Cholecystectomy Group Research Articles

Outcome of early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy for patients with acute cholecystitis

Background: This prospective randomized study was undertaken to to assess the outcomes of early versus delayed cholecystectomy for patient’s acute cholecystitis.Methods: 70 patients with acute cholecystitis were prospectively randomized to either an early laparoscopic cholecystectomy (n=35) or a delayed laparoscopic cholecystectomy group (n=35). The mean operative time, conversion rate, total hospital stay, intra-operative and post-operative complications, average hospital cost were evaluated between the two groups.Results: A total of 70 patients were enrolled, 35 patients in each group. There was no significant difference in the conversion rates (early, 8.57% vs delayed, 5.71%) and postoperative complications (early, 25% vs delayed, 20%). At the cost of an increased operating time (early, 81 minutes vs delayed, 78 minutes) and blood loss (early, 180.33ml vs delayed, 108.00 ml), early laparoscopic cholecytectomy significantly shortened the total hospital stay (early, 1.5 days vs. delayed, 7.95 days) and average hospital cost (early 9240 INR vs delayed, 12251 INR).Conclusions: The safety and efficacy of early and delayed laparoscopic cholecystectomy for acute cholecystitis were comparable in terms of morality, morbidity and conversion rate. However early laparoscopic cholecystectomy allows significantly shorter total hospital stay and reduction in days away from work at the cost of longer operating time and blood loss and offers definitive treatment at initial admission. Moreover it avoids repeated admissions for recurrent symptoms has both medical as well as socioeconomic benefits and should be the preferred approach for patients managed by surgeons with adequate experience in laparoscopic cholecystectomy.

Computed Tomography Measurements of Hepatic Steatosis in Cholelitihiasis and Cholecystectomy Cases Using Unenhanced Images

IntroductionComputed tomography (CT) measurements of hepatic steatosis can be performed using unenhanced CT images. The purpose of this study was to assess the occurrence of hepatic steatosis using unenhanced CT images for patients undergoing cholecystectomy or having cholelithiasis. MethodsA total of 143 unenhanced CT cases from a single centre were retrospectively examined. The CT number of liver, ratio of CT number of liver to spleen, and CT number of liver minus CT number of spleen were measured in three groups: (1) patients undergoing cholecystectomy, (2) patients having cholelithiasis, and (3) control group. Abdominal circumference, anterior subcutaneous fat tissue thickness, and body mass index were obtained. ResultsMean CT number of liver was significantly different between the group of patients with cholecystectomy and cholelithiasis and the control group (P < .001) and also between cases of cholecystectomy and cholelithiasis (P = .041), with the lowest CT number of liver in the cholecystectomy group. The mean CT number of liver minus CT number of spleen and mean CT number (liver/spleen) ratios, evaluated separately for both lobes, were not different comparing the cholelithiasis and cholecystectomy groups. The mean CT number of liver minus CT number of spleen and mean CT number (liver/spleen) ratios differed significantly between the control group and both patient groups (P < .001). Positive correlations were identified between abdominal circumference, subcutaneous fat depth, body mass index, and liver size and hepatic steatosis. ConclusionThere was an increased occurrence of hepatic steatosis in patients who have undergone a cholecystectomy compared with patients treated for cholelithiasis and the control group.

Cholecystectomy is associated with higher risk of recurrence after microwave ablation of hepatocellular carcinoma: a propensity score matching analysis.

