IN GALLBLADDER DISEASE IN BRAZIL

Gallbladder diseases (GBD) are one of the most common medical conditions requiring surgical intervention, both electively and urgently. It is widely accepted that sex and ethnic characteristics mighty influence both prevalence and outcomes.

IMPACT OF FGFR4 (GLY388ARG) GENE POLYMORPHISM ALONG WITH VISFATIN CYTOKINE AND HIGH MOBILITY GROUP BOX-1 (HMGB1) ON ACUTE CHOLECYSTITIS

OBJECTIVE

The aim: Evaluating the role SNP rs351855 of (FGFR4) gene and estimating the serum concentration of Visfatin cytokine and (HMGB-1) protein in AC patients and in healthy control blood samples.

PATIENTS AND METHODS

Materials and methods: Blood samples were collected from 35 patients and 35 healthy controls, and then the serum was used for ELISA test, another each 2 ml blood were used for DNA extraction and rs351855 of (FGFR4) PCR assay.

RESULTS

Results: there was no significant difference in mean HMG and mean visfatin among (FGFR4) rs351855 genotypes in patients and control group. There was no significant difference in mean (HMG) among (FGFR) rs351855 genotypes in patients` group (p = 0.923); there was also no significant difference in mean visfatin among FGFR rs351855 genotypes in patients` group (p=0.161) rs351855 genotypes showed that the homozygous GG, heterozygous A/G and homozygous AA. Despite these minor differences there was no significant variation (p = 0.323), also no significant difference in frequency distribution of individuals according to FGFR rs351855 G>A SNP polymorphism between patients` and control groups (p = 0.454). The same was applied to recessive and allelic analysis p>0.05.

CONCLUSION

Conclusions: There was no role for (FGFR4) rs351855G/A SNP in disease susceptibility to acute cholecystitis in Iraqi patients. Visfatin cytokine and HMGB-1 protein might act as a good biomarker for diseases.

DOES MALE GENDER INCREASE THE RISK OF LAPAROSCOPIC CHOLECYSTECTOMY?

Background:

Laparoscopic cholecystectomy is the preferable treatment for chronic or acute cholecystitis. Some factors may increase the rate of laparoscopic conversion to open cholecystectomy and perioperative complications. The role of gender as a risk factor for laparoscopic cholecystectomy is controversial.

Aim:

To evaluate the role of the gender on the operative findings and outcome of laparoscopic cholecystectomy.

Method:

All patients who underwent laparoscopic cholecystectomy for chronic or acute cholecystitis were included. Demographic, clinical, laboratory, imaging exams, intraoperative and postoperative data were obtained and analyzed. The data was obtained retrospectively from electronic medical records and study protocols.

Results:

Of a total 1,645 patients who were subjected to laparoscopic cholecystectomy, 540 (32.8%) were men and 1,105 (67.2%) were women. Mean age was similar in both genders (p=0.817). Operative time has longer in the male (72.48±28.50) than in the female group (65.46±24.83, p<0.001). The rate of acute cholecystitis was higher in the male (14.3%) than in the female group (5.1%, p<0.001). There was no difference between the genders in regard to the rate of conversion (p=1.0), intraoperative complication (p=1.0), postoperative complication (p=0.571), and operative mortality (p=1.0).

Conclusion:

Male gender is not an independent risk factor for laparoscopic conversion and perioperative complications.

Differences in Outcomes Based on Sex for Pediatric Patients Undergoing Pyloromyotomy

BACKGROUND

Males and females are known to have varied responses to medical interventions. Our study aimed to determine the effect of sex on surgical outcomes after pyloromyotomy.

MATERIALS AND METHODS

Using the Kids' Inpatient Database for the years 2003-2012, we performed a serial, cross-sectional analysis of a nationally representative sample of all patients aged <1 y who underwent pyloromyotomy for hypertrophic pyloric stenosis. The primary predictor of interest was sex. Outcomes included mortality, in-hospital complications, cost, and length of stay. Regression models were adjusted by race, age group, comorbidity, complications, and whether operation was performed on the day of admission with region and year fixed effects.

