Laparoscopic cholecystectomy: the evolution of general surgery

Impact of inter-hospital transfer on outcomes of urgent cholecystectomy

BACKGROUND

This study used a national cohort to characterize the impact of inter-hospital transfer status on outcomes following nonelective cholecystectomy for cholecystitis.

METHODS

Nonelective cholecystectomies were identified using the 2016-2019 National Inpatient Sample. Multivariable models adjusting for patient and hospital characteristics were utilized to assess outcomes of interest.

RESULTS

Of an estimated 530,696 patients, 5.3% were transferred. Transferred patients were older, more often male, and more likely to report income in the 0^th-25th percentile, compared to others. After adjustment, transfer was associated with increased odds of infectious complications (AOR 1.31, 95%CI 1.06-1.60) and non-home discharge (AOR 1.59, 95%CI 1.45-1.74), but not mortality. Transfer was linked to a $600 cost decrement at the operating hospital (95%CI -$880-330).

CONCLUSIONS

Transfer status is associated with greater postoperative infection, but not mortality. Given that disparities may play a role in transfer decisions, more work must be done to identify transfer drivers and improve patient outcomes.

Male gender: risk factor for severe symptomatic cholelithiasis

The aim of this study was to determine the effect of male gender on the clinical presentation of symptomatic cholelithiasis. Laparoscopic cholecystectomy (LC) has been accepted as standard procedure for the management of symptomatic cholelithiasis even when the gallbladder is acutely inflamed. With the accumulated experience in the management of acute cholecystitis, some factors including male gender were recognized to influence the clinical presentation of symptomatic cholelithiasis and increase the conversion rate during LC. This retrospective study tried to clarify the correlation between male gender and the clinical presentation of symptomatic cholelithiasis. The medical records of all patients presenting with symptomatic cholelithiasis from January 1994 to August 1999 were evaluated. These cases were divided into four groups as follows: (1) elective LC group: patients with a history of biliary colic or acute attack of cholecystitis but whose LC was performed electively without any inflammatory change in the gallbladder during operation; (2) acute LC group: patients presenting with acute cholecystitis, and LC was performed successfully without conversion; (3) acute conversion group: patients who underwent LC during the course of acute cholecystitis but the procedure were disturbed by severe inflammatory change so they were converted to open surgery; (4) acute open group: patients whose acute cholecystitis was managed by direct open surgery due to the preoperative prediction that LC would not succeed. The correlation of gender, age, and operating time were assessed among these four groups. We found that: (1) the male/female ratio increased (in the patient group sequence of simple LC, acute LC, acute open, and acute conversion group); (2) in the acute LC group male patients had significantly (p = 0.04, t-test) longer operating time than females; (3) although there was no significant difference between the mean age of male (55.7 +/- 13.4) and female (56.3 +/- 15.7) patients in the acute cholecystitis groups (i.e., all patients in the acute LC, acute conversion, and acute open groups), the distribution curve by age in male patients showed a significantly shift to a younger age compared with female patients (p = 0.009, Fisher's exact test).