Objective: To explore the association between cholecystectomy and the prognostic outcomes of patients with hepatocellular carcinoma (HCC) who underwent microwave ablation (MWA).Methods: Patients with HCC (n = 921) who underwent MWA were included and divided into cholecystectomy (n = 114) and non-cholecystectomy groups (n = 807). After propensity score matching (PSM) at a 1:2 ratio, overall survival (OS) and disease-free survival (DFS) rates were analyzed to compare prognostic outcomes between the cholecystectomy (n = 114) and non-cholecystectomy groups (n = 228). Univariate and multivariate Cox analyses were performed to assess potential risk factors for OS and DFS. Major complications were also compared between the groups.Results: After matching, no significant differences between groups were observed in baseline characteristics. The 1-, 3-, and 5-year OS rates were 96.5%, 82.1%, and 67.1% in the cholecystectomy group, and 97.4%, 85.2%, and 74.4% in the non-cholecystectomy group (P = 0.396); the 1-, 3-, and 5-year DFS rates were 58.4%, 34.5%, and 26.6% in the cholecystectomy group, and 73.6%, 44.7%, and 32.2% in the non-cholecystectomy group (P = 0.026), respectively. The intrahepatic distant recurrence rate in the cholecystectomy group was significantly higher than that in the non-cholecystectomy group (P = 0.026), and the local tumor recurrence and extrahepatic recurrence rates did not significantly differ between the groups (P = 0.609 and P = 0.879). Multivariate analysis revealed that cholecystectomy (HR = 1.364, 95% CI 1.023–1.819, P = 0.035), number of tumors (2 vs. 1: HR = 2.744, 95% CI 1.925–3.912, P < 0.001; 3 vs. 1: HR = 3.411, 95% CI 2.021–5.759, P < 0.001), and γ-GT levels (HR = 1.003, 95% CI 1.000–1.006, P < 0.024) were independent risk factors for DFS. The best γ-GT level cut-off value for predicting median DFS was 39.6 U/L (area under the curve = 0.600, P < 0.05). A positive correlation was observed between cholecystectomy and γ-GT level (r = 0.108, 95% CI −0.001–0.214, P = 0.047). Subgroup analysis showed that the DFS rates were significantly higher in the non-cholecystectomy group than the cholecystectomy group when γ-GT ≥39.6 U/L (P = 0.044). The 5-, 10-, 15-, 20-, and 25-year recurrence rates from the time of cholecystectomy were 2.63%, 21.93%, 42.11%, 58.77%, and 65.79%, respectively. A significant positive correlation was observed between cholecystectomy and the time from cholecystectomy to recurrence (r = 0.205, 95% CI 0.016–0.379, P = 0.029). There were no significant differences in complications between groups (P = 0.685).Conclusions: Patients with HCC who underwent cholecystectomy were more likely to develop intrahepatic distant recurrence after MWA, an outcome probably associated with increased γ-GT levels. Moreover, the recurrence rates increased with time.

Laparoscopic and open cholecystectomy: A comparative study

Background: Gallstone (GS) disease is a major health problem worldwide particularly in the adult population. Gallstones are a common occurrence in northern India. Prevalence of gallstone ranges from 10 to 20% in India. 2 It affects nearly 4. 3% of the population. Subjects and Methods: 146 Patients of cholelithiasis aged between 16 years to 65 years operated during the period from July 2017 to December 2019. They were divided into open and laparoscopic Cholecystectomy group. The patients were studied with respect to their clinical presentation and were categorized as patients with asymptomatic Gall stones, acute calculus cholecystitis and chronic calculus cholecystitis. Results: In open cholecystectomy group 45% were males and 55% females. In laparoscopic cholecystectomy group 36% were males and 64% females. The age range was from 16-65 year in both the groups. The mean age was 36. 29±14. 60 years for group open cholecystectomy and 34. 47±11. 20 years for group laparoscopic cholecystectomy. Symptoms of patients in both the groups were almost same. The mean operation time for Laparoscopic cholecystectomy was significantly longer than for Open cholecystectomy. Conclusion: The laparoscopic cholecystectomy is a safe and effective treatment of complicated gallstone disease. Laparoscopic cholecystectomy is better than open cholecystectomy in terms of post-operative pain, analgesic requirement and early return to work.

Вплив холецистектомії на стан серця, ліпідний метаболізм та активність запалення

Aim. Gallbladder disorders and ischemic heart disease share common etiopathogenetic factors of development and influence each other. Literature describes dependence of clinical presentation of ischemic heart disease on gallbladder condition, and improvement of heart condition after cholecystectomy. The aim of this study was to compare features of the heart condition, lipid metabolism parameters, inflammation activity, and their correlations in patients with ischemic heart disease after cholecystectomy and with different gallbladder conditions. Materials and Methods. We analyzed data of 197 patients with ischemic heart disease (namely, stable and unstable angina pectoris), which were diagnosed and treated according to the existing guidelines. These patients were divided into 6 groups: with intact gallbladder; with sludge, bile thickening, polyps, and cholesterosis; with bent gallbladder body and its deformations; with gallbladder neck deformations and signs of past cholecystitis; with cholelithiasis; and after cholecystectomy. Results and Discussion. It was revealed that cholecystectomy in chronic subtypes of ischemic heart disease was associated with minimal frequency of arrhythmias, and in acute subtypes - with maximal frequency. Structural and functional parameters of the heart were the best in patients with a history of cholecystectomy. This was reflected in the smallest sizes of the right ventricle (2.31 cm), the left atrium (3.95 cm), and the left ventricle (4.92 cm), along with the smallest thickness of the interventicular septum (1.14 cm) and the posterior wall of the left ventricle (1.11 cm). The patients with removed gallbladder were characterized by the lowest values of total cholesterol (4.41 mmol/L), triglycerides (1.37 mmol/L), cholesterol of low density lipoproteins (2.61 mmol/L) and the atherogenic index of plasma (2.77) among all the groups with different gallbladder condition. All the parameters were lower than the parameters of intact gallbladder group. Both Castellі indexes after cholecystectomy were lower than in the group with intact gallbladder. Conclusions. The patients with a history of cholecystectomy were characterized by better parameters of lipid metabolism than patients of the other groups with different gallbladder conditions. The cholecystectomy group was characterized by the lowest inflammation activity according to the band neutrophils count (1.77%), the neutrophils to lymphocytes ratio (3.01), and the total fibrinogen level (4.03 g/L). Key words: ischemic heart disease, cholecystectomy, echocardiography, gallbladder, lipidogram