RESULTS

Of 48,834 weighted operations, 81.8% were in males and 18.2% were in females. The most common reported race was white (47.3%) and most of the patients were ≥29 days old (72.5%). There was no difference in the odds of postoperative complications, but females had a significantly longer length of stay (incidence rate ratio, 1.28; 95% confidence interval [95% CI], 1.18-1.39; P ≤ 0.01), higher cost (5%, 95% CI, 1.02-1.08; P ≤ 0.01), and higher odds of mortality (odds ratio, 3.26; 95% CI, 1.52-6.98; P ≤ 0.01).

CONCLUSIONS

Our study demonstrated that females had worse outcomes after pyloromyotomy compared with males. These findings are striking and are important to consider when treating either sex to help set physician and family expectations perioperatively. Further studies are needed to determine why such differences exist and to develop targeted treatment strategies for both females and males with pyloric stenosis.

Advanced gallbladder inflammation is a risk factor for gallbladder perforation in patients with acute cholecystitis

Background

Acute perforated cholecystitis (APC) is probably the most severe benign gallbladder pathology with high rates of morbidity and mortality. The cause of APC has not been fully understood. We postulated that APC is a complication of advanced gallbladder inflammation. The aim of this study was to investigate the extent of gallbladder inflammation in patients with APC.

Methods

Patients with intraoperative and histopathologic diagnosis of APC were compared with cases with acute cholecystitis without perforation with respect to the extent of inflammation on histopathology as well as surgical outcomes.

Results

Fifty patients with APC were compared to 150 cases without perforation. Advanced age > 65 years and elevated CRP were confirmed on multivariate analysis as independent risk factors for APC. Advanced gallbladder inflammation was seen significantly more often in patients with APC (84.0 vs. 18.7%). Surgery lasted significantly longer 131.3 ± 55.2 min vs. 100.4 ± 47.9 min; the rates of conversion (22 vs. 4%), morbidity (24 vs. 7%), and mortality (8 vs. 1%) were significantly higher in patients with APC. ICU management following surgery was needed significantly more often in the APC group (56 vs. 15%), and the overall length of stay (11.2 ± 12.0 days vs. 5.8 ± 6.5 days) was significantly longer compared to the group without perforation.

Conclusion

Acute gallbladder perforation in patients with acute cholecystitis represents the most severe complication of cholecystitis. Acute perforated cholecystitis is a sequela of advanced gallbladder inflammation like empyematous and gangrenous cholecystitis and is associated with poor outcome compared to non-perforated cases.

Is the male gender an independent risk factor for complication in patients undergoing laparoscopic cholecystectomy for acute cholecystitis?

This paper was designed to investigate the gender dependent risk of complication in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. Laparoscopic cholecystectomy is the standard procedure for benign gallbladder disorders. The role of gender as an independent risk factor for complicated laparoscopic cholecystectomy remains unclear. A retrospective single-center analysis of laparoscopic cholecystectomies performed for acute cholecystitis over a 5-year period in a community hospital was performed. Within the period of examination, 1884 laparoscopic cholecystectomies were performed. The diagnosis was acute cholecystitis in 779 cases (462 female, 317 male). The male group was significantly older (P = 0.001). Surgery lasted significantly longer in the male group (P = 0.008). Conversion was done in 35 cases (4.5%). There was no significant difference in the rate of conversion between both groups. However the rate of conversion was significantly higher in male patients > 65 years (P = 0.006). The length of postoperative hospital stay was significantly longer in the male group (P = 0.007), in the group > 65 years (P = 0.001) and following conversion to open surgery (P = 0.001). The male gender was identified as an independent risk factor for prolonged laparoscopic cholecystectomy on multivariate analysis. The male gender could be an independent risk factor for complicated or challenging surgery in patients undergoing laparoscopic cholecystectomy for acute cholecystitis.