Decontamination of minimally invasive surgical endoscopes and accessories

(1) Infections following invasive endoscopy are rare and are usually of endogenous origin. Nevertheless, infections do occur due to inadequate cleaning and disinfection and the use of contaminated rinse water and processing equipment. (2) Rigid and flexible operative endoscopes and accessories should be thoroughly cleaned and preferably sterilized using properly validated processes. (3) Heat tolerant operative endoscopes and accessories should be sterilized using a vacuum assisted steam sterilizer. Use autoclavable instrument trays or containers to protect equipment during transit and processing. Small bench top sterilizers without vacuum assisted air removal are unsuitable for packaged and lumened devices. (4) Heat sensitive rigid and flexible endoscopes and accessories should preferably be sterilized using ethylene oxide, low temperature steam and formaldehyde (rigid only) or gas plasma (if appropriate). (5) If there are insufficient instruments or time to sterilize invasive endoscopes, or if no suitable method is available locally, they may be disinfected by immersion in 2% glutaraldehyde or a suitable alternative. An immersion time of at least 10 min should be adopted for glutaraldehyde. This is sufficient to inactivate most vegetative bacteria and viruses including HIV and hepatitis B virus (HBV). Longer contact times of 20 min or more may be necessary if a mycobacterial infection is known or suspected. At least 3 h immersion in glutaraldehyde is required to kill spores. (6) Glutaraldehyde is irritant and sensitizing to the skin, eyes and respiratory tract. Measures must be taken to ensure glutaraldehyde is used in a safe manner, i.e., total containment and/or extraction of harmful vapour and the provision of suitable personal protective equipment, i.e., gloves, apron and eye protection if splashing could occur. Health surveillance of staff is recommended and should include a pre-employment enquiry regarding asthma, skin and mucosal sensitivity problems and lung function testing by spirometry. (7) Possible alternative disinfectants to glutaraldehyde include peracetic acid (0.2-0.35%), chlorine dioxide (700-1100 ppm) and superoxidized water. These are very effective, killing vegetative bacteria, including mycobacteria, and viruses in 5 min and bacterial spores in 10 min. An endorsement of compatibility with endoscopes, accessories and processing equipment is required from both the solution/device manufacturer and the endoscope manufacturer. Other important considerations are stability, cost and safety from the user and environmental standpoints. (8) Cleaning and disinfection or sterilization should be undertaken by trained staff in a dedicated area, e.g., SSD or TSSU. A suitable training programme is described. (9) If endoscopes are processed by immersion in disinfectants, harmful residues must be removed by thorough rinsing. Sterile or bacteria free water is essential for rinsing all invasive endoscopes and accessories to prevent recontamination. (10) If an automated washer disinfector is used it must be effective, non-damaging, reliable, easy to use and its performance regularly monitored. (11) If used, washer disinfectors and other processing equipment should be disinfected on a regular basis, i.e., between patients or at the start of each session. This will prevent biofilm formation and recontamination of instruments during rinsing. Disinfection should include the water treatment system, if present. (12) To comply with the Medical Devices Directive, manufacturers are obliged to provide full details on how to decontaminate the reusable devices they supply. This should include details of compatibility with heat, pressure, moisture, processing chemicals and ultrasonics. (13) The Infection Control Team should always be involved in the formulation and implementation of decontamination policies. Wherever possible, the national good practice guidelines produced by the Medical Devices Agency and/or professional societies shoul

Growing use of laparoscopic cholecystectomy in the national Veterans Affairs Surgical Risk Study: effects on volume, patient selection, and selected outcomes

OBJECTIVE

To study the introduction of laparoscopic cholecystectomy to the 43 tertiary-care university-affiliated Veterans Administration medical centers (VAMCs) participating in the National Veterans Affairs Surgical Risk Study from October 1991 through December 1993.

SUMMARY BACKGROUND DATA

Previous studies in the private sector have documented growth in the number of cholecystectomies and falling clinical thresholds for cholecystectomy with the introduction of laparoscopic cholecystectomy.

METHODS

The following were analyzed for changes over time: measures of patient preoperative risk, complexity of surgery, severity of biliary disease, numbers of procedures, postoperative length of stay, and 30-day postoperative mortality and general complication rates.

RESULTS

The number of cholecystectomies performed laparoscopically increased, but the total number of cholecystectomies performed remained stable over time. The proportion of patients with acute cholecystitis, emergent cholecystectomies, and technically complex cholecystectomies did not change or increased slightly over time. Adjusted odds for postoperative general complications were lower for laparoscopic than for open cholecystectomy, but 30-day postoperative mortality and general complication rates for all cholecystectomies remained constant over time. Postoperative length of stay for all cholecystectomies fell significantly. Implementation rates of laparoscopic cholecystectomy varied widely between hospitals. Laparoscopic cholecystectomy was adopted more slowly and used in a lower percentage of cholecystectomies than in non-VA settings.

CONCLUSIONS

In contrast to non-VA studies showing increases in overall cholecystectomy volume since the introduction of laparoscopic cholecystectomy, these VAMCs implemented laparoscopic cholecystectomy without growth in cholecystectomies or a change in the clinical threshold for cholecystectomy. Laparoscopic cholecystectomy was associated with better outcomes, but its introduction in the setting of stable cholecystectomy volume and biliary disease case mix did not change postoperative mortality and complication rates. The stable cholecystectomy volume and biliary disease case mix, slower adoption, and lower use of laparoscopic cholecystectomy contrast with previous reports and may result from differences in patients and organization and financing of VA versus non-VA settings.