Three-port versus conventional four-port laparoscopic cholecystectomy: a comparative study

Objectives This prospective comparative study aims at evaluating the feasibility of three-port technique without affecting safety and at comparing the outcome of three-port and four-port techniques. Patients and methods This study included 94 patients with symptomatic gallstone disease and gallbladder polyp in Surgical Department, Minia University Hospital, from beginning of 2018 to beginning of 2019. Patients who were unwilling to be a part of the study, jaundiced patients with radiologically evidence of common bile duct stones, patients unfit for general anesthesia, patients with liver cirrhosis, patients with portal hypertension, patients with coagulopathy, patients with acute pancreatitis, patients with generalized peritonitis, or patients with malignancy were excluded. All patients were operated by the same operating team. Patients were randomized for three-port laparoscopic cholecystectomy (LC) group (45 patients) or four-port LC group (49 patients). Numeric Pain Rating Scale, operative time, operative difficulty, intraoperative and postoperative complications, duration required to stop oral analgesics, and duration required to return to normal activity were recorded. Results Numeric Pain Rating Scale, required number of diclofenac ampoules, duration required for oral analgesia, and duration required to return to normal activity were significantly less in three-port group. Other parameters were comparable between the two groups. Conclusion It seems that three-port LC is a safe and feasible technique with superior clinical outcomes to four-port LC.

What to Choose from Medical Treatment, Gallbladder Drainage or Cholecystectomy to Treat Acute Cholecystitis

The purpose of this study is to compare laparoscopic cholecystectomy with other treatment methods for acute cholecystitis at a university hospital. Treatments given to 197 patients with acute cholecystitis between 2016 and 2019 were examined. Three groups were set as first group of patients treated with interval cholecystectomy (n=107), second group of patients treated with early cholecystectomy (n=65) and third group of patients treated with gallbladder drainage (n=25). Demographic characteristics, hospitalization duration, laboratory results and ultrasonography findings obtained from patient files were statistically analysed. Among the 197 acute cholecystitis patients there was no significant difference between the groups in terms of initial laboratory findings. There were significant differences in terms of the gallbladder wall thickness, pericholecystic fluid collection and age and hospitalization duration between the 3 groups. No mortality was observed in these patients while one patient developed bilioenteric fistula and was treated. After the treatment of acute cholecystitis, the treatment approach should be decided according to response to medical treatment, comorbidities, surgical risk of patient, and radiological findings independent of the initial laboratory findings. In conclusion, it is suggested that clinicians to assess pericholecystic fluid for early intervention of the patient and gallbladder thickness to decide about gallbladder drainage for the treatment of the patient along with patient’s comorbidities.

Timing of cholecystectomy in the treatment of mild acute biliary pancreatitis

Aim: In this study, we aimed to compare the results of emergency and elective cholecystectomy in patients admitted due to acute biliary pancreatitis.Material and Methods: A total of 632 patients admitted due to acute biliary pancreatitis were retrospectively evalauted. Patients with Ranson ≥ 3 and hour 48 CRP > 15 were considered as severe pancreatitis and excluded from the study. Patients were divided into two groups. Group 1 consisted of the patients who underwent emergency cholecystectomy after 48 hours, while Group 2 included the patients who underwent interval cholecystectomy. Results: A total of 386 patients were enrolled in the study. Group 1 consisted of 214 patients. The mean Ranson score was found as 1.3±0.9 in Group 1 and 0.92±0.7 in Group 2. A total of 148 patients in Group 1 and 117 patients in Group 2 had comorbidity (p=0.81). Conversion was performed in 8 patients in Group 1 and 5 patients in Group 2 (p = 0.78). Bile duct injury was not detected in either group. Among the patients in the interval cholecystectomy group, 7 patients were admitted to the hospital due to acute pancreatitits and total 13 patients due to biliopancreatic reasons during the interval period. Conclusion: No effect of cholecystectomy timing was detected on the conversion rates and development of complications. However, development of recurrence and related complications in the waiting period of the patients could be prevented by performing early cholecystectomy.

