Is a drain required after laparoscopic cholecystectomy?

The Rationale of sub-hepatic drainage on a specialist biliary unit: a review of 6140 elective and urgent laparoscopic cholecystectomies and bile duct explorations

BACKGROUND

Drains are used to reduce abdominal collections after procedures where such risk exists. Using abdominal drains after cholecystectomy has been controversial since the open surgery era. Universally accepted indications and agreement exist that routine drainage is unnecessary but the role of selective drainage remains undetermined. This study evaluates the indications and benefits of sub-hepatic drainage in patients undergoing laparoscopic cholecystectomy (LC) and bile duct exploration (BDE) in a specialist unit with a large biliary emergency workload.

METHODS

Prospectively collected data from 6,140 LCs with a 46.6% emergency workload over 30 years was reviewed. Demographic factors, pre-operative presentations, imaging and operative details in patients with and without drains were compared. Sub-hepatic drains were inserted after all transductal explorations, subtotal cholecystectomies, almost all open conversions and 94% of LC for empyemas. Adverse or beneficial postoperative drain-related outcomes were analysed.

RESULTS

Abdominal drains were utilised in 3225/6140 (52.5%). Patients were significantly older with more males. 59.4% were emergency admissions. Preoperative imaging showed thick-walled gallbladders in 25.2% and bile duct stones or dilatation in 36.2%. At operation they had cystic duct stones in 19.8%, acute cholecystitis, empyema or mucocele in 28.4% and operative difficulty grades III or higher in 59%. 38% underwent BDE, 5.4% had fundus-first dissection and the operating times were longer ( 80 vs.45 min). Drain related complications were rare; 3 abdominal pains after anaesthetic recovery settling when drains were removed, 2 drain site infections and one re-laparoscopy to retrieve a retracted drain. 55.8% of 43 bile leaks and 35% of 20 other collections in patients with drains resolved spontaneously.

CONCLUSIONS

The utilisation of drains in this study was relatively high due to the high emergency workload and interest in BDE. While drains allowed early detection of bile leakage, avoiding some complications and monitoring conservative management to allow early reinterventions, the study has identified operative criteria that could potentially limit drain insertion through a selective policy.

Effectiveness of no drainage after elective day-case laparoscopic cholecystectomy, even with intraoperative gallbladder perforation: a randomized controlled trial

BACKGROUND

Laparoscopic cholecystectomy (LC) has been carried out as day-case surgery. Current guidelines do not mention the role of drainage after LC. In particular, data stay blank with no prospective study on drainage management when gallbladder perforation (GP) accidentally occurs intraoperatively.

METHODS

A randomized controlled trial was conducted to compare clinical outcomes of drainage and no drainage after elective day-case LC. Intraoperative GP was recorded. The primary and secondary outcomes were major and minor complications, respectively.

RESULTS

Two hundred patients were randomized. No major complications occurred in either group. In secondary outcomes, nausea/vomiting, pain, hospital stay, and cost were similar in the drainage group and no drainage group; postoperative fever, WBC, and CRP levels were significantly lower in the no drainage group. GP occurred in 32 patients. Male patients with higher BMI and CRP and abdominal pain within 1 month were more likely to occur GP. Subgroup analysis of GP, primary outcomes, and most secondary outcomes had no difference. Postoperative WBC and CRP were higher in the drainage group. Postoperative fever occurred in 63 patients. Univariate analysis of fever showed that blood loss, drainage, postoperative WBC, CRP, and hospital stay were significant. Multivariable logistic regression analysis demonstrated that drainage was an independent risk factor for fever after LC (OR 3.418, 95% CI 1.392-8.390; p = 0.007).

CONCLUSIONS

No drainage after elective day-case LC is safe and associated with fewer complications, even in intraoperative GP. The trial proves that drainage is an independent risk factor for postoperative fever. The use of a drain after LC may lead to an unsuccessful day-case procedure by causing fever, elevated CRP, and extended hospital stay (NCT03909360).

Systematic review and meta-analysis of factors which reduce the length of stay associated with elective laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is a safe ambulatory procedure in appropriately selected patients; however, day case rates remain low. The objective of this systematic review and meta-analysis was to identify interventions which are effective in reducing the length of stay (LOS) or improving the day case rate for elective laparoscopic cholecystectomy.

