Patienten* nach unauffälliger elektiver laparoskopischer Cholezystektomie können ohne Laborwertkontrollen entlassen werden – Ergebnisse einer prospektiven Studie

Hintergrund

Die Bedeutung postoperativer Laborkontrollen nach elektiver laparoskopischer Cholezystektomie (lap. CHE) ist umstritten. Das Ziel dieser prospektiven Studie war es, herauszufinden, ob Patienten* bei unauffälligem perioperativem Verlauf nach lap. CHE ohne Laborwertkontrollen sicher entlassen werden können.

Methodik

Vom 09/20 bis 03/22 wurden alle Patienten* mit einer lap. CHE gescreent und nach Erhalt des Einverständnisses in die Studie eingeschlossen. Der Verlauf wurde mit einem Scoring- (Punktewert 3–15 Punkte) und Befragungsbogen strukturiert verfolgt. Ein Scoringwert von ≤ 9 Punkten beschrieb einen unauffälligen perioperativen Verlauf. Die Ethikkommission Heidelberg hat dieser Studie zugestimmt (S-026/2020).

Ergebnisse

Es wurden 275 Patienten* mit Gallenblasenoperation erfasst. Davon unterzogen sich 80 % einer elektiven lap. CHE. 56 Patienten* (25 %) wurden in die Studie eingeschlossen, 51 Patienten* wurden bei einem Scoringwert ≤ 9 Punkten ohne Blutentnahme entlassen. Das Durchschnittsalter der 51 Patienten* war 50,8 Jahre, der durchschnittliche Krankenhausaufenthalt betrug 2,6 Tage. 40 von 51 Patienten* (78,4 %) konnten postoperativ befragt werden. Bei keinem der Patienten* kam es nach Entlassung zu relevanten Komplikationen. 27 der 40 Patienten* (67,5 %) sind postoperativ noch einmal zum Hausarzt gegangen. Aufgrund anderer Operationen und einer endoskopischen Intervention sind 4 Patienten* erneut stationär behandelt worden. Alle Patienten* waren mit dem chirurgischen Verlauf zufrieden.

Diskussion

Patienten* mit unauffälligem perioperativem Verlauf nach elektiver lap. CHE (Scoringwert ≤ 9 Punkten) können ohne postoperative Laborwertkontrolle entlassen werden.

[Which patient needs controls of laboratory values after elective laparoscopic cholecystectomy?-Can a score help?]

BACKGROUND

Laparoscopic cholecystectomy is nearly exclusively carried out as an inpatient operation in Germany. The aim of the study was to evaluate for which patients postoperative laboratory control values are necessary.

METHODS

This retrospective analysis included 100 patients who underwent elective laparoscopic cholecystectomy. A scoring and data collection sheet was developed, which enables a risk stratification. Using the scoring system patients can achieve between 3 and 15 points.

RESULTS

In total 100 patients were included in the study. Of the patients 64 (group 1) had between 3 and 8 points, 29 patients (group 2) between 9 and 11 points and 7 patients (group 3) between 12 and 15 points. In comparison to group 1 the C‑reactive protein values as well as the duration of hospital stay were significantly increased in group 2 and group 3 (p > 0.05). In group1 a total of 60 patients (93.7%) were discharged regularly on postoperative days 1-3. In group 2 there were 17 patients (58.6%) who could be discharged with unremarkable blood values and in group 3 there were 3 patients (42.8%). In the total collective hospital discharge without a laboratory control of blood values would have been justified in 80% of the patients.

CONCLUSION

A postoperative control of laboratory blood values is not routinely necessary for patients after elective laparoscopic cholecystectomy with a score <9 points.

Utility of liver function tests in acute cholecystitis

BACKGROUNDS/AIMS

Common bile duct stones (CBDS) affect the management of acute cholecystitis (AC). This study aims to investigate the utility of liver function tests (LFTs) in predicting the presence of CBDS in AC patients.

METHODS

Retrospective cohort study of adult patients with AC found in the American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2016. Patients were classified into two groups, without CBDS (AC-) and with CBDS (AC+). LFT results namely total bilirubin, SGOT and ALP were collected and categorized into normal and abnormal with the cut-offs of 1.2 mg/dl for total bilirubin, 40 U/L for SGOT and 120 IU/L for ALP. Measures of diagnostic accuracy for individual and combinations of LFTs were computed.