100 Outcomes of Acute Pancreatic in Patients With and Without History of Cholecystectomy

INTRODUCTION: Acute pancreatitis (AP) has been shown to have a high mortality of up to 21%. But, data are lacking on the mortality and other outcomes in patients who underwent cholecystectomy. We aimed to assess the outcomes of AP in patients who had history of cholecystectomy versus who retained their gall bladder. METHODS: Using data from the National Inpatient Sample (NIS) database between 2002 and 2014, we identified patients who were diagnosed with AP using appropriate ICD 9 coding. Patients with AP were divided into two groups: with history of cholecystectomy (study group) and without history of cholecystectomy (control group). We then performed multivariate logistic regression analysis to compare the outcomes of AP between the two groups. Outcomes of interest included: inpatient mortality (IM), respiratory failure (RF) and acute kidney injury (AKI). RESULTS: A total of 1,094,214 total patients with AP were identified, of which 18,263 patients (1.67%) had history of cholecystectomy. Patients with cholecystectomy were older (53 vs 52), more likely to female (56.6% vs 49.9%) and less likely to be African American (11% vs 16.6%) than the control group (P &lt; 0.001 for all). In addition, patients with cholecystectomy had less alcohol abuse (12.8% vs 22.8%, P &lt; 0.001) but more likely to be obese (13.1% vs 9.4%) and smokers (23.1% and 19.4%) when compared to the control group (P &lt; 0.001) (Table 1). Using Multivariate logistic regression, and after adjusting for potential cofounding factors including (age, race, gender, obesity, alcohol abuse, smoking and Elixhauser comorbidities), individuals in the cholecystectomy group had a lower rate of in-patient mortality (IM) (OR 0.21, 95%, CI: 0.16–0.28, P &lt; 0.001), respiratory failure (RF) (OR 0.30, 95%, CI: 0.26–0.34, P &lt; 0.001) and acute kidney injury (OR 0.58, 95%, CI: 0.54–0.63, P &lt; 0.001) when compared to patients without cholecystectomy (Figure 1). CONCLUSION: Our study suggests that cholecystectomy in patients admitted with acute pancreatitis is associated with lower risk of IM, RF and AKI and should be considered in all patients admitted with acute pancreatitis.

Safety of laparoscopic subtotal cholecystectomy in acute cholecystitis. Experience in Southeast Mexico

IntroductionSubtotal cholecystectomy has been employed in cases of tecnically difficult cholecystectomy to prevent common bile duct injury. Given that there are few reports in Mexico on the theme, we consider it important to present the 18-year experience of a surgical group in the South-Southeast of Mexico. AimTo determine the safety of laparoscopic subtotal cholecystectomy in patients with acute cholecystitis. Materials and methodsA retrospective, observational, and comparative study was conducted on patients with gallstones that underwent laparoscopic cholecystectomy. The variables analyzed were: anthropometric characteristics, comorbidities, conversion rate, surgery duration, hospital stay, and morbidity and mortality. Statistical analysis: Descriptive statistics were applied through measures of central tendency and dispersion and standard deviation, utilizing the SPSS v22 program. ResultsA total of 1,101 medical records of patients with gallstones were reviewed. Of those patients, 223 presented with acute cholecystitis (20.25%) and they were divided into 2 groups: A) total cholecystectomy (82.95%) and B) subtotal cholecystectomy (17.05%). The anthropometric characteristics, risk factors, conversion rate, and hospital stay were similar in both groups. Only surgery duration was longer in the subtotal cholecystectomy group. Complications were more frequent, there was 1 death, and there was no bile duct injury in the subtotal cholecystectomy group. Those results were not statistically significant between the two groups. ConclusionsSubtotal cholecystectomy is a valuable resource in patients with acute cholecystitis. In our case series, it was a safe and reliable procedure for preventing bile duct injury. A larger number of cases are needed to corroborate those results.

Outcomes Following an Index Emergency Admission With Cholecystitis: A National Cohort Study.

