Concurrent Cholecystectomy Research Articles

Concurrent Cholecystectomy Does Not Increase Splenectomy Morbidity in Patients With Hemolytic Anemia: A Pediatric NSQIP Analysis

PurposeChildren undergoing splenectomy for hemolytic anemia often have cholelithiasis, which may or may not be symptomatic. It is unclear whether concurrent cholecystectomy increases length of stay or morbidity after splenectomy. The purpose of this study was to compare morbidity among children undergoing laparoscopic splenectomy alone versus splenectomy with concurrent cholecystectomy in patients with hemolytic anemia. MethodsWe retrospectively evaluated children with hemolytic anemia undergoing non-traumatic laparoscopic splenectomy in the National Surgical Quality Improvement Program-Pediatric database (2012–2020). Outcomes were compared for patients undergoing splenectomy alone (n = 1010) versus splenectomy with cholecystectomy (n = 371). Pearson's Chi-square and Student's t-tests were utilized as appropriate. Propensity score-matching was completed, controlling for eight demographic and clinical variables. Results1381 patients were identified, 73.1% undergoing splenectomy alone and 26.9% splenectomy with cholecystectomy. Splenectomy with cholecystectomy patients were older (10.9 years vs. 8.4 years, p < 0.01), more likely to have hereditary spherocytosis (56.1% vs. 40.8%, p < 0.01), less likely to have sickle cell disease (12.1% vs. 33.5%, p < 0.01), more likely ASA class 1 or 2 (49.3% vs. 42.1%, p < 0.01), and had similar preoperative hematocrit levels (29.6 vs. 29.3, p = 0.33). The splenectomy with cholecystectomy group was less likely to receive preoperative blood transfusions (13.5% vs. 25.4%, p < 0.01). There were 360 pairs selected on propensity score-matching, and splenectomy with cholecystectomy was associated with increased operative time (182 min vs. 145 min, p < 0.01) and decreased occurrences of a postoperative transfusion (4.2% vs. 8.9%, p = 0.01). Length of stay after surgery (2.5 days vs. 2.3 days, p = 0.13), composite morbidity (3.9% vs. 3.4%, p = 0.69), and 30-day readmission rates (3.3% vs. 7.4%, p = 0.08) were all similar. ConclusionsSplenectomy with cholecystectomy is associated with similar postoperative morbidity, length of stay and readmission rates compared to splenectomy alone. These data support the safety of concurrent cholecystectomy with splenectomy for children with cholelithiasis in the setting of hemolytic anemia. Type of StudyRetrospective Cohort Study. Level of EvidenceLevel III.

Endobiliary Stent Migration Causing Ileal Perforation – A Case Report

Common bile duct drainage (CBDD) following operative common bile duct exploration (CBDE) is routinely performed. Primary choledochotomy closure with trans-sphinteric endobiliary stent (EBS) is a popular technique. A 72-year-old woman presented with abdominal pain, peritonism, and sepsis a month after an elective right hemicolectomy with concurrent cholecystectomy and CBDE with EBS placement. Radiological investigations implied a detrimental consequence from migrated EBS. Surgical exploration revealed the cause to be ileal perforation by the EBS. She had a resection of the aggravated bowel segment and a double-barreled stoma was matured from the resected ends. The stoma was reversed 6 weeks after the laparotomy and the patient is currently under regular surveillance for colon cancer. Migration of EBS precipitating enteric perforation are uncommon, recognised complications. Natural, congenital, and acquired luminal and mural causes have been documented. Primary choledochotomy closure without CBDD, alternative EBS which are smaller or softer, and the utilization of T-Tube CBDD are valid options when treating patients with recognised increased risk of EBS-related bowel perforation.

Duodenal switch without versus with laparoscopic cholecystectomy: a perioperative risk comparative analysis of the MBSAQIP database (2015-2019).

The results of concurrent cholecystectomy with Roux-en Y gastric bypass and sleeve gastrectomy have been well elucidated. Large-scale data on the outcomes of concomitant cholecystectomy during biliopancreatic diversion with duodenal switch (BPD-DS) are still lacking. Our study aimed to explore whether simultaneous cholecystectomy with BPD-DS alters the 30-day postoperative outcomes. We conducted a retrospective analysis of the MBSAQIP database between 2015 and 2019. Propensity-score matching (PSM) in BPD-DS with cholecystectomy (Group 1) and BPD-DS without cholecystectomy (Group 2) cohorts was performed (PSM ratio 1:2). The two groups were matched for a total of 21 baseline variables including age, gender, BMI, ASA class, and other medical comorbidities and conditions. The 30-day postoperative morbidity, mortality, reoperation, reintervention, and readmissions were obtained. Initially, 568 patients in Group 1 and 5079 in Group 2 were identified. After performing PSM, 564 and 1128 patients respectively were compared. The BPD-DS with cholecystectomy group reported a higher rate of reoperation and reintervention compared to BPD-DS alone (3.9% versus 2.4% and 3.2% versus 2%, respectively), even though it did not reach statistical significance. The intervention time was significantlyhigher in Group 1 compared to Group 2 (192.4 ± 77.6 versus 126.4 ± 61.4min). Clavien-Dindo complications (1-5) were similar between these two PSM cohorts. Concomitant cholecystectomy during BPD-DS increases operative times but does not affect the other outcomes. Based on our results, the decision of cholecystectomy at the time of BPD-DS should be left to the surgeon's judgment.

