Article

Different setups of laparoscopic cholecystectomy: Conversion and complication rates: A retrospective cohort study

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Abstract

Background: Laparoscopic cholecystectomy (LC) is the gold standard treatment for gall bladder disease. Methods: We retrospectively reviewed charts of patients who underwent LC. Four LC groups were defined: elective LC - Group I; interval LC - Group II; LC during acute cholecystitis - Group III; and LC following percutaneous cholecystostomy (PCC) - Group IV. Results: The study comprised 1658 patients [mean age: 51.0 years (range 17-94)]: Group I: 1221 patients (73.6%); Group II: 271 patients (16.3%); Group III: 125 patients (7.6%); Group IV: 41 patients (2.5%). The operative time was significantly different between the groups (p < 0.05). The conversion rate was highest in Group III (24.8%) and was significantly higher than all the other groups. Group II had a higher conversion rate than Group I (p < 0.05). The length of hospital stay was not significantly different between Groups I and II (1.5 and 1.96 days, respectively), and between Groups III and IV (4.46 and 4.78 days, respectively). The differences between Groups I and II, and between Groups III and IV were significant. Complication rates were significantly different between Groups I (2.2%), II (5.6%), and III (13.6%) (p < 0.05.) There were no differences between Groups III and IV and there were no significant differences in 30-day readmission rates between the groups. Conclusions: The highest conversion and complication rates were encountered in patients undergoing LC during acute cholecystitis. A gradual increase of conversion and complication rates was noted between the groups of elective LC, interval LC and LC post PCC. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

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... Laparoscopic cholecystectomy is one of the most common operations in the world, and the everyday challenge for general surgeons usually performed as elective surgery with low mortality (0.01%) and morbidity (2-8%). [12][13][14] In most recent studies, it has been reported that 2.9 to 3.2% of elective laparoscopic cholecystectomies are converted to open surgery. Converted cases are associated with a 9-fold increase of trans and postoperative complications (13-18.7%), ...
... 4 However, others believe that an emergency LC would potentially increase the incidence of complications in the treatment of acute complicated cholecystitis. 5 PTGBD was developed and has been used in the clinic for nearly 30 years, with many reports confirming its safety, ease of use, and effectiveness in alleviating symptoms of acute cholecystitis. [6][7][8] Due to the advantages of PTGBD, it has been our departmental policy to routinely combine PTGBD with LC to treat acute complicated cholecystitis, with the duration of gallbladder drainage limited to 3 to 5 days to ensure effective relief of gallbladder inflammation but without atrophy or adhesion of the gallbladder. ...
Article
Controversy exists on the suitability of laparoscopic cholecystectomy (LC) in acute cholecystitis, especially in patients with severe comorbidities. Recently, many nonsurgical departments have indicated a preference for percutaneous transhepatic gallbladder drainage (PTGBD), but surgeons consider LC as the final treatment option for cholecystitis. This analysis evaluated the curative efficacy of PTGBD in combination with LC as compared with emergency LC (e-LC). We retrospectively analyzed clinical data of 86 patients with acute complicated cholecystitis. Patients were divided into two groups as those who received e-LC and those who underwent PTGBD combined with LC (PTGBD+LC), and baseline characteristics, perioperative data, and operative parameters were compared to check for intergroup differences. Baseline characteristics were similar for the study groups. However, although the operating duration (P = 0.12) and postoperative hospital stay (P = 0.39) did not evidence significant differences, the PTGBD+LC group had significantly better outcomes than the e-LC group with regard to blood loss (P < 0.05), peritoneal drainage duration (P < 0.05), and time to postoperative resumption of oral intake (P < 0.05). Moreover, conversion to open surgery, complications during LC, and mortality rate were all higher in the e-LC group. PTGBD combined with LC is an effective treatment for acute complicated cholecystitis, especially in elderly patients or those with serious comorbidities. To some extent, the curative effect of this method can be considered superior to that of emergency LC.
... These findings suggest that ELC should be performed as soon as possible, but preferably during the day. On the other hand, another study 58 suggested that patients undergoing emergency laparoscopic cholecystectomy for acute cholecystitis suffered the highest conversion and complication rates, whereas elective surgery was superior. However, elective laparoscopic cholecystectomy was not defined clearly and was performed mostly in a specialized hospital, which may have introduced bias. ...
Article
Previous studies comparing early laparoscopic cholecystectomy (ELC) with delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis were incomplete. A meta-analysis was undertaken to compare the cost-effectiveness, quality of life, safety and effectiveness of ELC versus DLC. PubMed, Embase, the Cochrane Library and Web of Science were searched for randomized clinical trials (RCTs) that compared ELC (performed within 7 days of symptom onset) with DLC (undertaken at least 1 week after symptoms had subsided) for acute cholecystitis. Sixteen studies reporting on 15 RCTs comprising 1625 patients were included. Compared with DLC, ELC was associated with lower hospital costs, fewer work days lost (mean difference (MD) -11·07 (95 per cent c.i. -16·21 to -5·94) days; P < 0·001), higher patient satisfaction and quality of life, lower risk of wound infection (relative risk 0·65, 95 per cent c.i. 0·47 to 0·91; P = 0·01) and shorter hospital stay (MD -3·38 (-4·23 to -2·52) days; P < 0·001), but a longer duration of operation (MD 11·12 (4·57 to 17·67) min; P < 0·001). There were no significant differences between the two groups in mortality, bile duct injury, bile leakage, conversion to open cholecystectomy or overall complications. For patients with acute cholecystitis, ELC appears as safe and effective as DLC. ELC might be associated with lower hospital costs, fewer work days lost, and greater patient satisfaction. © 2015 BJS Society Ltd. Published by John Wiley & Sons, Ltd.
... Even a standard procedure such as cholecystectomy is not performed by 1 type of algorithm. Despite the fact that laparoscopic cholecystectomy is a gold standard in gallbladder disease treatment, 3 the procedure can be performed using different surgical techniques and tools, with different numbers of incisions (1, 2, 3, or 4). Cholecystectomy can also be performed as natural orifice transluminal endoscopic surgery, 4 the hybrid techniques natural orifice transluminal endoscopic surgery and single-incision laparoscopic surgery. ...
Article
A comparison of 1-port, 2-port, 3-port, and 4-port laparoscopic cholecystectomy techniques from the point of view of workflow criteria was made to both identify specific workflow components that can cause surgical disturbances and indicate good and bad practices. As a case study, laparoscopic cholecystectomies, including manual tasks and interactions within teamwork members, were video-recorded and analyzed on the basis of specially encoded workflow information. The parameters for comparison were defined as follows: surgery time, tool and hand activeness, operator's passive work, collisions, and operator interventions. It was found that 1-port cholecystectomy is the worst technique because of nonergonomic body position, technical complexity, organizational anomalies, and operational dynamism. The differences between laparoscopic techniques are closely linked to the costs of the medical procedures. Hence, knowledge about the surgical workflow can be used for both planning surgical procedures and balancing the expenses associated with surgery.