Preoperative factors predicting the need for additional ports during single-incision laparoscopic cholecystectomy

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) is gaining popularity as a minimally invasive technique that provides some benefits in terms of improved cosmesis. However, the insertion of an additional port is required in a subset of cases.

METHODS

We retrospectively analyzed 308 SILC procedures in patients with benign gallbladder diseases, except acute cholecystitis, to identify preoperative factors predicting the need for an additional port.

RESULTS

SILC was completed with a single incision in 272 patients (88%); the insertion of at least one additional port was required in 36 patients (12%). The additional port requirement was associated with a longer operative time (P < 0.0001), greater intraoperative blood loss (P < 0.0001), and longer postoperative hospital stay (P = 0.0002). Multivariate analysis revealed male gender (odds ratio: 2.57, P = 0.0170), prior history of upper abdominal surgery (odds ratio: 5.53, P = 0.0132), and a higher preoperative white blood cell count (odds ratio: 3.62, P = 0.0244) to be independent factors associated with the requirement for an additional port.

CONCLUSION

Our results suggest that gender, prior history of upper abdominal surgery, and white blood cell count can predict the likelihood of requiring an additional port in SILC.

[Not Available]

OBJECTIVES

Database review to analyse age and sex differences in complication and conversion rates and influence on return to normal daily activities and work after laparoscopic cholecystectomy (LC).

METHODS

658 patients had a laparoscopic cholecystectomy for proven gallstones between 9/4/2001 and 15/2/2006 under the care of one surgeon (F. H.) at Benenden hospital, Kent, UK.

RESULTS

We had a 65.5% response rate with 431 replies at a mean follow up of 22.4 months (2.3-52.8). There was a male to female ratio of 5:23 with a mean age of 54.2 years (22-83). Using linear regression we found no significant correlation with operative time and variables of age and sex (df = 2, 251, R (2) = 0.03, F = 0.574, p < 0.564). No significant correlation with number of complications and age or sex (df = 2, 334, R (2) = 0.004, F = 1.615, p < 0.200). Age (Exp(B) = 1.040, p < 0.51) and sex (Exp(B) = 0.863, p < 0.855) had no effect on conversion. No difference was found in relation to age and sex with return to normal daily activities (df = 2, 307, F = 0.904, p < 0.406). Age was a non-significant predictor of return to work (Beta = 0.040, p < 0.572) however men return to work significantly sooner (Beta = 0.191, p < 0.007).

CONCLUSIONS

Operative time, number of complications, conversion to open and return to normal daily activities may not be affected by age or sex of patients. Hospital stay may be longer in older patients. Men appear to return to work sooner. Further analysis with validated questionnaires are required.

Critically ill patients with acute cholecystitis are at increased risk for extensive gallbladder inflammation

Background

Acute cholecystitis is a common diagnosis and surgery is the standard of care for young and fit patients. However, due to high risk of postoperative morbidity and mortality, surgical management of critically ill patients remains a controversy. It is not clear, whether the increased risk of perioperative complications associated with the management of critically ill patients with acute cholecystitis is secondary to reduced physiologic reserve per se or to the severity of gallbladder inflammation.

Methods

A retrospective analysis of prospectively collected data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a university hospital over a three-year-period was performed. The ASA scores at the time of presentation were used to categorize patients into two groups. The study group consisted of critically ill patients with ASA 3 and 4, while the control group was made up of fit patients with ASA 1 and 2. Both groups were compared with regard to perioperative data, postoperative outcome and extent of gallbladder inflammation on histopathology.