Comparing Outcomes of Laparoscopic Transgastric Necrosectomy to Endoscopic Cystgastrostomy: Single Institution Cohort Study

Introduction: Laparoscopic transgastric necrosectomy (LTGN) and endoscopic cystgastrostomy (EC) with lumen-apposing metal stents (LAMS) are alternative approaches for debridement of retrogastric walled-off pancreatic necrosis (WOPN) when the necrosum abuts the gastric wall. However, comparative data is sparse. We present a comparative analysis of outcomes for these two procedures at our institution. Method: This is a retrospective study which included patients who underwent LTGN or EC for WOPN between 2011 and 2021. Outcomes included number of debridement procedures, time to symptom resolution, morbidity, and mortality. Logistic regression analysis was performed to predict outcomes. Results: Among 98 patients, 43 (43.9%) underwent EC and 55 (56.1%) had LTGN. The two groups were similar except as noted in Table 1. Six (14.0%) patients in the EC group had had a recent laparotomy that precluded laparoscopy. EC required a mean of 3.7 debridements (range 2-8). Seven (15.9%) of the EC patients required additional surgical debridement. Among the LTGN patients, 45% underwent concurrent cholecystectomy. Five (8.8%) of the LTGN patients underwent additional endoscopic debridement after LTGN. LTGN provided single-step debridement for 89% of patients (no additional operative, percutaneous or endoscopic drainage) and had shorter time to symptom resolution (7.1 vs 2.2 months, see Table 1). Conclusions: LTGN and EC are complementary approaches with similar safety profiles. LTGN offers single-stage debridement, may be combined with cholecystectomy and appears to result in faster symptom resolution. EC is a multi-stage debridement with low upfront morbidity and is particularly suitable for patients in whom surgery is contraindicated.

Concurrent Cholecystectomy Is Associated with a Lower Risk of Recurrence after Curative Resection in Early-Stage Hepatocellular Carcinoma: A 10 Year Observational Single-Center Study.

Background: Cholecystectomy has been reported to be associated with increased risk of developing hepatocellular carcinoma (HCC). However, there is little information about the impact of cholecystectomy on the outcome of HCC. Aims: To evaluate the long-term effect of concurrent cholecystectomy on recurrence and overall survival in HCC after curative hepatectomy. Patients and Methods: We retrospectively enrolled 857 patients with BCLC stage 0 or A HCC who underwent primary resection from January 2001 to June 2016. The impact of concurrent cholecystectomy on overall survival (OS) and recurrence-free survival (RFS) were analyzed by Cox’s proportional hazards models after one-to-one propensity score matching (PSM). Results: Of the 857 patients, 539 (62.9%) received concurrent cholecystectomy (cholecystectomy group) and 318 (37.1%) did not (non-cholecystectomy group). During the mean follow-up period of 75.0 months, 471 (55.0%) patients experienced recurrence, and 321 (37.5%) died. RFS and OS were not significantly different between the groups. After PSM, a total of 298 patients were enrolled in each group. RFS was significantly higher in the cholecystectomy than non-cholecystectomy group (p = 0.044). In multivariate analysis, age (p = 0.022), serum AFP (p = 0.008), liver cirrhosis (p < 0.001), diabetes (p = 0.004), tumor number (p = 0.005), tumor size (p = 0.002), histological grade (p = 0.001), microvascular invasion (p < 0.001) and cholecystectomy (p = 0.021) were independent risk factors for HCC recurrence. However, there were no significant differences in OS between the cholecystectomy and non-cholecystectomy groups. Conclusions: Concurrent cholecystectomy may reduce recurrence in early-stage HCC after curative resection. Further studies are needed to validate our results.

Does the adoption of an emergency general surgery service model influence volume of cholecystectomies at a tertiary care center.