... Placement of a percutaneous cholecystostomy tube is considered a relatively safe option in critically ill patients presenting with acute cholecystitis [13,14]. Whether or not this procedure is associated with higher conversion rates when laparoscopic cholecystectomy is performed is still debated [15][16][17]. ...
Article
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Introduction: Conversion rates for Laparoscopic Cholecystectomy (LC) still range from 1.9% to 15 % and are higher when it comes to acute cholecystitis. Preoperative risk factors for conversion to open (CTO) technique are: previous upper abdominal surgery, male gender, age over 65, high BMI and history of acute cholecystitis treated conservatively. Besides that, the reported incidence of iatrogenic bile duct injuries varies between 0, 1% and 0, 5%. Case Presentation: 67-year-old male with a history of previous laparoscopic distal spleno- pancreatectomy complicated by severe pancreatitis, infected pseudocyst and colonic stula. During this complex postoperative course he also developed acute cholecystitis with suspicion of rupture and pericholecystic abscess treated with a cholecystostomy tube. Months later, still with the cholecystostomy in place, we performed a robotic cholecystectomy, without intra- or post-operative complications. Conclusion: e intrinsic advantages of the robotic platform and the use of Indocyanine green uorescent cholangiography (ICG) could make dissection and identi cation of anatomy easier, thus possibly reducing the rates of CTO and biliary tract injuries. Robotic assisted surgery could be an option for complex cases of cholecystectomy. ICG is an additional tool that can help identify the cystic and common bile duct during the dissection of the Calot’s triangle.
... La tasa de complicaciones generales en relación con este proceder es menor que en la colecistectomía convencional o abierta, aunque la lesión de la vía biliar y la infección intraabdominal por cálculos abandonados en la cavidad peritoneal son más frecuentes en la colecistectomía laparoscópica. 6 En esta serie, el coleperitoneo por lesión iatrogénica de la vía biliar resultó ser la complicación más frecuente, lo cual muchas veces se asocia con dificultades anatómicas, hemorragias y un tiempo quirúrgico prolongado. ...
Article
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Introduction: vesicular lithiasis is the disease of the alimentary tract mostly requiring hospitalization. Objective: to characterize the patients with vesicular lithiasis treated with minimal access surgery. Method: a descriptive and retrospective observational study of 1 271 patients with vesicular lithiasis treated with minimal access surgery at the General Surgery Service from "Saturnino Lora Torres" Teaching Provincial Clinical Surgical Hospital in Santiago de Cuba was carried out from January, 2011 to September, 2014. Results: the female sex (84.1%), the age group 45-65 years (47.7%), as well as the choleperitoneum as iatrogenic lesion of the biliary pathways as main complication and most frequent cause of reintervention prevailed in the series; also, the presence of the chronic vesicular abscess turned out to be the reason of change to open surgery (25.0%) and only 0.2% of the affected patients died. The hospital stay was shorter than 24 hours in 96.6% of the total of patients and 93.8% of the members of the study were operated with a surgical time of 60 minutes or less. Conclusions: there was low incidence of complications, conversions and reinterventions, without prolonged surgical times and a short hospital stay
... The need for conversion is not the failure of operating surgeon but an attempt to avoid complications which might ensue if expeditious surgery is performed 12 . The conversion rates according to the studies do show geographical variations from 1-19% [13][14][15][16] and some have shown increase propensity towards male gender 1 however in our series, females were predominant with P value 0.106. The main reasons for conversion in our series were difficult per-operative anatomy, empyema gallbladder, and hemorrhage 17 as shown in Graph 1. ...
Article
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Objective: To identify peri-operative risk factors leading to conversion in patients undergoing laparoscopic cholecystectomy. Study Design: Observational / descriptive study. Place and Duration of Study: This study was conducted at the Liaquat National Hospital & Medical College, in Karachi from Jan 2009 to Dec 2011. Materials and Methods: The Study was started after formal approval of General Surgery faculty. Theater records of all patients who underwent Laparoscopic to open conversion admitted to the department, Liaquat National Hospital & Medical College, from January 2009 to December 2011 were retrieved & reviewed. All data was entered into a designated proforma and SPSS ver 19.0 was used for statistical analysis. Results: During the period from January 2009 to December 2011 (3 years), total 1281 patients admitted for cholecystectomies. Out of which 156 patients had planned open cholecystectomies and were therefore excluded from the study. 1125 patients underwent laparoscopic cholecystectomies out of which n=45 were converted to open cholecystectomies with the conversion rate of 4%. In our series, males were 20 and females were 25 with mean age of 48.20 ± 13.048. 36 patients were admitted through the OPD with the mean hospital stay was 8.56 ± 5.294 days. Pre-surgery 28 of the patients had acute symptoms and 31 patients had normal liver function tests at the time of admission. 33 patients did not show any ultrasound evidence of acute cholecystitis. All patients were operated in direct supervision of the consultant with minimum experience of performing > 500 laparoscopic cholecystectomies. Intraoperative causes leading to conversion were difficult anatomy in 44 patients, empyema in 17, perforated gall bladder in 5) , bleeding in 4 and instrument failure in 1. 17 of the patients required per-operative cholangiogram (POC)for deranged LFTS and for delineation of difficult anatomy. Conclusion: Laparoscopic cholecystectomy in a tertiary care hospital has acceptable conversion rates as compared to local and international standards. In our series, patients with difficult per-operative anatomy and empyema gallbladder were significant risk factors for conversion. Key Words: Open conversion, laparoscopic cholecystectomy, risk factors
... Some surgical procedures are performed as MIS in usual practice. One example is laparoscopic cholecystectomy, which is considered the gold standard in the removal of the gallbladder [2]. However, this procedure can be performed with different surgical laparoscopic techniques. ...
Article
Purpose: With reference to four different minimally invasive surgery (MIS) cholecystectomy the aims were: to recognize the factors influencing dominant wrist postures manifested by the surgeon; to detect risk factors involved in maintaining deviated wrist postures; to compare the wrist postures of surgeons while using laparoscopic tools. Materials and methods: Video films were recorded during live surgeries. The films were synchronized with wrist joint angles obtained from wireless electrogoniometers placed on the surgeon’s hand. The analysis was conducted for five different laparoscopic tools used during all surgical techniques. Results: The most common wrist posture was extension. In the case of one laparoscopic tool, the mean values defining extended wrist posture were distinct in all four surgical techniques. For one type of surgical technique, considered to be the most beneficial for patients, more extreme postures were noticed regarding all laparoscopic tools. We recognized a new factor, apart from the tool’s handle design, that influences extreme and deviated wrist postures. It involves three areas of task specification including the type of action, type of motion patterns and motion dynamism. Conclusions: The outcomes proved that the surgical technique which is most beneficial for the patient imposes the greatest strain on the surgeon’s wrist.
... About 14% of patients develop acute cholecystitis, 5% develop biliary pancreatitis and 5% develop common bile duct stones 5,9,10 . Complicated cholelithiasis usually requires emergency admission and has a longer hospital stay, longer operative time, higher chance of complications and has a higher cost of treatment 11,12 . The gold standard treatment for both symptomatic and complicated cholelithiasis is laparoscopic cholecystectomy 11 . ...