Results

Two hundred and seventeen cases of acute cholecystitis with complete charts were available for analysis. The study group included 67 critically ill patients with ASA 3 and 4, while the control group included 150 fit patients with ASA 1 and 2. Both groups were comparable with regard to perioperative data. Histopathology confirmed severe cholecystitis in a significant number of cases in the study group compared to the control group (37 % vs. 18 %, p = 0.03). Significantly higher rates of morbidity and mortality were recorded in the study group (p < 0.05). Equally, significantly more patients from the study group were managed in the ICU (40 % vs. 8 %, p = 0.001).

Conclusion

Critically ill patients presenting with acute cholecystitis are at increased risk for extensive gallbladder inflammation. The increased risk of morbidity and mortality seen in such patients might partly be secondary to severe acute cholecystitis.

Gastrointestinal quality-of-life after cholecystectomy: indication predicts gastrointestinal symptoms and abdominal pain

BACKGROUND

Despite the fact that cholecystectomy is a common surgical procedure, the impact on long-term gastrointestinal quality of life is not fully known.

METHODS

All surgical procedures for gallstone disease performed at Mora County Hospital, Sweden, between 2 January 2002 and 2 January 2005, were registered on a standard database form. In 2007, all patients under the age of 80 years at follow-up were requested to fill in a form containing the Gastrointestinal Quality-of-Life Index (GIQLI) questionnaire and a number of additional questions. The outcome was analysed with respect to age, gender, smoking, surgical technique, and original indication for cholecystectomy.

RESULTS

A total of 627 patients (447 women, 180 men) underwent cholecystectomy, including laparoscopic cholecystectomy (N = 524), laparoscopic cholecystectomy converted to open cholecystectomy (N = 43), and open cholecystectomy (N = 60). The mean time between cholecystectomy and follow-up with the questionnaire was 49 months. The participation rate was 79 %. Using multivariate analysis in the form of generalised linear modelling, the original indication for cholecystectomy in combination with gender (p = 0.0042) was found to predict the GIQLI score. Female gender in combination with biliary colic as indication for cholecystectomy correlated with low GIQLI scores. Female gender also correlated with a higher risk for pain in the right upper abdominal quadrant after cholecystectomy (p = 0.028).

CONCLUSIONS

We found the original indication for cholecystectomy, together with gender, to predict gastrointestinal symptoms and abdominal pain after cholecystectomy. Careful evaluation of symptoms is important before planning elective cholecystectomy.

PREOP-Gallstones: A Prognostic Nomogram for the Management of Symptomatic Cholelithiasis in Older Patients

OBJECTIVE AND BACKGROUND

The decision regarding elective cholecystectomy in older patients with symptomatic cholelithiasis is complicated. We developed and validated a prognostic nomogram to guide shared decision making for these patients.

METHODS

We used Medicare claims (1996-2005) to identify the first episode of symptomatic cholelithiasis in patients older than 65 years who did not undergo hospitalization or elective cholecystectomy within 2.5 months of the episode. We described current patterns of care and modeled their risk of emergent gallstone-related hospitalization or cholecystectomy at 2 years. Model discrimination and calibration were assessed using a random split sample of patients.

RESULTS

We identified 92,436 patients who presented to the emergency department (8.3%) or physician's office (91.7%) and who were not immediately admitted. The diagnosis for the initial episode was biliary colic/dyskinesia (65.3%), acute cholecystitis (26.6%), choledocholithiasis (5.7%), or gallstone pancreatitis (2.4%). The 2-year emergent gallstone-related hospitalization rate was 11.1%, with associated in-hospital morbidity and mortality rates of 56.5% and 6.5%. Factors associated with gallstone-related acute hospitalization included male sex, increased age, fewer comorbid conditions, complicated biliary disease on initial presentation, and initial presentation to the emergency department. Our model was well calibrated and identified 51% of patients with a risk less than 10% for 2-year complications and 5.4% with a risk more than 40% (C statistic, 0.69; 95% confidence interval, 0.63-0.75).

CONCLUSIONS

Surgeons can use this prognostic nomogram to accurately provide patients with their 2-year risk of developing gallstone-related complications, allowing patients and physicians to make informed decisions in the context of their symptom severity and its impact on their quality of life.