The purpose of this study was to evaluate the rate of cholecystectomy before and after adoption of an emergency general surgery (EGS) model at our institution. A longitudinal, observational study was conducted prior to and following introduction of an EGS model at our institution. Using the New York SPARCS Administrative Database, all adult patients presenting to the emergency department with gallbladder-related emergencies were identified. The rates of laparoscopic and open cholecystectomies performed 3years prior and 3years following the adoption of the EGS model were examined. A multivariable logistic regression model was used to compare the incidence of cholecystectomy at initial ED visit at our institution pre- and post-EGS introduction as well as to those in the rest of the state as an external control group, while adjusting for potentially confounding factors. There were 176,159 total ED visits of patients with gallbladder emergencies (154,743 excluding repeat presenters) in the studied period in NY State. Of these, 63,912 patients (41.3%) had a concurrent cholecystectomy in NY State. The rate of cholecystectomy at these institutions remained relatively steady from 38.8% from 2010 to 2013 and 38.6% from 2013 to 2016. At our institution, there were 2039 gallbladder emergencies, and of those 755 underwent cholecystectomy. At our institution, there was an increase from 28.21% 3years prior to the adoption of the EGS model to 40.2% in the following 3years (RR = 1.06, 95% CI 1.0164-1.1078, p = 0.0069). The initiation of the EGS model at a tertiary center was associated with a significant increase in the number of concurrent cholecystectomies from 28.21 to 40.2% over a 6-year period. This change was accompanied by an increase in the number of patient comorbidities and a lower insurance status.

Laparoscopic Splenectomy: Has It Become the Standard Surgical Approach in Pediatric Patients?

BackgroundSplenectomy is often required in the pediatric population as part of the treatment of hematologic disorders and can be performed laparoscopically or open. We evaluated the comparative effectiveness of laparoscopic (LS) and open (OS) splenectomies using the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) data set. MethodsThe NSQIP-P data set was used to identify children who underwent elective splenectomy between January 2012 and December 2016. Thirty-day outcomes between OS and LS, and LS alone and concurrent LS and cholecystectomy were compared using univariate and multivariate analysis. ResultsMost of the splenectomies (91%) were performed laparoscopically. There was no difference in overall complications between OS (n = 60) and LS (n = 613), although OS had a higher risk of perioperative transfusion (OR 3.19, 95% CI 1.52-6.69). LS was associated with a shorter median hospital length of stay (2 versus 4 d, P < 0.001) and similar mean operative times compared to OS (120 versus 133 min, P = 0.559). There was no difference in outcomes of children undergoing LS versus LS and concurrent cholecystectomy (n = 129). ConclusionsLS has become the standard approach for elective splenectomies in the pediatric population and has minimal morbidity, and when indicated, concurrent cholecystectomies do not increase the risk of complications. Levels of evidenceIII.

Cholecystectomy during esophagectomy is safe but unnecessary

Background: Prophylactic cholecystectomy has been proposed as a concomitant procedure during upper gastrointestinal surgery. This study evaluates the safety and the need of concurrent cholecystectomy during esophagectomy for cancer.Methods: All consecutive esophagectomies for esophageal cancer at the Center for Esophageal Diseases in Padova (Italy) between 1992 and 2011 were included. The safety of concurrent cholecystectomy was evaluated by surgical outcomes (length of stay, postoperative mortality and perioperative complications). The need for concurrent cholecystectomy was evaluated by occurrence of biliary duct stones and of cholelithiasis/cholecystitis after esophagectomy.Results: Cholecystectomy was performed during 67 out of 1087 esophagectomies (6.2%). Cirrhosis or chronic liver disease was associated with receiving cholecystectomy during esophagectomy (OR: 1.99, 95%C.I. 1.10–3.56). Patients receiving and those not receiving cholecystectomy showed similar length of stay (median 14 days, p = .87), postoperative mortality (3.0% vs. 2.5%, p = .68), intraoperative complication (4.5% vs. 7.1%, p = .62), early complications (52.2% vs. 44.6%, p = .25) and late complications (20.9% vs. 24.8%, p = .56). Cholelithiasis/cholecystitis after esophagectomy occurred in 61 (6.1%) patients, with only four requiring cholecystectomy during follow-up. The biliary stone occurrence was nil. Only pathologic stage III-IV (OR: 2.17, 95%C.I. 1.19–3.96) was associated with cholelithiasis/cholecystitis after esophagectomy.Conclusion: Routine prophylactic cholecystectomy during esophagectomy could be safe but unnecessary.