Article
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p> Background: Cholelithiasis is a common disease managed by surgeons. The patient may present with asymptomatic incidentally detected cholelithiasis, uncomplicated symptomatic cholelithiasis or complicated symptomatic cholelithiasis. The perioperative outcome varies in patients with symptomatic uncomplicated and complicated disease. Objectives: To compare the perioperative outcomes between patients with uncomplicated and complicated cholelithiasis. Methodology: A prospective analytical study was conducted among all the patients undergoing elective laparoscopic cholecystectomy during the study period. The patients were categorized into two groups, uncomplicated and complicated. The comparison was done among these groups in terms of length of hospital stay, operative duration, and post-operative complications. Results: Total of 107 patients 22(20.56%) males and 85(79.43%) females were included in the study. 83(77.57%) were uncomplicated and 24(22.42%) were complicated cases. The average length of the hospital was 2.33 vs 6 days (p-value <0.01), mean operative duration 42.23 vs 70.17 minutes (p-value <0.00) and postoperative complication were 0 vs 6 in uncomplicated and complicated group respectively. Conclusion: Patients operated for uncomplicated cholelithiasis had a better perioperative outcome in terms of operative duration, post-operative hospital stay and complications rate as compared to patients operated for complicated cholelithiasis.</p
... In our series, prophylactic cholecystectomy was the only factor associated with a lower occurrence of biliary stone disease and related complications. Concurrent cholecystectomy at time of resection of midgut NEN is not associated with significantly higher morbidity or mortality [17,18]. On the opposite, cholecystectomy performed after primary resection may present more complications because of postoperative adhesions; moreover, in patients with midgut carcinoids, the tendency of abdomen fibrosis formation needs to be taken into account [10]. ...
Article
Background: Somatostatin analogs are the backbone of neuroendocrine neoplasms treatment. Biliary stone disease is a potentially severe adverse event of somatostatin analogs: an increased incidence has been reported in somatostatin analogs-treated acromegalic patients, but studies on patients with neuroendocrine neoplasms are lacking. Aims: To evaluate biliary stone disease incidence and associated factors in a large series of patients treated with somatostatin analogs for neuroendocrine neoplasms. Methods: A prospectively-collected database of patients with a diagnosis of neuroendocrine neoplasms of any grade and site, treated with somatostatin analogs at our Institution between 1995 and 2017, was retrospectively analyzed. Patients' demographics and disease characteristics were analyzed to evaluate the incidence and the factors related to biliary stone disease. Results: Three-hundred patients were included; 101 (33.7%) patients underwent cholecystectomy before starting somatostatin analogs. Among 164 patients with gallbladder in situ and no history of stone disease, 60 (36.6%) developed gallstones after a mean of 36.7 months (range 1-239) from treatment start with a mean yearly incidence of 8.73%. Previous cholecystectomy was associated with a lower rate of development of gallstones (p < 0.001) or related complications (p = 0.017). Conclusion: We observed a high incidence of biliary stone disease in patients treated with somatostatin analogs-treated for neuroendocrine neoplams. Previous cholecystectomy was the only factor associated with a lower occurrence of biliary stone disease.
... In fact as many as 81% of patients would like to have their procedure recorded and as many as 63% are willing to pay extra for this service [24]. Given the low intraoperative and postoperative complication rates in modern minimally invasive bariatric surgery [6,25], laparoscopic cholecystectomy [5,26] and TEP [27], the present study is by far too small to evaluate any impact of audio-video recording on perioperative complication rates. A different study design would be needed to address this end-point, and this was never the primary aim of the present study. ...
Article
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Background The prevalence of perioperative surgical complications is a worldwide issue: In many cases, these events are preventable. Audio-video recording during laparoscopic surgery provides useful information for the purposes of education and event analyses, and may have an impact on the focus of the surgeons operating. The aim of the present study was to investigate how audio-video recording in the operating room during laparoscopic surgery affects the focus of the surgeon and his/her assistant. Methods A group of laparoscopic procedures where video recording only was performed was compared to a group where both audio and video recordings were made. All laparoscopic procedures were performed at Lindesberg Hospital, Sweden, during the period August to September 2017. The primary outcome was conversation not relevant to the ongoing procedure. Secondary outcomes were intra- and postoperative adverse events or complications, operation time and number of times the assistant was corrected by the surgeon. Results The study included 41 procedures, 20 in the video only group and 21 in the audio-video group. The material comprised laparoscopic cholecystectomies, totally extraperitoneal inguinal hernia repairs and bariatric surgical procedures. Irrelevant conversation time fell from 4.2% of surgical time to 1.4% when both audio and video recordings were made (p = 0.002). No differences in perioperative adverse event or complication rates were seen. Conclusion Audio-video recording during laparoscopic abdominal surgery reduces irrelevant conversation time and may improve intraoperative safety and surgical outcome. Trial registration Available at FOU Sweden (ID: 232771) and retrospectively at Clinical trials.gov (ID: NCT03425175; date of registration 7/2 2018).
... Al momento de realizar la CL como tratamiento definitivo se debe tener especial precaución, ya que aunque la inflamación vesicular ha disminuido o desaparecido, las comorbilidades del paciente generalmente persisten, por lo que podría tratarse de una cirugía más complicada de 58,59 . En este escenario se ha reportado una frecuencia de conversión a cirugía abierta de entre el 11 y el 32% [60][61][62][63] . ...
Article
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La colecistitis aguda es una de las enfermedades más frecuentes a la que debe enfrentarse el cirujano general. En las últimas décadas se han observado distintos factores pronósticos y descrito modalidades de tratamiento efectivas con la finalidad de mejorar los resultados en pacientes con este padecimiento (baja morbimortalidad, menor estancia hos- pitalaria y mínima conversión de procedimientos laparoscópicos a abiertos). En general, la colecistectomía laparoscópica es el tratamiento estándar de la colecistitis aguda, pero dicho procedimiento quirúrgico no está exento de complicaciones, principalmente en pacientes con múltiples comorbilidades o en estado crítico. La colecistostomía percutánea surgió como una alternativa menos invasiva para el tratamiento de la colecistitis aguda en pacientes con falla orgánica o riesgo quirúrgico prohibitivo. Aunque es un procedimiento efectivo, existe contro- versia sobre su utilidad sobre las indicaciones precisas. Aunado a lo anterior, la evidencia sobre el manejo de la sonda de colecistostomía es escasa. Realizamos una revisión abordando las principales cuestiones que los médicos involucrados con el manejo de esta patología deben conocer.
... 57 At the time of performing LC as definitive treatment, special care must be taken, given that even though inflammation of the gallbladder has decreased or disappeared, patient comorbidities generally persist, meaning that surgery can be more complicated than first contemplated. 58,59 A frequency of conversion to open surgery in that scenario has been reported between 11 and 32%. 60---63 Interval cholecystectomy is generally performed with no technical problems in young patients with no comorbidities. ...
