Comparison of laparoscopic cholecystectomy in children at paediatric centres and adult centres: a systematic review and meta-analysis

INTRODUCTION

Paediatric laparoscopic cholecystectomy (LC) is performed by both paediatric and adult surgeons. The aim of this review was to compare outcomes at paediatric centres (PCs) and adult centres (ACs).

METHODS

A literature search was conducted, in accordance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, for papers published between January 2000 and December 2020. Statistical analysis was performed using Stata® version 16 (StataCorp, College Station, TX, US).

RESULTS

A total of 92 studies involving 74,852 paediatric LCs met the inclusion criteria. Over half (59%) of the LCs were performed at ACs. No significant differences were noted in the male-to-female ratio, mean age or mean body mass index between PCs and ACs. The main indications were cholelithiasis (34.1% vs 34.4% respectively, p=0.83) and biliary dyskinesia (17.0% vs 23.5% respectively, p<0.01). There was no significant difference in the median inpatient stay (2.52 vs 2.44 days respectively, p=0.89). Bile duct injury was a major complication (0.80% vs 0.37% respectively, p<0.01). Reoperation rates (2.37% vs 0.74% respectively, p<0.01) and conversion to open surgery (1.97% vs 4.74% respectively, p<0.01) were also significantly different. Meta-analysis showed no significant difference in overall complications (p=0.92).

CONCLUSIONS

The number of LCs performed, intraoperative cholangiography use and conversion rates were higher at ACs whereas bile duct injury and reoperation rates were higher at PCs. Despite a higher incidence of bile duct injury at PCs, the incidence at both PCs and ACs was <1%. In complex cases, a joint operation by both paediatric and adult surgeons might be a better approach to further improve outcomes. Overall, LC was found to be a safe operation with comparable outcomes at PCs and ACs.

High rate of stone-related complications after stapling the cystic duct during laparoscopic cholecystectomy-an underrecognized risk

BACKGROUND

Laparoscopic staplers (LS) have been suggested as a safe alternative to metal clips in laparoscopic cholecystectomy when the cystic duct is too inflamed or wide for complete clip occlusion. We aimed to evaluate the perioperative outcomes of patients whose cystic ducts were controlled by LS and evaluate the risk factors for complications.

METHODS

Patients who underwent laparoscopic cholecystectomy with LS used to control the cystic duct from 2005 to 2019 were retrospectively identified from an institutional database. Patients were excluded for open cholecystectomy, partial cholecystectomy, or cancer. Potential risk factors for complications were assessed using logistic regression analysis.

RESULTS

Among 262 patients, 191 (72.9%) were stapled for size and 71 (27.1%) for inflammation. In total, 33 (16.3%) patients had Clavien-Dindo grade ≥ 3 complications, with no significant difference when surgeons chose to staple for duct size versus inflammation (p = 0.416). Seven patients had bile duct injury. A large proportion had Clavien-Dindo grade ≥ 3 postoperative complications specifically related to bile duct stones [n = 29 (11.07%)]. Intraoperative cholangiogram was protective against postoperative complications [odds ratio (OR) = 0.18 (p = 0.022)].

CONCLUSION

Whether these high complication rates reflect a technical issue with stapling, more challenging anatomy, or worse disease, findings question whether the use of LS during laparoscopic cholecystectomy is truly a safe alternative to the already accepted methods of cystic duct ligation and transection. Based on these findings, an intraoperative cholangiogram should be performed when considering a linear stapler during laparoscopic cholecystectomy to: (1) ensure the biliary tree is free of stones; (2) prevent inadvertent transection of the infundibulum rather than the cystic duct; and, (3) allow opportunity for safe alternative strategies when an IOC is not able to confirm anatomy. Otherwise, surgeons employing LS devices should be aware that patients are at higher risk for complications.

Timing is everything: outcomes of 30,259 delayed cholecystectomies in New York State

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.

Reporting of complications after laparoscopic cholecystectomy: a systematic review

BACKGROUND

Consistent measurement and reporting of outcomes, including adequately defined complications, is important for the evaluation of surgical care and the appraisal of new surgical techniques. The range of complications reported after LC has not been evaluated. This study aimed to identify the range of complications currently reported for laparoscopic cholecystectomy (LC), and the adequacy of their definitions.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for prospective studies reporting clinical outcomes of LC, between 2013 and 2016.

RESULTS

In total 233 studies were included, reporting 967 complications, of which 204 (21%) were defined. One hundred and twenty-two studies (52%) did not provide definitions for any of the complications reported. Conversion to open cholecystectomy was the most commonly reported complication, reported in 135 (58%) studies, followed by bile leak in 89 (38%) and bile duct injury in 75 (32%). Mortality was reported in 89 studies (38%).

CONCLUSION

Considerable variation was identified between studies in the choice of measures used to evaluate the complications of LC, and in their definitions. A standardised set of core outcomes of LC should be developed for use in clinical trials and in evaluating the performance of surgical units.

Surgical management for bile duct injury

The management of bile duct injury (BDI) remains a considerable challenge in hepatobiliary surgery. BDI is mainly iatrogenic, and mostly occurs in cholecystectomy. Laparoscopic cholecystectomy (LC) has been performed widely, however, the incidence of BDI associated with LC increases 2-3 times compared to that in open cholecystectomy (OC). BDI also occurs in robotic cholecystectomy. In China, the evidence-based Practice Guideline for Diagnosis and Treatment of BDI was published by the Biliary Surgery Group of Surgery Branch of Chinese Medical Association, with the purpose of reducing the incidence of BDI as well as promoting its optimal diagnosis and treatment. Surgery remains the mainstay of treatment for BDI and traumatic bile duct stricture. The definitive repair involves a series of procedures including exposing the proximal and distal bile duct, anastomotic bile duct tissue preparation, minimally invasive tissue anastomoses, and so on. Successful management is a surgical challenge requiring great specialized experience and precise surgical skill. The application of precision biliary surgery is recommended for promoting standardized management of BDI.

Intraoperative cholangiography during cholecystectomy among hospitalized medicare beneficiaries with non-neoplastic biliary disease

BACKGROUND

Prior studies of Medicare beneficiaries with both neoplastic and non-neoplastic indications for cholecystectomy demonstrated a reduced risk of common bile duct (CBD) injury when intraoperative cholangiography (IOC) was used. We sought to determine the association between IOC and CBD injury during inpatient cholecystectomy for non-neoplastic biliary disease and compare survival among those with or without CBD injury.

METHODS

Retrospective study of patients ≥66 who underwent inpatient cholecystectomy (2005-2010) for gallstones, cholecystitis, cholangitis, or gallbladder obstruction. The association between IOC and CBD injury was analyzed using multivariable logistic regression and survival after cholecystectomy was analyzed using multivariable Cox regression.

RESULTS

Among 472,367 patients who underwent cholecystectomy, 0.3% had a CBD injury. IOC was associated with increased CBD injury (adjusted OR 1.41[1.27-1.57]). CBD injury was associated with increased hazards of death (adjusted HR 1.37[1.25-1.51]).

CONCLUSIONS

IOC in patients with non-neoplastic biliary disease was associated with increased odds of CBD injury. This likely reflects its selective use in patients at higher risk of CBD injury or as a confirmatory test when an injury is suspected.