Is gallbladder inflammation more severe in male patients presenting with acute cholecystitis?

BACKGROUND

The male gender is considered a risk factor for complications in patients undergoing laparoscopic cholecystectomy. The reasons for this gender associated risk are not clearly understood. The extent of gallbladder inflammation has been shown to influence surgical outcome. The aim of this study was to investigate whether or not gallbladder inflammation is more severe in male patients presenting with acute cholecystitis.

METHODS

A retrospective gender dependent comparison of the data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a primary care facility within a five-year period was performed.

RESULTS

138 patients, 69 males and 69 females were included for analysis. Severe gallbladder inflammation (gangrenous and necrotizing cholecystitis) was seen in a significant portion of the male population compared to the female population (p = 0.002). The male gender was confirmed in a multivariate analysis as an independent risk factor for severe cholecystits (p = 0.018).

CONCLUSION

The male gender is a risk factor for severe gallbladder inflammation. An early surgical intervention may be needed to prevent complications.

Trends in cholecystectomy rates in a defined population during and after the period of transition from open to laparoscopic surgery

OBJECTIVE

To evaluate cholecystectomy rates in a Norwegian county during the transition time from open to laparoscopic surgery, with focus on the incident rate of laparoscopic operations, sex differences, age at operation, and indications for cholecystectomy.

MATERIAL AND METHODS

All 2615 patients living in North Trondelag County and operated with cholecystectomy for benign biliary disease between 1990 and 2011 were identified. Poisson regression was used to analyze factors associated with cholecystectomy incidence rate ratios (IRRs).

RESULTS

The proportion of completed laparoscopic cholecystectomies was 8% in 1992, 50% in 1994, 94% in 2003 and 99% in 2011. The incidence of cholecystectomy increased from 6.2 per 10 000 person-years in 1990-1992, 8.0 in 1993-1997, to 10.0 in 1998-2003 and remained at this level with a rate of 10.7 during 2004-2011. Adjusting for age at each year of surgery the IRR for females compared with males was 2.3(2.1-2.5) p < 0.001. The median age at operation was 60.2 years (13-90) in males, 50.1 years (12-93) in females p < 0.001. The median age diminished by 5 years in both males and females. A conversion from laparoscopic to open surgery decreased significantly by calendar year of surgery, increased with age of the patient, and was less often in surgery for gallstone colic than for other indications.

CONCLUSIONS

During the introduction of laparoscopic surgery, the rates of cholecystectomy increased and remained stable at a higher level during the later years of the study. The rate of completed laparoscopic operations increased from 8% in 1992 to 99% in 2011.

Does sex affect the outcome of laparoscopic cholecystectomy? A retrospective analysis of single center experience

INTRODUCTION

The aim of our study was to determine the effect of sex on the outcome of laparoscopic cholecystectomy in terms of operative time, conversion to open cholecystectomy, postoperative complications and mean hospital stay.

METHODS

In this retrospective observational study, we analyzed the medical records of 2061 patients who underwent laparoscopic cholecystectomy in the surgical department of Khyber Teaching Hospital (Peshawar, Pakistan) between March 2008 and January 2010. χ(2) test and t-test were respectively used to analyze categorical and numerical variables. P ≤ 0.05 was considered significant.

RESULTS

The study included 1772 female and 289 male patients. The mean age for male patients was 44.07 ± 11.91 years compared to 41.29 ± 12.18 years for female patients (P = 0.706). Laparoscopic cholecystectomy was successfully completed in 1996 patients. The conversion rate was higher in men (P < 0.001), and the mean operating time was longer in men (P < 0.001). Bile duct injuries occurred more frequently in men (P < 0.001). Gallbladder perforation and gallstone spillage also occurred more commonly in men (P = 0.001); similarly severe inflammation was reported more in male patients (P = 0001). There were no statistically significant differences in mean hospital stay, wound infection and port-site herniation between men and women. Multivariate regression analysis showed that the male sex is an independent risk factor for conversion to open cholecystectomy (odds ratio = 2.65, 95% confidence interval: 1.03-6.94, P = 0.041) and biliary injuries (odds ratio = 0.95, 95% confidence interval: 0.91-0.99, P-value = 0.036).