Article
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Acute cholecystitis is one of the most frequent diseases faced by the general surgeon. In recent decades, different prognostic factors have been observed, and effective treatments described, to improve the results in patients with said pathology (lower morbidity and mortality, shorter hospital stay, and minimum conversion of laparoscopic to open procedures). In general, laparoscopic cholecystectomy is the standard treatment for acute cholecystitis, but it is not exempt from complications, especially in patients with numerous comorbidities or those that are critically ill. Percutaneous cholecystostomy emerged as a less invasive alternative for the treatment of acute cholecystitis in patients with organ failure or a prohibitive surgical risk. Even though it is an effective procedure, its usefulness and precise indications are subjects of debate. In addition, there is little evidence on cholecystostomy catheter management. We carried out a review of the literature covering the main aspects physicians involved in the management of acute cholecystitis should be familiar with. Resumen: La colecistitis aguda es una de las enfermedades más frecuentes ante la cual debe enfrentarse el cirujano general. En las últimas décadas se han observado distintos factores pronósticos y descrito modalidades de tratamiento efectivas con la finalidad de mejorar los resultados en pacientes con este padecimiento (baja morbilidad y mortalidad, menor estancia hospitalaria y mínima conversión de procedimientos laparoscópicos a abiertos). En general, la colecistectomía laparoscópica es el tratamiento estándar de la colecistitis aguda, sin embargo, dicho procedimiento quirúrgico no está exento de complicaciones, principalmente en pacientes con múltiples comorbilidades o en estado crítico. La colecistostomía percutánea surgió como una alternativa menos invasiva para el tratamiento de colecistitis aguda en pacientes con falla orgánica o riesgo quirúrgico prohibitivo. Aunque es un procedimiento efectivo, existe controversia sobre su utilidad e indicaciones precisas. Aunado a lo anterior, la evidencia sobre el manejo de la sonda de colecistostomía es escasa. Realizamos una revisión abordando las principales cuestiones que los médicos involucrados con el manejo de esta patología deben conocer. Keywords: Percutaneous cholecystostomy, Acute calculous cholecystitis, Acute acalculous cholecystitis, Palabras clave: Colecistostomía percutánea, Colecistitis aguda litiásica, Colecistitis aguda alitiásica
... We read the article by Hasan Kais et al. entitled 'Different setups of laparoscopic cholecystectomy: Conversion and complication rates: A retrospective cohort study' [1] with great interest. ...
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Background: Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgical procedures. Despite this, patterns of readmission following LC are not well defined. This meta-analysis aimed to determine rates and predictors of readmission. Methods: An ethically approved International Prospective Register of Systematic Reviews (PROSPERO)-registered meta-analysis was undertaken searching PubMed, Scopus, Web of Science and Cochrane Library databases from January 2013–June 2018 adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Published literature potentially suitable for data analysis was graded using methodological index for non-randomised studies (MINORS) criteria; papers scoring ≥ 16/24 for comparative and ≥ 10/16 for non-comparative studies were included. A meta-analysis of potential risk factors was performed by computing the odds ratio using Mantel-Haenszel method and fixed-effects model with 95% confidence intervals. Results: Three thousand and eight hundred thirty-two articles were reduced to 44 studies qualifying for a final analysis of 1,573,715 laparoscopic cholecystectomies from 25 countries. Overall readmission rate was 3.3% (range: 0.0–11.7%); 52,628 readmissions out of 1,573,715 LCs. Surgical complications accounted for 76% of reported reasons for readmission, predominantly bile duct complications (33%), wound infection (17%) and nausea and vomiting (9%). Pain (15%) and cardiorespiratory complications (8%) account for the remainder. Obesity, single port LC and day case LC were not associated with increased rates. Conclusions: Pain, nausea and vomiting and surgical complications, particularly bile duct obstruction are the most common causes for readmission. Intra-operative cholangiography may reduce readmission rates. Causes for readmission were inconsistently reported throughout. The mean readmission rate of 3.3% may act as a quality benchmark for improving LC, and clearer reporting of reasons for readmission are required to advance care.
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INTRODUCTION: The incidence of biliary duct injuries requiring surgical reconstruction has stabilised between 0.30.7%. Biliary reconstruction in the hands of a trained hepatobiliary surgeon may lead to better short- and long-term outcomes in patients with this infrequent, but serious complication. METHODS: This study presents a retrospective analysis of single surgeon experience with biliary injury repair during the period of 20072016. Extramucosal hepaticojejunostomy on the excluded segment of the jejunal loop was performed without the use of any transanastomotic drain. Immediate reconstruction of on-table recognised injuries was carried out; patients presenting with biliary leak were reconstructed early and patients presenting with biliary stricture underwent reconstruction depending on the degree of obstruction, presence of cholangitis and feasibility of endoscopic or percutaneous intervention. Postoperative complications were evaluated using Dindo-Clavien and ISGLS classification, and the effect of reconstruction was assessed according to McDonald criteria. RESULTS: 15 biliary reconstructions in 14 patients were performed during the study period. More than a half of the patients experienced some postoperative complication (53.33%); serious complication occurred in 2 patients. One patient (82 years old) died of non-surgical postoperative complications. Biliary leak occurred in three patients (20%), and deep surgical site infection (fasciitis) in four patients (33.33%). The average length of stay was 12.13 days. There was no revisional surgery during the index hospitalisation in any of the patients. There were two readmissions up to 90 days after biliary reconstruction (13.33%). The patients are currently followed up for an average of 4.01 years; compliance with follow-up is 100%. Successful reconstruction was achieved in 92.86% of patients; one patient required rehepaticojejunostomy (7.14%). According to McDonald criteria excellent results were accomplished in 6 patients (42.86%), good results in another 5 patients (35.71%) and 2 patients underwent percutaneous intervention on the reconstruction (14.28%). CONCLUSION: When comparing results among various centres, we should take into account: 1. Experience of the centre/surgeon; 2. Case-mix (exact classification); 3. Timing of reconstruction; 4. Criteria for successful reconstruction; and 5. The length of follow-up. Patients in our centre who fulfil McDonald A and B criteria during the whole follow-up period are considered to have a successful repair. Reconstruction in McDonald C patients is also considered as a success by some authors, although this remains debatable as an early intervention on the reconstruction may be appropriate.Key words: cholecystectomy - bile duct injury - hepaticojejunostomy stricture.
Article
Background: We compared observed postoperative outcomes from laparoscopic cholecystectomy performed for acute cholecystitis (AC) to outcomes predicted by the ACS-NSQIP risk calculator.We also noted and compared any differences in observed outcomes across the different Tokyo Guidelines (TG) levels of AC severity.We hypothesized that ACS-NSQIP would accurately predict complications and length of stay (LOS) and that increased TG severity levels would correlate with more complications, increased conversion to open surgery, and longer LOS. Methods: A review of all patients who underwent laparoscopic cholecystectomy for acute cholecystitis over eighteen months was performed. Results: ACS-NSQIP predicted a complication rate of 4.6% (11% found) and LOS of 0.73 days (2.5 found), p < 0.05. Increased TG severity had LOS of 1.89, 2.75, and 5.33, respectively, p < 0.05. The complication numbers and conversion to open cholecystectomy were insignificant between the TG classes. Conclusion: ACS-NSQIP did not accurately predict complications or LOS. TG classifications did not show a significant difference in complications or conversion to open surgery, but positively correlated with LOS. ACS-NSQIP may not accurately predict patient outcomes and the TG, originally created with the purpose of differentiating levels of inflammation and severity, may only be useful for predicting LOS.