The objective of this study was to evaluate the differences between patients who undergo cholecystectomy following index admission for cholecystitis, and those who are managed nonoperatively. Index emergency cholecystectomy following acute cholecystitis is widely recommended by national guidelines, but its effect on clinical outcomes remains uncertain. Data collected routinely from the Hospital Episode Statistics database (all admissions to National Health Service organizations in England and Wales) were extracted between April 1, 2002 and March 31, 2015. Analyses were limited to patients aged over 18 years with a primary diagnosis of cholecystitis. Exclusions included records with missing or invalid datasets, patients who had previously undergone a cholecystectomy, patients who had died without a cholecystectomy, and those undergoing cholecystectomy for malignancy, pancreatitis, or choledocholithiasis. Patients were grouped as either "no cholecystectomy" where they had never undergone a cholecystectomy following discharge, or "cholecystectomy." The latter group was then subdivided as "emergency cholecystectomy" when cholecystectomy was performed during their index emergency admission, or "interval cholecystectomy" when a cholecystectomy was performed within 12 months following a subsequent (emergency or elective) admission. Propensity Score Matching was used to match emergency and interval cholecystectomy groups. Main outcome measures included 1) One-year total length of hospital stay due to biliary causes following an index emergency admission with cholecystitis. 2) One-year mortality; defined as death occurring within 1 year following the index emergency admission with acute cholecystitis. Of the 99,139 patients admitted as an emergency with acute cholecystitis, 51.1% (47,626) did not undergo a cholecystectomy within 1 year of index admission. These patients were older, with more comorbidities (Charlson Comorbidity Score ≥ 5 in 23.5% vs. 8.1%, P < 0.001) when compared to patients who did have a cholecystectomy. While all-cause 1-year mortality was higher in the nonoperated versus the operated group (12.2% vs. 2.0%, P < 0.001), gallbladder-related deaths were significantly lower than all other causes of death in the non-operated group (3.3% vs. 8.9%, P < 0.001). Following matching, 1-year total hospital admission time was significantly higher following emergency compared with interval cholecystectomy (17.7 d vs. 13 d, P < 0.001). Over 50% of patients in England did not undergo cholecystectomy following index admission for acute cholecystitis. Mortality was higher in the nonoperated group, which was mostly due to non-gallbladder pathologies but total hospital admission time for biliary causes was lower over 12 months. Increasing the numbers of emergency cholecystectomy may risk over-treating patients with acute cholecystitis and increasing their time spent admitted to hospital.

Minimally Invasive Single-Site Cholecystectomy in Obese Patients: Laparoscopic vs. Robotic.

PurposeLaparoscopic cholecystectomy is treatment method for management of benign gallbladder diseases. Further attempts are made to operate single-port laparoscopic cholecystectomy. However, single-port laparoscopic cholecystectomy, the procedure remains technically difficult, especially in obese patient. Recently, a robotic surgical system for minimal invasive surgery was introduced to overcome the limitations of conventional laparoscopic surgery.MethodsFrom April 2009 to August 2017, we retrospectively reviewed the medical records of patients with single-site, minimally invasive (laparoscopic and robotic) cholecystectomy with high BMI (>25 kg/m2). We analyzed general characteristics and perioperative outcomes between the single-fulcrum laparoscopic cholecystectomy group and the robotic single-site cholecystectomy (RSSC) group.ResultsOperation time (57.56±11.10 vs 98.5±12.28 p<0.001) was significantly longer and postoperative pain score (3.61 vs 5.15 p=0.000) was significantly higher in the robotic single-site cholecystectomy (RSSC) group, but the actual dissection time (25.85±11.09 vs 25.79±13.35 p=0.978) was not significantly different between the two approaches. Iatrogenic gallbladder perforation, (13 vs 6 p=0.005), patients undergoing RSSC showed a significantly smaller amount than did those undergoing single-fulcrum laparoscopic cholecystectomy (SFLC).ConclusionIt is difficult to say for certain that RSSC is clearly better than SFLC in obese patients. However, because of the technical convenience and efficiency of surgery with RSSC, RSSC can be practically worthwhile. Further study is mandatory.

Preoperative and Operative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy in Pakistan.