CONCLUSIONS

Laparoscopic cholecystectomy is often challenging in men on account of more adhesions and inflammation. This leads to higher conversion rates and more postoperative complications. Optimized planning and a more experienced operating surgeon may help overcome these problems.

Laparoscopic cholecystectomy in a single, non-teaching hospital: an analysis of 1557 patients

BACKGROUND

Laparoscopic cholecystectomy may lead to serious complications, although it is the gold standard treatment for gallstones. In this article, the aim was to review our experience with laparoscopic cholecystectomies.

SUBJECTS AND METHODS

All laparoscopic cholecystectomies were performed in a single, non-teaching hospital between January 2000 and October 2010 and were reviewed retrospectively to analyze the effect of preoperative risk factors on outcome and the associated major complications.

RESULTS

This study included 1557 laparoscopic cholecystectomies, and the mean age of the patients was 54.1±12.3 years. The mean duration of the operation and the mean length of stay were 43.4 minutes and 1.2 days, respectively. Conversion to an open cholecystectomy was necessary in 39 patients, and thus the conversion rate was 2.5%. In total, 57 (3.7%) complications occurred in 51 patients. Serious common bile duct injury was seen in 4 (0.27%) cases. The other common complications included bile leakage in 10 (0.64%) and postoperative bleeding in 7 (0.45%) patients. The mortality rate was 0.13%. Risk factors for conversion to open surgery were male gender, age >55 years, emergency admission due to acute cholecystitis, and a history of previous acute cholecystitis attacks. Factors that increased the morbidity rate were male gender, an American Society of Anesthesiologists score of III, emergency admission due to acute cholecystitis, and a history of previous acute cholecystitis attacks.

CONCLUSIONS

Our results may serve as a baseline for comparison with future studies done at single, non-teaching hospitals where surgical teams perform laparoscopic cholecystectomies over a long period of time.

Risk factors in laparoscopic cholecystectomy: a multivariate analysis

BACKGROUND

Laparoscopic cholecystectomy (LC) is the operation of choice in the treatment of symptomatic gallstone disease. The aim of this study is to identify risk factors for LC, outcomes include operating time, length of stay, conversion rate, morbidity and mortality.

METHODS

All patients undergoing LC between 1998 and 2007 in a single district general hospital. Risk factors were examined using uni- and multivariate analysis.

RESULTS

2117 patients underwent LC, with 1706 (80.6%) patients operated on electively. Male patients were older, had more co-morbidity and more emergency surgery than females. The median post-operative hospital stay was one day, and was positively correlated with the complexity of surgery. Conversion rates were higher in male patients (OR 1.47, p = 0.047) than in females, and increased with co-morbidity. Emergency surgery (OR 1.75, p = 0.005), male gender (OR 1.68, p = 0.005), increasing co-morbidity and complexity of surgery were all positively associated with the incidence of complications (153/2117 [7.2%]), whereas only male gender was significantly associated with mortality (OR 5.71, p = 0.025).

CONCLUSION

Adverse outcome from LC is particularly associated with male gender, but also the patient's co-morbidity, complexity and urgency of surgery. Risk-adjusted outcome analysis is desirable to ensure an informed consent process.

What necessitates the conversion to open cholecystectomy? A retrospective analysis of 5164 consecutive laparoscopic operations

OBJECTIVE

Laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease, but conversion to open cholecystectomy is still inevitable in certain cases. Knowledge of the rate and impact of the underlying reasons for conversion could help surgeons during preoperative assessment and improve the informed consent of patients. We decided to review the rate and causes of conversion from laparoscopic to open cholecystectomy.