Article
Background Cholecystectomy is one of the most commonly performed operations in the United States, yet it still carries up to a 6% risk of major morbidity. Lawsuits are a major source of emotional, financial, and personal stress for surgeons. We sought to characterize malpractice claims associated with gallbladder surgery as well as define contributing factors and costs with these claims. Methods The Westlaw database (Thomson Reuters Corporation, Toronto, Canada) was queried for jury verdicts and settlements related to cholecystectomy and malpractice between 2000 and 2018. Data were abstracted from the case files and details of the settlements, jury verdicts, and factors related to the claims were assessed. Results Among 231 cases, a plaintiff verdict was reached in 45 (19.5%) and a defendant verdict was reached in 122 (53%); other cases were either settled (n = 29, 12%), dismissed (n = 31, 13%), or denied (n = 4, 2%). Plaintiff cases often involved young (median age, 44 years [interquartile range: 35–57]) female (n = 146, 63%) patients. The attending surgeon accounted for 59% of defendants. Procedural error (49%), wrongful death (18%), or failure to treat in a timely manner (13%) were the most commonly cited reasons for litigation. Among the 134 cases where a second surgical procedure was performed, the most common types of procedures were biliary tract repair (n = 82, 61%) and bowel repair (n = 16, 12%). The total cost of the claims over the study period was $22 million with a median payout of $500,000; the median time from operative event to final disposition was over 5 years (interquartile range: 4–7). Conclusion A plaintiff verdict or settlement was reached in 1 in 3 cases, and large payouts were common. Minimizing procedural error and improving care of patients after cholecystectomy complications should be emphasized.
Article
Introduction: There are often cases with postoperative complications after laparoscopic cholecystectomy (LC), resulting in severe consequences. This study aimed to identify potential risk factors of postoperative complications in cases of LC for acute cholecystitis. Materials and methods: A total of 423 patients with cholecystitis underwent LC. We divided the patients into two groups: group without postoperative complications (Group A) and group with postoperative complications (Group B). Pre-operative findings, surgical findings, and the methods for evaluating the risk of peri-operative complications were compared between the two groups with a univariate analysis. Independent risk factors of postoperative complications were then evaluated in a multivariate analysis with the factors shown to be statistically significant in the univariate analysis. Results: A Physiological and Operative severity Score for enUmeration of Mortality and morbidity (POSSUM) of ≥ 48.3 and moderate or severe cholecystitis were independent risk factors of postoperative complications in LC. Conclusions: This study indicated that POSSUM morbidity and moderate or severe cholecystitis were potential risk factors of postoperative complications. The pre-operative management of the general condition and cholecystitis using antibiotics, infusion, percutaneous transhepatic gallbladder drainage, and other approaches may be significant for the prevention of postoperative complications. Once the POSSUM morbidity reaches the threshold after LC, postoperative management becomes difficult, so strict control of the general condition should be performed.
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Laparoscopic cholecystectomy is the “gold standard” in the treatment of symptomatic gallbladder’s lithiasis. Difficult gallbladder (DGB) means a procedure with an increased surgical risk and high conversion rate compared to standard cholecystectomy. Acute cholecystitis is the most frequent clinical condition and also scleroatrophic cholecystitis and cholecystectomy in cirrhosis represent a difficult gallbladder pattern. The conversion rate increases depending on the degree of gallbladder inflammation, patient comorbidities, and the skills of surgeon.
Article
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Laparoscopic cholecystectomy is increasingly used on an ambulatory basis. This study aimed to examine its effectiveness for carefully selected patients. A systematic review of Cochrane, Embase, and Medline using the keywords "ambulatory," "laparoscopic," and "cholecystectomy" was performed. Postoperative complications leading to admissions and readmissions were compared between day care and inpatient laparoscopic cholecystectomy groups. Postoperative quality of life, patient satisfaction, and cost effectiveness also were analyzed. The search process identified seven clinical trials suitable for meta-analysis. These trials, consisting of 598 patients, compared day care and inpatient procedures. The unplanned admission rate in the ambulatory group was comparable with the prolonged hospitalization of inpatients (odds ratio [OR], 1.979; 95% confidence interval [CI], 0.846-4.628). There was no significant difference between the readmission rates of the two groups (OR, 0.964; 95% CI, 0.318-2.922). The quality-of-life indicators were similar for the ambulatory and overnight-stay patients (p = 0.195). The cost effectiveness was better for the day care procedures because of the shorter mean hospital stay. Ambulatory laparoscopic cholecystectomy can be performed safely for selected patients, with reduced cost and a high level of patient satisfaction.
Article
This is the protocol for a review and there is no abstract. The objectives are as follows: To determine whether early laparoscopic cholecystectomy is preferable to delayed laparoscopic cholecystectomy in acute cholecystitis. The following null hypothesis will be tested: there is no difference in outcome between early and delayed laparoscopic cholecystectomy in acute cholecystitis.
Article
Background: Bile duct injury (BDI) is a severe complication of laparoscopic cholecystectomy (LC). There is general agreement about the increase of this complication after LC vs open cholecystectomy (OC), but comparative studies are scarce. The aim of this paper has been to compare the incidence and clinical features of BDI after LC vs open procedures. Materials and methods: 3,051 OC, performed from June 1977 to December 1988 were retrospectively analyzed and compared with 1,630 LCs performed from June 91 to August 96, for which data were prospectively recorded. Age, sex, type of BDI, performance of intraoperative cholangiography (IOC), underlying biliary pathology, morbidity, mortality, and late morbidity were all analyzed. Results: BDI incidence was higher in group II (LC) (N: 16, 0.95%) than in group I, (OC, N: 19, 0.6%). BDI incidence was also higher in the group of patients in which it was necessary to convert to an open procedure (3/109, 2.7%, p < 0.05). BDIs were more frequently diagnosed intraoperatively in group I (OC, 18/19) than in group II (LC, 12/16). In both groups, BDI was more prevalent in cases operated by staff surgeons than residents, mainly in complicated gallbladder patients, with a bile duct of less than 7-mm diameter. Morbidity, postoperative stay, mortality, and late morbidity were similar after a BDI in both types of approach. Conclusion: (1) BDI increases with LC. (2) BDI after LC carries a similar postoperative morbidity and mortality to those after OC. (3) Incidence of BDI in converted cases increases significantly and this constitutes a high-risk group.