RESULTS

A total of 32,839 patients were included in the study, with 8,801 (26.8%) AC+ and 24,038 (73.2%) AC- patients. Their mean age was 52.4 (±18.6) years and over half (59.1%) were females. Mean LFT results were significantly higher in the AC+ group for total bilirubin (1.82 vs 0.97), SGOT (110.9 vs 53.3) and ALP (164.4 vs 102.3) (p<0.0001). The proportions of abnomal LFTs were significantly higher in the AC+ group for total bilirubin (47.7% vs 20.2%), SGOT (62.8% vs 27.1%) and ALP (56.6% vs 21.0%) (p<0.0001). Among AC+, the odds of having abnormal results for bilirubin, SGOT and ALP were found to be 3.61, 4.54 and 4.90 times higher than among AC-, respectively.

CONCLUSIONS

Abnormal LFTs are strong predictors for the presence of CBDS in patients with AC. Normal LFTs should be interpreted with caution as some patients with AC and CBDS might not present with characteristic abnormalities in results.

Routine ultrasound and blood tests after laparoscopic cholecystectomy-are they worthwhile? A diagnostic accuracy study

PURPOSE

Delayed recognition of complications can have life-threatening sequelae and is a leading cause of medical litigation. Minimal evidence exists for benefits of postoperative surveillance. This study investigated whether ultrasound (US) and blood tests can detect complications after laparoscopic cholecystectomy.

METHODS

A series of 772 laparoscopic cholecystectomies performed between February 2008 and October 2009 was retrospectively analyzed. Routine US was performed within 6 h postoperatively, and a blood sample was taken at the second postoperative day.

RESULTS

Postoperative US was performed in 722 patients. Fluid accumulation was documented in 104 patients; only two of these patients had clinically significant findings requiring treatment. The best predictor of infectious complications was elevated postoperative C-reactive protein (≥123 mg/L), with an area under the curve (AUC) of 0.94 and a number needed to misdiagnose (NNM) of 8.7. To predict postoperative choledocholithiasis, a combination of total bilirubin, aspartate aminotransferase and alkaline phosphatase elevations, with cutoff values of 1.3 mg/dL, 37 IU/L, and 136 IU/L, respectively, attained the highest accuracy with a NNM of 29.5. Ultrasonographic detection of bile duct dilation further improved specificity, while lowering sensitivity.

CONCLUSIONS

The value of early routine postoperative US is low, unless there is clinical suspicion of complications. Routine blood tests have a high sensitivity for infectious complications and a high specificity for remnant biliary duct stones. Therefore, we recommend avoiding routine US postoperatively and performing routine postoperative blood tests. We also recommend facilitating easy access to postoperative US, as it can aid the decision to take therapeutic measures in symptomatic patients.

A scoring system for the prediction of choledocholithiasis: a prospective cohort study

BACKGROUND

Techniques for diagnosing choledocholithiasis pose significant morbidity and mortality risks.

OBJECTIVES

We aimed to develop and validate a clinical scoring system for predicting choledocholithiasis.

DESIGN

Data from a prospectively maintained database of all patients with gallstones.

SETTING

Patients were admitted to the general surgery department of a military hospital.

PATIENTS AND METHODS

We enrolled consecutive patients with symptomatic gallstones, biliary pancreatitis, obstructive jaundice, or cholangitis, who subsequently underwent biochemical testing and ultrasonography. A predictive model was developed from a scoring system using their imaging and laboratory data. Endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography were used for confirmatory diagnoses. The predictive efficacy of the scoring system was validated using a retrospective cohort of 272 patients.

MAIN OUTCOME MEASURES

Predictive accuracy of the scoring system.

RESULTS

We enrolled 155 patients in the development group. The common bile duct diameter, alkaline phosphatase of >=200 IU, elevated bilirubin levels, alanine transaminase of >=220 IU, and male age of >=50 years were significantly associated with choledocholithiasis and were included in the scoring system. Ninety-six patients (35%) had scores of >=8 (high risk), 86 patients (32%) had scores of 4-7 (intermediate risk), and 27 patients (10%) had scores of 1-3 (low risk). In the validation cohort, the positive predictive value for a score of >=8 was 91.7%, and the scoring system had an area under the curve of 0.896.

CONCLUSION

Scores of >=8 were strongly correlated with choledocholithiasis in the developmental and validation groups, which indicates that our scoring system may be useful for predicting the need for therapeutic ERCP. However, prospective validation in a large multicenter cohort is needed to fully understand the benefits of the system.