METHOD

This study included all laparoscopic cholecystectomies due to gallstone disease undertaken from May 1999 to June 2010. The exclusion criteria were malignancy and/or existence of gallbladder polyps detected pathologically. Patient demographics, indications for cholecystectomy, concomitant diseases, and histories of previous abdominal surgery were collected. The rate of conversion to open cholecystectomy, the underlying reasons for conversion, and postoperative complications were also analyzed.

RESULTS

Of 5382 patients for whom LC was attempted, 5164 were included this study. The overall rate of conversion to open cholecystectomy was 3.16% (163 patients). There were 84 male and 79 female patients; the mean age was 52.04 years (range: 26-85). The conversion rates in male and female patients were 5.6% and 2.2%, respectively (p < 0.001). The most common reasons for conversion were severe adhesions caused by tissue inflammation (97 patients) and fibrosis of Calot's triangle (12 patients). The overall postoperative morbidity rate was found to be 16.3% in patients who were converted to open surgery.

CONCLUSION

Male gender was found to be the only statistically significant risk factor for conversion in our series. LC can be safely performed with a conversion rate of less than 5% in all patient groups.

Sex differences in laparoscopic cholecystectomy

BACKGROUND

Conversion from laparoscopic to open cholecystectomy may not be desirable due to the increased complication rate and prolonged convalescence. In Denmark, nationwide data show that 7.7% of the laparoscopic cholecystectomies are converted to open surgery. This article aims to document the relationship of gender to conversion rate and length of hospital stay after laparoscopic cholecystectomy in a national cohort of patients.

METHODS

The gender of 5,951 patients from the 2007 National Danish Cholecystectomy Database was compared with conversion rate, length of hospital stay, and various risk factors using multivariate analyses.

RESULTS

The findings showed that 14.3% of the patients had acute cholecystitis and that men had the highest risk (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.66-2.27). The operative findings for the men included sequelae from previous acute cholecystitis more frequently than the findings for the women (OR, 1.89; 95% CI, 1.67-2.15). The rate for conversion from laparoscopic to open surgery was 7.7%, and male sex was highly associated with conversion (OR, 2.48; 95% CI, 2.04-3.01). Thus, 259 (5.8%) of the 4,451 operations for women were converted to laparotomy compared with 199 (13.3%) of the 1,500 operations for men. No significant sex differences were found in the proportion of bile duct lesions (those requiring reconstructive surgery as well as those that could be handled by endoscopy or T-tube drainage, suturing, or both) or in the 30-day mortality rate. The multivariate analyses showed that male sex was a significant factor for conversion but not for length of postoperative stay or readmission.

CONCLUSION

Men showed a significantly higher risk of the operation being converted from laparoscopic to open cholecystectomy than women (OR, 2.48; 95% CI, 2.04-3.01). The main reason for this may be that men more frequently had acute cholecystitis or sequelae from previous acute cholecystitis. These results can be used to give patients a better basis for their informed consent and better resource management in connection with the operation.

Factors influencing the successful completion of laparoscopic cholecystectomy

This study found that advanced age, presentation with acute cholecystitis, and choledocholithiasis are independent risk factors for conversion from laparoscopic to open cholecystectomy.

Objective:

To analyze the preoperative factors contributing to the decision to convert laparoscopic to open cholecystectomy.

Methods:

Retrospective identification of 324 consecutive patients undergoing laparoscopic cholecystectomy, with univariate and multivariate analysis of the following parameters: age, gender, obesity, previous abdominal surgery, presentation with acute cholecystitis, pancreatitis or obstructive jaundice, gallbladder wall thickening, gallbladder or common bile duct stones.