METHODS

Comparative English-language studies describing perioperative interventions applicable to elective laparoscopic cholecystectomy in adult patients and their impact on LOS or day case rate were included.

RESULTS

Quantitative data were available for meta-analysis from 80 studies of 10,615 patients. There were an additional 17 studies included for systematic review. The included studies evaluated 14 peri-operative interventions. Implementation of a formal day case care pathway was associated with a significantly shorter LOS (MD = 24.9 h, 95% CI, 18.7-31.2, p < 0.001) and an improved day case rate (OR = 3.5; 95% CI, 1.5-8.1, p = 0.005). Use of non-steroidal anti-inflammatories, dexamethasone and prophylactic antibiotics were associated with smaller reductions in LOS.

CONCLUSION

Care pathway implementation demonstrated a significant impact on LOS and day case rates. A limited effect was noted for smaller independent interventions. In order to achieve optimal day case targets, a greater understanding of the effective elements of a care pathway and local barriers to implementation is required.

Dry Mopping vs. Saline Irrigation of Gallbladder Fossa After Bile Spillage During Laparoscopic Cholecystectomy: Randomized Control Trial

Introduction The laparoscopic approach, as compared to open cholecystectomy, is still considered the gold standard, despite a higher incidence of micro insults. The most common approach to treat spilled biliary contents and lost stones in laparoscopic cholecystectomy is the retrieval of the stone through an open approach, or laparoscopically, ending with a peritoneal wash and aspiration. Material and methods We conducted a double-blinded randomized controlled trial. In the study group, patients with bile spillage during cholecystectomy underwent suction of all spilled bile and evacuation of all visible stones followed by dry mopping of the gallbladder fossa with gauze swab through an epigastric port. In the control group, after suction of all bile and visible stones, the gallbladder fossa was washed with 250 ml of saline, and fluid was aspirated through the epigastric port. Results Sixty patients were included (30 patients in each group), 71.6% were female and the rest were male. There was a statistically significant difference in pain scores between the two groups (p=0.001). The dry mopping group had lower pain scores as compared to the other group postoperatively. The incidence of the intraabdominal collection in both groups are statistically insignificant, however, port site infection and intraabdominal collection are higher in the control group (irrigation group). Conclusion Although there is not much literature on the best approach to biliary spillage in laparoscopic cholecystectomy. We believe that dry mopping had better postoperative patient outcome as compared to the saline wash.

Role of Procalcitonin in Evaluation of the Severity of Acute Cholecystitis

OBJECTIVE

The aim of this study is to investigate the relationship between procalcitonin (PCT) level and the severity of acute cholecystitis.

MATERIALS AND METHODS

This study included 200 patients diagnosed with acute cholecystitis. To diagnose and assess the severity of acute cholecystitis; physical examination and abdominal ultrasound findings were evaluated and blood samples were taken to determine white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and levels of coagulation factors, blood gas, C-reactive protein (CRP) and PCT. Patients were classified into three stages, namely, mild, moderate, and severe, according to the severity of acute cholecystitis using the Tokyo guidelines. The role of PCT level in the assessment of severity of acute cholecystitis and the correlation between the stages and PCT level were statistically analyzed.

RESULTS

Among patients with acute cholecystitis, 110 (55%) were classified as mild, 61 (30.5%) as moderate, and 29 (14.5%) as severe. Leukocytosis or leukopenia was positive in 48.5%, ESR elevation was found in 72.5%, CRP positivity in 55.5%, PCT elevation in 27%, and positive findings of ultrasonographic imaging in 54.5% of the patients. Serum WBC count, ESR, and CRP and PCT levels increased as the severity of disease increased (p<0.05). PCT could discriminate grade I from grade II-III with 95.45% sensitivity and 46.67% specificity at the best cut-off value of ≤0.52 (p<0.001). PCT could also discriminate grade III from grade I-II with 72.4% sensitivity and 90.06% specificity at the best cut-off value of >0.8 (p<0.001).

CONCLUSION

PCT level may be considered to be a parameter that could be added to the assessment of the severity of acute cholecystitis in the Tokyo guidelines, although further studies are needed to support our findings.