Health care technology in the United States

The US health care system reflects the free market of the US economy--there is no fixed budget and no limit on expenditures in the loosely structured matrix of largely private-sector health industry components. Mainly because of the inaccessibility of adequate health care for a large segment of the population, and because of the enormous cost of care threatens financial ruin for many more people, the first major reform of the system was debated in Congress for most of 1994, though, in the end, no leglislation was passed. One focus of the debate on spending has been the problem of excessive use of expensive medical technology and the need for some control, which, by and large, is lacking in the existing system. Health care technology assessment itself is a thriving industry in the United States, used by government, insurers, medical societies, hospitals, and other groups for their own purposes. At the national policy level, few opportunities for technology assessment to affect the health care industry exist, so most effort is directed at trying to affect medical practice at the level of the individual hospital and practitioner. The discernible effect of technology assessment has been minimal.

Pulmonary function after cholecystectomy performed through Kocher's incision, a mini-incision, and laparoscopy

Comparative pulmonary function after cholecystectomy performed through Kocher's incision, a mini-incision, and laparoscopy was evaluated. Forty-five patients were randomly and prospectively divided into three groups of 15 each, depending on the surgical access employed. Forced vital capacity (FVC), forced expiratory volume at 1 second (FEV1), and forced expiratory flow at 25% to 75% (FEF25-75%) were determined 1 to 3 days before and 16 to 24 hours after cholecystectomy. The percent reduction of FVC (p = 0.0170), FEV1 (p = 0.0191), and FEF25-75% (p = 0.0045) was smaller after laparoscopic cholecystectomy than after Kocher's incision cholecystectomy. The percent reduction of FVC (p = 0.0170) was smaller after mini-incision cholecystectomy than after Kocher's incision cholecystectomy. There was no difference in the FEV1 (p = 0.0971) or FEF25-75% (p = 0.2058) between these two groups. FEF25-75% was significantly less impaired in the laparoscopic group than in the mini-incision group (p = 0.0327). No difference between these two groups was found in FVC (p = 0.5755) or FEV1 (p = 0.3952). It is concluded that postoperative pulmonary function is less impaired after laparoscopic cholecystectomy than after either mini-incision or Kocher's incision cholecystectomy.

Mechanical retraction in laparoscopic surgery: intraoperative cholangiography

The utility of mechanical retraction in laparoscopic surgery is presented. The steps required for its utilization during intraoperative laparoscopic cholangiography are outlined.

Cholelithoptysis. A complication following laparoscopic cholecystectomy

A 59-year-old woman who underwent laparoscopic cholecystectomy for symptomatic cholecystitis presented four months later with fever, malaise, anorexia, hemoptysis and lithoptysis. Chemical analysis of the expectorated lithes revealed them to be gallstones. Ultrasound studies of the right upper quadrant demonstrated both supradiaphragmatic and subdiaphragmatic fluid collections containing echogenic fragments. ERCP failed to demonstrate retained ductal stones or fistula formation. To our knowledge, this is the first reported case of cholelithoptysis and demonstrates an unusual complication of gallstone retention following laparoscopic cholecystectomy.

The dynamics of innovation in minimally invasive therapy

The emergence of minimally invasive therapy (MIT), which provides alternatives to major open-surgery procedures, is affecting all aspects of medical care delivery. In the present environment of resource and cost constraint in health services, an uncommon consensus among patients, physicians, providers, and payers has evolved regarding the rapid acceptance of this area of medical intervention, an acceptance that, in turn, is stimulating further innovation. This paper discusses the dynamics of medical innovation and analyzes these forces in the context of three minimally invasive therapies: percutaneous transluminal coronary angioplasty, extracorporeal shock wave lithotripsy, and laparoscopic cholecystectomy. The different experiences of the United States and Europe are used to illustrate how scientific, medical, economic, and regulatory factors affect both the rate and direction of technological change in minimally invasive therapy.