Article
In the present era laparoscopic cholecystectomy (LC) has become the gold standard treatment of choice for gallstone disease. This technique has made a new revolution in minimal invasive surgery, but also the spectrum of complications has changed. In this paper we shared our personal experience of LC in 400 hundred cases from January 2007 to December 2010, its complications and prevention. According to our experience the complications were liver bed injury (n=32, 8%), spilled gall stones (n=29, 7.25%), port site infection (n=11, 2.75%), vascular injury (n=18, 4.5%), conversion to open surgery (n=16, 4%), biliary leak (n=10, 2.5%), bowel injury (n=3, 0.75%), CBD stricture (n=4, 1%) and umbilical port hernia (n=2, 0.5%). Before the procedure, patient consent and awareness to all possible complications which may occur intra-operatively is very important. A good surgical team and experience in this procedure seems to prevent hazardous complications.
Article
: In many countries laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute episode has settled because of the anticipated increased risk of morbidity and higher conversion rate from laparoscopic to open cholecystectomy. : A systematic review was performed with meta-analysis of randomized clinical trials of early laparoscopic cholecystectomy (ELC; performed within 1 week of onset of symptoms) versus delayed laparoscopic cholecystectomy (performed at least 6 weeks after symptoms settled) for acute cholecystitis. Trials were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded and reference lists. Risk ratio (RR) or mean difference was calculated with 95 per cent confidence intervals (c.i.) based on intention-to-treat analysis. : Five trials with 451 patients were included. There was no significant difference between the two groups in terms of bile duct injury (RR 0.64 (95 per cent c.i. 0.15 to 2.65)) or conversion to open cholecystectomy (RR 0.88 (95 per cent c.i. 0.62 to 1.25)). The total hospital stay was shorter by 4 days for ELC (mean difference -4.12 (95 per cent c.i. -5.22 to -3.03) days). : ELC during acute cholecystitis appears safe and shortens the total hospital stay.
Article
To compare clinical outcomes after laparoscopic cholecystectomy (LC) for acute cholecystitis performed at various time-points after hospital admission. Symptomatic gallstones represent an important public health problem with LC the treatment of choice. LC is increasingly offered for acute cholecystitis, however, the optimal time-point for LC in this setting remains a matter of debate. Analysis was based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery and included patients undergoing emergency LC for acute cholecystitis between 1995 and 2006, grouped according to the time-points of LC since hospital admission (admission day (d0), d1, d2, d3, d4/5, d ≥6). Linear and generalized linear regression models assessed the effect of timing of LC on intra- or postoperative complications, conversion and reoperation rates and length of postoperative hospital stay. Of 4113 patients, 52.8% were female, median age was 59.8 years. Delaying LC resulted in significantly higher conversion rates (from 11.9% at d0 to 27.9% at d ≥6 days after admission, P < 0.001), surgical postoperative complications (5.7% to 13%, P < 0.001) and re-operation rates (0.9% to 3%, P = 0.007), with a significantly longer postoperative hospital stay (P < 0.001). Delaying LC for acute cholecystitis has no advantages, resulting in significantly increased conversion/re-operation rate, postoperative complications and longer postoperative hospital stay. This investigation-one of the largest in the literature-provides compelling evidence that acute cholecystitis merits surgery within 48 hours of hospital admission if impact on the patient and health care system is to be minimized.
Article
Bile duct injury (BDI) is a severe complication of laparoscopic cholecystectomy (LC). There is general agreement about the increase of this complication after LC vs open cholecystectomy (OC), but comparative studies are scarce. The aim of this paper has been to compare the incidence and clinical features of BDI after LC vs open procedures. 3,051 OC, performed from June 1977 to December 1988 were retrospectively analyzed and compared with 1,630 LCs performed from June 91 to August 96, for which data were prospectively recorded. Age, sex, type of BDI, performance of intraoperative cholangiography (IOC), underlying biliary pathology, morbidity, mortality, and late morbidity were all analyzed. BDI incidence was higher in group II (LC) (N: 16, 0.95%) than in group I, (OC, N: 19. 0.6%). BDI incidence was also higher in the group of patients in which it was necessary to convert to an open procedure (3/109, 2.7%, p < 0.05). BDIs were more frequently diagnosed intraoperatively in group I (OC, 18/19) than in group II (LC, 12/16). In both groups, BDI was more prevalent in cases operated by staff surgeons than residents, mainly in complicated gallbladder patients, with a bile duct of less than 7-mm diameter. Morbidity, postoperative stay, mortality, and late morbidity were similar after a BDI in both types of approach. (1) BDI increases with LC. (2) BDI after LC carries a similar postoperative morbidity and mortality to those after OC. (3) Incidence of BDI in converted cases increases significantly and this constitutes a high-risk group.
Article
We reviewed the cumulative experience with laparoscopic cholecystectomy reported in the surgical literature, including 12,397 patients selected to undergo laparoscopic cholecystectomy, 95% of which were performed on an elective basis. Although the indications for operation varied, 90% of patients had evidence of cholelithiasis and biliary colic. Conversion to open cholecystectomy was required in 534 patients (4%); of these, 52% were converted because of acute or chronic inflammation or adhesions. Laparoscopic cholangiography was attempted in 3,696 of 9,231 patients (40%) and was successful in 84%. The incidence of major bile duct injury, minor bile duct injury, bile leak, and overall morbidity was 0.3%, 0.1%, 0.4%, and 4%, respectively. The mortality rate was 0.08%. Results from individual reports indicate that 54% to 98% of patients were discharged on the 1st or 2nd postoperative day, and 77% to 98% returned to full activity within 7 to 14 days. The incidence of bile duct injury, overall morbidity, and mortality compare favorably with published reports for open cholecystectomy. The collective data would also indicate that laparoscopic cholecystectomy is a safe and efficacious procedure that offers a viable alternative to conventional cholecystectomy.
Article
The purpose of this study was to perform a meta-analysis of large laparoscopic cholecystectomy case-series and compare results concerning complications, particularly bile duct injury, to those reported in open cholecystectomy case-series. Since the introduction of laparoscopic cholecystectomy in the United States, hundreds of reports about the technique have been published, many including statements about the advantages of laparoscopic cholecystectomy compared with those of open cholecystectomy. There is an unevenness in scope and quality of the studies. Nevertheless, enough data have accumulated from large series to permit analyses of data regarding some of the most important issues. Articles identified via a MEDLINE (the National Library of Medicine's computerized database) search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes of cholecystectomy were abstracted and summarized across studies. Outcomes of laparoscopic cholecystectomy are examined for 78,747 patients reported on in 98 studies and compared with outcomes of open cholecystectomy for 12,973 patients reported on in 28 studies. Laparoscopic cholecystectomy appears to have a higher common bile duct injury rate and a lower mortality rate. Estimated rates of other types of complications after laparoscopic cholecystectomy generally were low. Most conversions followed operative discoveries (e.g., dense adhesions) and were not the result of injury. There is wide variability in the amount and type of data reported within any single study, and patient populations may not be comparable across studies. Except for a higher common bile duct injury rate, laparoscopic cholecystectomy appears to be at least as safe a procedure as that of open cholecystectomy.