Results:

Thirty-nine patients (12%) underwent conversion to open cholecystectomy. Patients aged over 65 years were four times more likely to require conversion than patients under 50 years of age. Under 50 years of age, males had equal conversion rates to females, and above this age there was a non-significant increased conversion rate in males. Obese patients had higher conversion rates than non-obese patients (23% versus 9%, P < 0.003). Thirty-eight percent of patients with choledocholithiasis required conversion. Age, acute cholecystitis and choledocholithiasis independently predicted conversion. A patient aged less than fifty years with neither acute cholecystitis nor choledocholithiasis had a conversion rate of just 2%, while almost 60% of those over 65 years of age with acute cholecystitis or choledocholithiasis required conversion.

Conclusion:

The parameters of age, acute cholecystitis and choledocholithiasis must be considered in the clinical decision making process when planning laparoscopic cholecystectomy.

Are histological alterations observed in the gallbladder precancerous lesions?

INTRODUCTION

Gallbladder cancer, which is characterized by rapid progression and a poor prognosis, is a complex disease to treat. Unfortunately, little is known currently about its etiology or pathogenesis. A better understanding of its carcinogenesis and determining risk factors that lead to its development could help improve the available treatment options.

METHOD

Based on this better understanding, the histological alterations (such as acute cholecystitis, adenomyomatosis, xanthogranulomatous cholecystitis, polyps, pyloric metaplasia, intestinal metaplasia, dysplasia, cancer and others) in gallbladders from 1,689 patients who underwent laparoscopic cholecystectomy for cholecystolithiasis were analyzed. The association of these gallbladder histological alterations with clinical data was studied.

RESULTS

Gender analysis revealed a greater incidence of inflammatory changes in males, while dysplasia and cancer were only found in women. The incidence of cholesterolosis was greater in the patients 60 years of age and under, and the incidence of adenomyomatosis and gangrene was greater in the elderly patients. A progressive increase in the average age was observed as alterations progressed through pyloric metaplasia, intestinal metaplasia, dysplasia and then cancer, suggesting that the metaplasia-dysplasia-carcinoma sequence may occur in gallbladder cancer. Gallbladder histological alterations were also observed in asymptomatic patients.

CONCLUSION

The results of this study suggest that there could be an association between some histological alterations of gallbladder and cancer, and they also suggest that the metaplasia-dysplasia-carcinoma sequence could in fact be true in the case of gallbladder cancer. Nevertheless, further studies directed towards a perfect understanding of gallbladder carcinogenesis are required.

Laparoscopic cholecystectomy in patients with empyematous cholecystitis: an outcome analysis

BACKGROUND

Laparoscopic cholecystectomy (LC), the procedure of choice for elective cholelithiasis, is now also used in the management of acute cholecystitis. Empyema of the gallbladder is unexpectedly encountered in a proportion of these patients. This paper describes our experience with LC in the treatment of patients with empyema of the gallbladder.

METHODS

From May 1992 to July 2007, 315 patients with a clinical diagnosis of acute cholecystitis underwent LC. Operative and histopathology reports were used to identify patients with empyema of the gallbladder, to which retrospective chart reviews were applied. Factors associated with conversion and complications were assessed to determine their predictive power.

RESULTS

Being male and having high levels of aspartate transaminase (AST), alanine transaminase (ALT), and white blood cells significantly influenced the prediction of empyema. The conversion rate was significantly higher for empyema and acute cholecystitis, but the complication rate did not differ significantly between these conditions. Previous abdominal surgery was an independent risk factor for conversion and complications. Also, temperature >37.5°C, AST >60 IU/l, and ALT >60 IU/l were associated with higher conversion rates. The hospital stay was longer in patients with empyema, while the operation time did not differ between the two groups.

CONCLUSION

Empyema of the gallbladder can be encountered in patients with presumed acute cholecystitis. Preoperatively differentiating between simple acute cholecystitis and empyema is difficult, if not impossible. The conversion rate is expected to be higher when empyema is approached laparoscopically than for simple acute cholecystitis or symptomatic cholelithiasis.