LIMITATIONS

The retrospective validation cohort might have introduced selection and observational biases. The study may have been underpowered because of the sample size of the developmental cohort. The delay between admission and the time of ERCP theoretically may have increased the number of negative ERCP results, but our false negative rate for ERCP was consistent with the previously reported rates.

Clinical characteristics of acute cholecystitis with elevated liver enzymes not associated with choledocholithiasis

AIM/BACKGROUND

Elevated liver enzymes are observed occasionally in patients with acute cholecystitis who do not have choledocholithiasis. The etiology and mechanism of this phenomenon are not well known. We aimed to compare the clinical characteristics between acute cholecystitis with and without choledocholithiasis in patients with elevated liver enzymes.

PATIENTS AND METHODS

The medical records of acute cholecystitis patients who underwent cholecystectomy between January 2001 and October 2011 were retrospectively reviewed. We retrieved data of patients who showed abnormal liver enzymes and underwent endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography, or intraoperative cholangiography.

RESULTS

We analyzed clinical characteristics and comorbidities in 424 patients. Among 424 cholecystectomy patients with abnormal liver enzymes, 178 (42%) patients did not have choledocholithiasis and 246 (58%) patients had choledocholithiasis. The median AST, ALT, and total bilirubin were 47, 82.5 IU/dl, and 1.21 mg/dl, respectively, in patients without choledocholithiasis and 58, 96 IU/dl, and 1.53 mg/dl, respectively, in patients with choledocholithiasis. In a multivariate logistic regression analysis, fatty liver [odds ratio (OR): 0.218; P<0.001], radiologic findings (OR: 0.414; P=0.001), and the level of total bilirubin (OR: 1.410; P=0.001) were independent predictors of choledocholithiasis.

CONCLUSION

Elevated liver enzymes in patients with cholecystitis who do not have choledocholithiasis are correlated with the presence of fatty liver and the severity of radiologic finding.

Bile duct injuries in the era of laparoscopic cholecystectomies

Bile duct injuries incurred during laparoscopic cholecystectomies remain a major complication in an otherwise safe surgery. These injuries are potentially avoidable with proper techniques and correct interpretation of the anatomy. The scope of the injury can range from a simple cystic duct leak to the injury of the left and right hepatic duct confluence. The key to successful outcomes from these injuries is to know when a referral to a specialized tertiary center is necessary. Evaluation and treatment of bile duct injuries is complex and often requires the expertise of an advanced endoscopist, interventional radiologist, and hepatobiliary surgeons. Before any planned intervention or operative repair, detailed evaluation of the biliary system and its associated vasculature is required. Better outcomes are achieved when patients are referred to centers specialized in biliary injury evaluation, treatment, and performing pretreatment planning early.

Jackson Pratt drain fluid-to-serum bilirubin concentration ratio for the diagnosis of bile leaks

BACKGROUND

Jackson Pratt (JP) drain fluid bilirubin levels may be assayed in the evaluation of possible bile leaks. Although fluid color and bilirubin level may prompt additional evaluation, there are no reference data available.

OBJECTIVE

To assess the JP drain fluid-to-serum bilirubin ratio in patients with documented bile leaks.

DESIGN

Prospective case series.

SETTING

Tertiary referral center.

METHODS

Patients referred for ERCP for the management of documented bile leaks with a JP drain in place were included. Demographic data, bile leak etiology, and serum bilirubin levels were recorded. JP drain fluid was sent for color evaluation and bilirubin concentration. Control subjects included both patients after nonbiliary surgery with a JP drain in place and medical patients with ascites undergoing paracentesis.

RESULTS

JP drain fluid-to-serum bilirubin concentration and fluid color evaluation was performed on 23 patients with documented bile leaks by ERCP and compared with 26 controls (16 surgical and 10 medical). The JP drain fluid/ascites-to-serum bilirubin ratio was significantly higher in those with bile leaks (mean ratio 45.6) compared with combined controls (mean ratio 0.9). Use of a cutoff JP drain fluid-to-serum bilirubin ratio of 5 would be 100% sensitive and specific for the prediction of a bile leak in the selected control group. There was overlap in fluid color evaluation between the groups.

LIMITATIONS

Controls did not include those with suspected bile leaks and negative technetium 99m-HIDA scintigraphy or ERCP findings.

CONCLUSIONS

JP drain fluid-to-serum bilirubin concentration ratio greater than 5 seems to be highly sensitive and specific for the detection of a bile leak. Used along with clinical criteria, this ratio could be used to select patients to proceed directly to ERCP.