Article
To compare the results of laparoscopic cholecystectomy (LC) with those of open cholecystectomy (OC) in the treatment of acute cholecystitis. A prospective, nonrandomized trial. "Virgen de la Arrixaca" University Hospital, El Palmar (Murcia), Spain. One hundred fourteen patients underwent LC, and 110 underwent OC. The patients underwent surgery within 72 hours of the onset of symptoms. The patients were selected for LC or OC depending on the surgeon's experience in laparoscopic surgery. Operating time, rate of conversion from LC to OC, complications, and length of hospital stay. Conversion from LC to OC was necessary in 15% of the patients. The mean operating time was 77 minutes for the OC group and 88 minutes for the LC group (P<.001). Complications occurred in 14% of the patients in the LC group and in 23% of the patients in the OC group, with no significant differences between the 2 groups (P=.06). The number of moderate or severe complications was similar in both groups, whereas mild complications were more common in the OC group (P<.02). The length of the hospital stay averaged 8.1 days for the OC group and 3.3 days for the LC group (P<.001). Laparoscopic cholecystectomy is a safe, valid alternative to OC in patients with acute cholecystitis. The technique has a low rate of complications, implies a shorter hospital stay, and offers the patient a more comfortable postoperative period than OC.
Article
A prospective randomized study was undertaken to compare early with delayed laparoscopic cholecystectomy for acute cholecystitis. Laparoscopic cholecystectomy for acute cholecystitis is associated with high complication and conversion rates. It is not known whether there is a role for initial conservative treatment followed by interval elective operation. During a 26-month period, 99 patients with a clinical diagnosis of acute cholecystitis were randomly assigned to early laparoscopic cholecystectomy within 72 hours of admission (early group, n = 49) or delayed interval surgery after initial medical treatment (delayed group, n = 50). Thirteen patients (four in the early group and nine in the delayed group) were excluded because of refusal of operation (n = 6), misdiagnosis (n = 5), contraindication for surgery (n = 1), or loss to follow-up (n = 1). Eight of 41 patients in the delayed group underwent urgent operation at a median of 63 hours (range, 32 to 140 hours) after admission because of spreading peritonitis (n = 3) and persistent fever (n = 5). Although the delayed group required less frequent modifications in operative technique and a shorter operative time, there was a tendency toward a higher conversion rate (23% vs. 11%; p = 0.174) and complication rate (29% vs. 13%; p = 0.07). For 38 patients with symptoms exceeding 72 hours before admission, the conversion rate remained high after delayed surgery (30% vs. 17%; p = 0.454). In addition, delayed laparoscopic cholecystectomy prolonged the total hospital stay (11 days vs. 6 days; p < 0.001) and recuperation period (19 days vs. 12 days; p < 0.001). Initial conservative treatment followed by delayed interval surgery cannot reduce the morbidity and conversion rate of laparoscopic cholecystectomy for acute cholecystitis. Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients managed by surgeons with adequate experience in laparoscopic cholecystectomy.
Article
Laparoscopic cholecystectomy (LC) has become the treatment of choice for elective cholecystectomy, but controversy persists over use of this approach in the treatment of acute cholecystitis. We undertook a randomised comparison of the safety and outcome of LC and open cholecystectomy (OC) in patients with acute cholecystitis. 63 of 68 consecutive patients who met criteria for acute cholecystitis were randomly assigned OC (31 patients) or LC (32 patients). The primary endpoints were hospital mortality and morbidity, length of hospital stay, and length of sick leave from work. Analysis was by intention to treat. Suspected bile-duct stones were investigated by preoperative endoscopic retrograde cholangiography (LC group) or intraoperative cholangiography (OC group). The two randomised groups were similar in demographic, physical, and clinical characteristics. 48% of the patients in the OC group and 59% in the LC group were older than 60 years. 13 patients in each group had gangrene or empyema, and one in each group had perforation of the gallbladder causing diffuse peritonitis. Five (16%) patients in the LC group required conversion to OC, in most because severe inflammation distorted the anatomy of Calot's triangle. There were no deaths or bile-duct lesions in either group, but the postoperative complication rate was significantly (p=0.0048) higher in the OC than in the LC group: seven (23%) patients had major and six (19%) minor complications after OC, whereas only one (3%) minor complication occurred after LC. The postoperative hospital stay was significantly shorter in the LC than the OC group (median 4 [IQR 2-5] vs 6 [5-8] days; p=0.0063). Mean length of sick leave was shorter in the LC group (13.9 vs 30.1 days; 95% CI for difference 10.9-21.7). Even though LC for acute and gangrenous cholecystitis is technically demanding, in experienced hands it is safe and effective. It does not increase the mortality rate, and the morbidity rate seems to be even lower than that in OC. However, a moderately high conversion rate must be accepted.
Article
Laparoscopic cholecystectomy (LC) has become a popular alternative to open cholecystectomy (OC). Previous studies comparing outcomes in LC and OC used small selected cohorts of patients and did not control for comorbid conditions that might affect outcome. The aims of this study were to characterize the morbidity, mortality, and costs of LC and OC in a large unselected cohort of patients. We used the population-based North Carolina Discharge Abstract Database (NCHDAD) for January 1, 1991, to September 30, 1994 (n = 850,000) to identify patients undergoing OC and LC. We identified the indications for surgery, complications, and type of perioperative biliary imaging used. We compared length of stay, hospital charges, complications, morbidity, and mortality between OC and LC patients. To account for variations in outcomes from differences in age and comorbidity between the OC and LC groups, we used the age-adjusted Charlson Comorbidity Index in regression analyses quantifying the association between type of surgery and outcome. Our cohort consisted of 43,433 patients (19,662 LC and 23,771 OC). The mean age-adjusted Charlson Comorbidity Index score was slightly higher for the OC compared to the LC group (4.3 vs 4.1, p < 0.05). The OC patients had longer hospitalizations, generated more charges ($12,125 vs $9,139, p < 0.05), and required home care more often. The crude risk ratio comparing risk of death in OC to LC was 5.0 (95% CI = 3.9-6.5). After controlling for age, comorbidity, and sex, the odds of dying in the OC group was still 3.3 times (95% CI = 1.4-7.3) greater than in the LC group. In the LC group, the number of patients with acute cholecystitis rose over the study period, whereas the number of patients with chronic cholecystitis declined. In the OC group, the number of patients with acute and chronic cholecystitis declined. The use of intraoperative cholangiography was greater in the OC group but declined in both groups over the study period. The use of ERCP was greater in the LC group and increased in both groups over time. The introduction of LC has resulted in a change in the management of cholecystitis. Despite a higher proportion of patients with acute cholecystitis, the risk of dying was significantly less in LC than in OC patients, even after controlling for age and comorbidity. Based on lower costs and better outcomes, LC seems to be the treatment of choice for acute and chronic cholecystitis.