IntroductionThe currently available literature suggests a wide range of conversion (4.9-20%) from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) despite the increase in surgical expertise. Open cholecystectomy is important as the last resort for safe surgical practice in complicated cases. Increased number of pre-operative and perioperative risk factors need to be identified to pre-empt conversion. However, there has been a significant decrease in conversion rates over the past few decades. This study was conducted to determine conversion rates in our population and to identify any significant risks for conversion.MethodsThis prospective study was conducted at the Shifa International Hospital, Islamabad, Pakistan, including 1081 cholecystectomies, performed over a two-year period from January 2017 to January 2019. Comparison of risk factors between the two groups; laparoscopic cholecystectomy (LC) group and conversion to open cholecystectomy (OC) group was done. Statistical analysis was done using SPSS 24.0.1. P<0.05 were considered significant.ResultsIn our study, the overall conversion rate was 7.78%. Factors of conversion to open cholecystectomy (OC) included age ≥65, morbid obesity, diabetes mellitus, and previous abdominal surgery. Deranged alkaline phosphatase (ALP), increased total bilirubin, increased common bile duct (CBD) diameter, and multiple stones in ultrasonography showed a statistically significant association with the conversion. Per-operative findings of increased adhesions >50%, empyema gallbladder (GB), perforated GB, and scleroatrophic GB showed a higher risk of conversion too (p <0.05). However, there was no statistical association with preoperative endoscopic retrograde cholangiopancreatography (ERCP) to OC in our population.ConclusionAn open cholecystectomy is a safe approach for patients with complicated gallbladder disease. No doubt laparoscopic cholecystectomy is the gold standard having its outstanding benefits. This study identifies predictors of choice for OC in addition to the decision to convert to OC. In view of the raised morbidity and mortality associated with open cholecystectomy, distinguishing these predictors will serve to decrease the rate of OC and to address these factors preoperatively.

Early cholecystectomy (≤ 8weeks) following percutaneous cholecystostomy tube placement is associated with higher morbidity.

Percutaneous cholecystostomy tube (PCT) placement is often the initial management approach to severe acute cholecystitis in the unstable patient. However, the timing of cholecystectomy after PCT has not been carefully examined. The purpose of this study was to compare outcomes of early versus late cholecystectomy following PCT placement. The New York SPARCS administrative database was searched for all patients undergoing PCT placement between 2000 and 2012. Patients were followed for subsequent cholecystectomy (CCX) procedures up to 2014. Subsequent cholecystectomies were divided into early (≤ 8weeks) versus late (> 8weeks) groups. Outcomes included overall complications, 30-day readmissions, 30-day Emergency Department (ED) visits, and length of stay (LOS). Multivariable regression models were used to examine the differences in clinical outcomes between these two groups, after adjusting for possible confounding factors. There were 9728 patients who underwent PCT placement identified during the time period, as early subsequent cholecystectomy was performed in 1211 patients (40.4%), while 1787 (59.6%) patients had a late cholecystectomy. Average time to cholecystectomy was 38days in the early group, versus 203days in the late group. After adjusting for other confounding factors, patients with early CCX had a significantly higher risk of overall complications and longer LOS compared to the late CCX group (P = 0.01 and P = 0.0004, respectively). There were no significant differences in 30-day readmissions and 30-day ED visits. Furthermore, there was no significant difference in the risk of CBD injury between the two groups (n = 21, 1.7% in the early cholecystectomy group and n = 26, 1.5% in the late cholecystectomy group). Early cholecystectomy (≤ 8weeks) is associated with a higher risk of complications and longer hospital LOS compared to cholecystectomy performed at > 8weeks. Surgeons should be aware and should delay cholecystectomy beyond 8weeks to improve outcomes.

Timing of Cholecystectomy after Emergent Endoscopic Retrograde Cholangiopancreatography for Cholangitis

Debate remains regarding the timing of laparoscopic cholecystectomy after emergent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. We hypothesized that patients undergoing early laparoscopic cholecystectomy would have fewer operative complications and a lower conversion rate. This study is a retrospective review of an ERCP database from 2012 to 2016 of adults with a diagnosis of cholangitis secondary to choledocholithiasis who underwent ERCP followed by a laparoscopic cholecystectomy. Patient demographics, ERCP details, timing of operation (<72 hours vs >72 hours after ERCP), complications, and mortality were recorded. Analysis included chi-square, Fisher's exact, and Wilcoxon rank-sum tests, where appropriate. In the 127 patients (65 per cent male; median age, 67 years; 48 (38%) early surgery), there were no differences in demographics, BMI, vital signs, or laboratory values. Patients in the late surgery group were more likely to have a Charlson Comorbidity Index > 3 (P = 0.002), require pre-operative endoscopic sphincterotomy (P < 0.002), need pre-operative insertion of a ductal stent (P < 0.03), and had more postoperative complications (P = 0.04). Patients in the late laparoscopic cholecystectomy group had more comorbidities and suffered more complications.

Routine near infra-red indocyanine green fluorescent cholangiography versus intraoperative cholangiography during laparoscopic cholecystectomy: a case-matched comparison.

