Is there a role for drain use in elective laparoscopic cholecystectomy? A controlled randomized trial

BACKGROUND

Although the issue of drain use in open cholecystectomy has been adequately addressed by prospective randomized trials, there is lack of evidence on the usefulness of drains in elective laparoscopic cholecystectomy, and the surgeons follow their beliefs and bias on this debate. Therefore, a controlled randomized trial was designed to assess the value of drains in elective laparoscopic cholecystectomy.

METHODS

During a 5-year period (January 2002 to December 2006), 284 patients were randomized to have a drain placed (group A), whereas 281 patients were randomized not to have a drain (group B) placed in the subhepatic space. End points of this trial were to detect any differences in morbidity, postoperative pain, and hospital stay between the 2 groups.

RESULTS

There was no mortality in either group and no statistically significant difference in morbidity or hospital stay between the 2 groups. However, postoperative pain was significantly increased in patients who had a drain placed; median visual analog scale (VAS) score was 5 (range 1 to 8) versus 3 (range 1 to 8), in the non-drained group (P < .0001). Interestingly, in 2 of 3 patients in whom a drain was placed against randomization because of bile leak suspicion, a bile leak occurred.

CONCLUSIONS

The routine use of a drain in elective laparoscopic cholecystectomy has nothing to offer; in contrast, it is associated with increased pain. It would be reasonable, however, to leave a drain if there is a worry about an unsolved or potential bile leak, bearing in mind that drain placement, although sometimes providing a false sense of security, does not guarantee either prevention or treatment of postoperative bile collections, bleeding, or bile peritonitis.

Laparoscopic cholecystectomy in the pediatric population

BACKGROUND

The experience with laparoscopic cholecystectomy in children trails the adult numbers and remains underreported. Therefore, we reviewed our experience with this approach.

METHODS

A retrospective review of our most recent 6-year experience with laparoscopic cholecystectomy at Children's Mercy Hospital (Kansas City, MO) between September 5, 2000, and June 1, 2006, was performed. Data points reviewed included patient demographics, indication for operation, operative time, complications, and recovery.

RESULTS

During the study period, 224 patients underwent a laparoscopic cholecystectomy. The mean age was 12.9 years (range, 0-21) with a mean weight of 58.3 kg (range, 3-121). Indications for laparoscopic cholecystectomy were symptomatic gallstones in 166 children, biliary dyskinesia in 35, gallstone pancreatitis in 7, gallstones and an indication for splenectomy in 6, calculous cholecystitis in 5, choledocholithiasis in 1, gallbladder polyps in 1, acalculous cholecystitis in 1, and congenital cystic duct obstruction in 1. The mean operative time (excluding patients with concomitant operations) was 77 minutes (range, 30-285). An intraoperative cholangiogram was performed in 38 patients. Common bile duct (CBD) stones were cleared intraoperatively in 5 patients. Two patients required a postoperative endoscopy to retrieve CBD stones. One sickle-cell patient developed a postoperative hemorrhage, requiring a laparotomy. There were no conversions, ductal injuries, bile leaks, or mortality. Biliary dyskinesia was diagnosed in 10% of the first 30 patients in this series and 40% of the most recent 30 patients. The mean ejection fraction in these patients was 21%. All experienced an improvement in their symptoms after the cholecystectomy.

CONCLUSIONS

Laparoscopic cholecystectomy is safe and effective in children. Biliary dyskinesia is becoming more frequently diagnosed in children, and these patients respond favorably to cholecystectomy. As opposed to the adult population, the incidence of complicated gallstone disease appears less common in children, as most present with symptomatic cholelithiasis without active inflammation, accounting for the very low rate of ductal complications.