Article
Ambulatory laparoscopic cholecystectomy is an established practice in our institution, with an experience of more than 800 cases. The present study is conducted to evaluate the contemporary outcomes of day-case laparoscopic cholecystectomy in the setting of a major teaching hospital. A retrospective analysis of 200 patients who underwent ambulatory laparoscopic cholecystectomies was performed to evaluate the postoperative morbidity, unplanned admission, and readmission rates. Causes for unanticipated admission and readmission were analyzed. Uneventful recovery was attained in 185 (92.5%) patients. The mean length of the operation was 56 +/- 20 (SD) minutes. There was no hospital mortality, and no patient required conversion to open cholecystectomy. Nine patients were admitted overnight after operation because of nausea and vomiting (n = 3), pain (n = 2), urinary retention (n = 2), medical observation n = 1), and patient's preference (n = 1), leading to an unanticipated admission rate of 4.5%. Six patients required readmission because of postoperative complications (n = 4) and abdominal pain (n = 2), giving a readmission rate of 3%. The overall postoperative morbidity rate was 3% (n = 6), including retained stones n = 4), bile leakage (n = 1), and hepatic subcapsular hematoma (n = 1). Ambulatory laparoscopic cholecystectomy is a safe practice in appropriately selected patients. Postoperative nausea and vomiting was the commonest reason for unanticipated admission after operation, and retained stones was the most frequent postoperative morbidity necessitating readmission.
Article
Background: Early laparoscopic cholecystectomy has been advocated for the management of acute cholecystitis, but little evidence exists to support the superiority of this approach over delayed-interval operation. The current systematic review was undertaken to compare the outcomes and efficacy between early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis in an evidence-based approach using metaanalytical techniques. Methods: A search of electronic databases, including MEDLINE and EMBASE, was conducted to identify relevant articles published between January 1988 and June 2004. Only randomized or quasi-randomized prospective clinical trials in the English language comparing the outcomes of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were recruited. Both qualitative and quantitative statistical analyses were performed. The effect size of outcome parameters was estimated by odds ratio or weighted mean difference where feasible and appropriate. Results: A total of four clinical trials comprising 504 patients met the inclusion criteria. Failure of conservative treatment requiring emergency cholecystectomy occurred for 43 patients (23%) in the delayed group. Metaanalyses demonstrated a significantly shortened total length of hospital stay in the early group (weighted mean difference, -1.12; 95% confidence interval [CI], -1.42 to -0.99; p < 0.001). Pooled estimates did not show any significant differences between the two approaches in terms of operation time, conversion rate, overall complication rate, incidence of bile leakage, and intraabdominal collection. Conclusions: The safety and efficacy of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were comparable. Because evidence suggested that early laparoscopic cholecystectomy reduced the total length of hospital stay and the risk of readmissions attributable to recurrent acute cholecystitis, it is therefore a more cost-effective approach for the management of acute cholecystitis.
Article
Cholecystectomy for symptomatic gallstones is mainly performed after an acute cholecystitis episode settles. The main reason is the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis. This systematic review of five randomised trials shows that there is no significant difference in the complication rate or the conversion rate in regard to the time when the laparoscopic cholecystectomy is performed during acute cholecystitis versus performed 6 to 12 weeks after the symptoms settle. No mortality was reported in any of the trials. Early laparoscopic cholecystectomy during acute cholecystitis appears to be safe and shortens the total hospital stay.
Article
Older age, male sex, and low yearly hospital volume of cholecystectomy may increase the risk of bile duct injury (BDI), whereas the use of intraoperative cholangiography may decrease the risk. The incidence of BDI at cholecystectomy may have increased after the introduction of laparoscopic cholecystectomy. Nationwide population-based study of all cholecystectomies registered in the Swedish Inpatient Registry from 1987 through 2001. All hospitals performing inpatient cholecystectomies in Sweden. Cholecystectomies were identified using International Classification of Diseases, Ninth and 10th Revisions surgical procedure codes. After exclusion of patients with hepatobiliary and pancreatic malignancies, patients with codes indicating reconstructive bile duct operations within 1 year after cholecystectomy were considered BDI cases. Risk factors for BDI were analyzed using multivariate logistic regression. The incidence proportion of BDI was calculated by dividing the number of cases by the number of cholecystectomies. Relative risks were estimated using odds ratios with 95% confidence intervals, and incidence proportion was used to describe incidence. Among 152 776 cholecystectomies, 613 reconstructed BDIs (0.40%) were identified. Older age and male sex were positively associated with BDI, whereas intraoperative cholangiography was negatively associated with BDI. The incidence proportion of BDI was 0.40% from 1987 to 1990, decreased to 0.32% from 1991 to 1995, and increased to 0.47% from 1996 to 2001. The mean yearly hospital volume did not affect the risk of BDI. Older age and male sex increased the risk of BDI, whereas intraoperative cholangiography was protective. There was a small to moderate long-term increase in the risk of BDI after the introduction of laparoscopic cholecystectomy compared with the pre-laparoscopic era.
Article
The appropriate timing for laparoscopic cholecystectomy in the treatment of acute cholecystitis remains controversial. More recent evaluation indicates early laparoscopic surgery may be a safe option in acute cholecystitis, although conversion rates may be higher. No conclusive evidence establishing best practice in terms of clinical benefit exists. All randomized clinical studies published between 1987 and 2006 comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis were analyzed, irrespective of language, blinding, or publication status. Exclusions were quasi-randomized trials, inadequate follow-up description, or allocation concealment. Endpoints included conversion rates, postoperative complications, total hospital stay, and operation time. Random and fixed-effect models were used to aggregate the study endpoints and assess heterogeneity. Four studies containing 375 patients were included. No significant study heterogeneity or publication bias was found. There was no significant difference in conversion rates (odds ratio = .915 [95% confidence interval (CI), .567-1.477], P = .718) and postoperative complications (odds ratio = 1.073 [95% CI, .599-1.477], P = .813) between both groups. Operation time was significantly reduced (weighted mean difference [WMD] = .412 [95% CI, .149-.675], P = .002) with delayed cholecystectomy. The total hospital stay was significantly reduced (WMD = .905 [95% CI, .630-1.179], P = .0005) with early cholecystectomy. The postoperative stay was significantly reduced in the delayed group (WMD = .393 [95% CI, .128-.659], P = .004). These meta-analysis data suggest that early laparoscopic cholecystectomy allows significantly shorter total hospital stay at the cost of a significantly longer operation time with no significant differences in conversion rates or complications.
Article
Traditionally, cholecystectomy for cholecystitis is performed within 3 days of the onset of symptoms or after 5 weeks, allowing for resolution of the inflammatory response. This study reviewed the outcomes of cholecystectomy performed for patients with gallstone disease in the acute (n = 45), intermediate (n = 55), and delayed (n = 102) periods after the onset of symptoms. The medical records of 202 patients who underwent laparoscopic cholecystectomy at a large municipal hospital were reviewed retrospectively. The primary outcomes studied were length of hospital stay, conversion to open cholecystectomy, and complications. There was no significant difference in the conversion rate (acute [18%] vs intermediate [20%] vs delayed [11%]) or complication rate (acute [16%] vs intermediate [9%] vs delayed [7%]) among the 3 groups. The delayed group had a significantly shorter length of hospital stay than the intermediate or acute group (3.1 +/- 3.8 vs 4.3 +/- 3.8 vs 1.7 +/- 2.1, respectively, P < .001). Patients who present with acute symptoms of cholecystitis should undergo surgery during the same admission, regardless of the duration of symptoms.