The aim is to evaluate safety and efficacy of near infra-red (NIR) indocyanine green (ICG) fluorescence structural imaging during laparoscopic cholecystectomy (LC) (Group A) and to compare perioperative data, including operative time, with a series of patients who underwent LC with routine traditional intraoperative cholangiography (IOC) (Group B). Forty-four patients with acute or chronic cholecystitis underwent NIR-ICG fluorescent cholangiography during LC. ICG was administered intravenously at different time intervals or by direct gallbladder injection during surgery. Fluorescence intensity and anatomy identification were scored according to a visual analogue scale between 1 (least accurate) and 5 (most accurate). Group B patients (n = 44) were chosen from a prospectively maintained database of patients who underwent LC with routine IOC, matched for age, sex, body mass index, and diagnosis with group A patients. No adverse reactions were recorded. In group A, mean time between intravenous administration of ICG and surgery was 10.7 ± 8.2 (range 2-52)h. Administered doses ranged from 3.5 to 13.5mg. Fluorescence was present in all cases, scoring ≥ 3 in 41 patients. Mean operative time was 86.9 ± 36.9 (30-180)min in group A and 117.9 ± 43.4 (40-220)min in group B (p = 0.0006). No conversion to open surgery nor bile duct injuries were observed in either group. LC with NIR-ICG fluorescent cholangiography is safe and effective for early recognition of anatomical landmarks, reducing operative time as compared to LC with IOC, even when residents were the main operator. NIR-ICG fluorescent cholangiography was effective in patients with acute cholecystitis and in the obese. Data collection into large registries on the results of NIR-ICG fluorescent cholangiography during LC should be encouraged to establish whether this technique might set a new safety standard for LC.

Meta-analysis of randomized clinical trials of early versus delayed cholecystectomy for mild gallstone pancreatitis.

Gallstones account for 30-50 per cent of all presentations of acute pancreatitis. While the management of acute pancreatitis is usually supportive, definitive treatment of gallstone pancreatitis is cholecystectomy. Guidelines from the British Society of Gastroenterology suggest definitive treatment on index admission or within 2 weeks of discharge, whereas joint recommendations from the International Association of Pancreatology and the American Pancreatic Association recommend definitive treatment on index admission. Evidence suggests that uptake of these guidelines is low. Embase, MEDLINE and Cochrane databases were searched for RCTs investigating early versus delayed cholecystectomy in patients with a confirmed diagnosis of mild gallstone pancreatitis. The pooled synthesis was undertaken using a random-effects meta-analysis of the primary outcome of recurrent biliary complications causing hospital readmission. Secondary outcomes included intraoperative and postoperative complications, and total length of hospital stay (LOS). All analyses were performed using RevMan5 software. Five RCTs were identified, which included 629 patients (318 in the early cholecystectomy (EC) group and 311 in the delayed cholecystectomy (DC) group). Recurrent biliary events that required readmission were reduced in patients undergoing EC compared with the number in patients having DC (odds ratio (OR) 0·17, 95 per cent c.i. 0·09 to 0·33). There was no difference in the rate of intraoperative (OR 0·58, 0·17 to 1·92) or postoperative (OR 0·78, 0·38 to 1·62) complications. EC following mild gallstone pancreatitis does not increase the risk of intraoperative or postoperative complications, but reduces the readmission rate for recurrent biliary complications.

Comparative Study of Conventional Electrocautery Versus Ultrasonic Dissector in Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy (LC) is very commonly performed for removal of gallstones. In routine, ultrasonic devices are used for laparoscopy involving the deeper operating fields, while electrosurgical devices are preferred for LC. However, nowadays both of these devices are used for LC. The objective of this study was to compare the surgical outcomes of ultrasonic dissector over conventional electrocautery in patients planned for LC. Material and Methods: This non-randomized clinical trial was conducted in general surgery unit, Jinnah hospital Lahore. The study duration was 15th January 2015 to 31st December 2016. In group A (n=100), patients were operated through three-port standard laparoscopic cholecystectomy and conventional electrosurgical cautery was used for dissection. While in group B (n=50), patients were operated through single incision laparoscopic surgery (SILS) and Harmonic dissector was used for sealing of cystic artery and cystic duct. SPSS version 23 was used for data analysis. Complications between electrocautery and ultrasonic dissector were compared using chi-square test/Fischer exact test and operative time was compared using student’s t-test with p-value ≤ 0.05 considered as statistically significant.Results: Out of 150 patients planned for laparoscopic cholecystectomy, 33 (22%) were males and 117 (78%) females. The mean age was 40±6.45 years with an age range of 12-80 years. In group A, intraoperative gall bladder perforation was found in 5 patients whereas in group B, there was only one patient with perforation. A total of 4 cases were converted to open cholecystectomy in group A due to difficult dissection in Calot’s triangle as compared to 1 case in group B. In group A, 3 cases had postoperative bile leakage in the drain. In two patients it settled over a period of 3 days. About 03 cases had wound infection in group A and 1 in group B. Mean operative time in group A was 42.2±8.93 minutes versus 35.7±4.85 minutes in group B (p-value 0.001).Conclusion: In this study, the rate of post-operative complications was similar between the two groups, but operative time was significantly shorter in the group B. Harmonic dissector enabled easy dissection of tissues with good hemostasis and less trafficking of instrument, avoiding use of clips and sutures during minimal invasive surgery.

С-reactive Protein and Its Role in Pathogenesis of Heart Disorders (Literature Review and Own Data)

C-reactive protein is a criterion of inflammation and a significant marker of cardiovascular risk.The objective: to estimate condition of problem of CRP usage according to the literature and own data.Matherials and methods. We held a literature review in Pubmed database and domestic sources. We also analyzed data of 75 patients with hemorrhagic vasculitis, divided into groups according to gallbladder (GB) condition. Data was processed using Statistica 6.0 software.Results. CRP was crystallized in 1947 by Maclyn McCarty, who proposed to use it for control of rheumatism course. CRP is a nonspecific acute phase protein, which is synthesized in liver during inflammation. Main function of CRP is to eliminate pathogens and endotoxins. CRP level can vary between &lt;1,0 mg/L and 1000 times bigger values. CRP is studied as a marker of infection, inflammation and tissue damage in ischemic heart disease, stroke, cognitive disorders, cardiovascular death. High level of CRP is associated with increase of caediovascular morbidity and mortality. In our patients with hemorrhagic vasculitis mean level CRP was 7,51±1,22 mg/L, which is almost twice bigger than the normal values. This can suggest a high cardiovascular risk. CRP level was maximal in cholelithiasis and cholecystectomy groups. Independently of GB condition CRP correlated with left atrium size and acute phase parameters of blood.Conclusions. According to the literature, CRP eliminates pathogens, endotoxins, necrotized cells. In patients with hemorrhagic vasculitis CRP directly correlated with inflammation parameters and left atrium size, indirectly – with anemic syndrome. CRP level was dependent of GB condition, being the highest in groups with cholelithiasis and prior cholecystectomy.

Cholecystostomy: Are we using it correctly?

BackgroundPercutaneous Cholecystostomy Tubes (PCT) have become an accepted and common modality of treating acute cholecystitis in patients that are not appropriate surgical candidates. As percutaneous gallbladder drainage has rapidly increased newer research suggests that the technique may be overused, and patients may be burdened with them for extended periods. We examined our experience with PCT placement to identify independent predictors of interval cholecystectomy versus destination PCT. MethodsAll patients with cholecystitis initially treated with PCT from 2014 to 2017 were stratified by whether they underwent subsequent interval cholecystectomy. Demographic data, initial laboratory values, Tokyo Grade, Charlson Comorbidity Index, ASA Class, complications related to PCT, complications related to cholecystectomy, and mortality data were retrospectively collected. Descriptive statistics, univariable, and multivariable Poisson regression were performed. Results165 patients received an initial cholecystostomy tube to treat cholecystitis. 61 (37%) patients went on to have an interval cholecystectomy. There were 4 complications reported after cholecystectomy. A total of 46 (27.9%) deaths were reported, only one of which was in the cholecystectomy group. Age, Tokyo Grade, liver function tests, ASA Class, and Charlson Comorbidity Index were significantly different between the interval cholecystectomy and no-cholecystectomy groups. Univariable regression was performed and variables with p < 0.2 were included in the multivariable model. Multivariable Poisson regression showed that increasing Tokyo Grade (IRR 0.454, p = 0.042, 95% CI 0.194–0.969); and increasing Charlson Comorbidity Score (IRR 0.890, p = 0.026, 95% CI 0.803–0.986) were associated with no-cholecystectomy. Higher Albumin (IRR 1.580, p = 0.011, 95% CI 1.111–2.244) was associated with having an interval cholecystectomy. ConclusionPatients in the no-cholecystectomy group were older, had more comorbidities, higher Tokyo Grade, ASA Class, and initial liver function test values than those that had interval cholecystectomy. Since interval cholecystectomy was performed with a low rate of complications, we may be too conservative in performing cholecystectomy after drainage and condemning many patients to destination tubes.