Early Onset Cholelithiasis and Macrocytic Anemia: A Fragile Combination

Hemolytic anemia is caused by shortened lifespan of circulating red blood cells (RBCs) due to their premature destruction. Studies have shown that at least 25% of patients with hereditary hemolytic anemia have biliary disease. Early splenectomy is expected to decrease the incidence of gallbladder disease due to decreased activity of the hemolytic process. We present a case report of a patient with early onset symptomatic choledocholithiasis due to undiagnosed hereditary spherocytosis. A 14-year-old female with ADHD presented with two days of progressive right upper quadrant abdominal pain and jaundice. Significant laboratory data included a transaminitis and total bilirubin of 7.7. Right upper quadrant ultrasound revealed gallstones, dilation of the common bile duct (CBD) to 1.3cm, and questionable stone in the distal CBD. Endoscopic retrograde cholangiopancreatography (ERCP) revealed diffuse dilation of the main, right hepatic, and left hepatic bile ducts with largest diameter of 10mm. The lower third of the main bile duct contained one 5mm stone which was removed with biliary sphincterotomy and balloon extraction. Because of jaundice and mild inflammatory distal narrowing, one biliary stent was placed into the CBD. Two days later, the patient underwent cholecystectomy for cholelithiasis and chronic cholecystitis. Elevated reticulocyte distribution width and count, a mean corpuscular volume of 111, and spherocytes on peripheral smear suggested hemolytic disease. Ultimately, the osmotic fragility test returned positive, confirming the diagnosis of early onset cholelithiasis due to hereditary spherocytosis. Though not well established, ERCP is recommended for pediatric patients with symptomatic choledocholithiasis. Hemolytic anemia should be considered in any young person who develops cholelithiasis. When gallbladder disease is noted at time of splenectomy, patients undergo concurrent cholecystectomy, but there is no proven role for prophylactic cholecystectomy. Retrospective studies in adults with hereditary spherocytosis suggest detectable gallstones in 37-43% of patients. Because of the increased incidence of cholelithiasis in hereditary spherocytosis, radiographic gallbladder evaluation is indicated in each patient.2146_A Figure 1 No Caption available.2146_B Figure 2 No Caption available.

Prophylactic Cholecystectomy at Time of Surgery for Small Bowel Neuroendocrine Tumor Does Not Increase Postoperative Morbidity.

Prophylactic cholecystectomy at time of surgery for small bowel neuroendocrine tumor (SBNET) has been advocated, as these patients often go on to require somatostatin analogue therapy, which is known to increase risk of cholestasis and associated complications. Little is known regarding patterns of adoption of this practice or its associated morbidity. The American College of Surgeons National Surgical Quality Improvement Program database (2008-2014) was queried to identify patients who underwent SBNET resection. The risk differences of morbidity and mortality associated with performance of concurrent cholecystectomy were determined with multivariable adjustment for confounders. Among 1300 patients who underwent SBNET resection, 144 (11.1%) underwent concurrent cholecystectomy. Median age of patients undergoing cholecystectomy was 62years [interquartile range (IQR) 52-69years], and 75 were male. They more commonly had disseminated cancer (36.1 vs. 11.6%, p<0.001) or SBNET located in duodenum (10.4 vs. 4.9%, p=0.045) without difference in other baseline characteristics. Operative time was significantly longer in the cholecystectomy group (median 172 vs. 123min, p<0.001). Rate of postoperative morbidity was not significantly different between cholecystectomy and no-cholecystectomy groups (11.8 vs. 11.1%, p=0.79). After adjustment for confounding, the risk difference of morbidity attributable to cholecystectomy was +0.4% [95% confidence interval (CI) -4.9 to +5.6%]. Mortality within 30days was not significantly different between cholecystectomy and no-cholecystectomy groups (1.4 vs. 0.6%, p=0.29). Concurrent cholecystectomy at time of resection of SBNET is not associated with higher morbidity or mortality yet is performed in a minority of patients. Prospective study can identify which patients may derive benefit from this approach.

Concurrent Cholecystectomy at Time of Surgery for Small Bowel Neuroendocrine Tumor Is Not Associated with Increased Morbidity

Concurrent Cholecystectomy at Time of Surgery for Small Bowel Neuroendocrine Tumor Is Not Associated with Increased Morbidity

Gallstones and Bariatric Surgery: To Treat or Not to Treat?

Obesity and rapid weight loss after bariatric surgery are risk factors for gallstone disease. The present study sought to evaluate the feasibility of selective concomitant cholecystectomy only in patients with symptomatic disease and study risk factors for the development of symptomatic gallstones after bariatric surgery. Between January 2010 and December 2012, 734 consecutive patients presenting to our institution underwent bariatric surgery. From these, 81 patients were excluded due to prior or concurrent cholecystectomy. The remaining 653 patients with in situ gallbladder were followed for 12months and were clinically screened for symptomatic or complicated cholelithiasis. Clinical and demographic characteristics were compared at baseline and 12months after surgery. Of the 653 patients with in situ gallbladder, only 24 (3.3%) developed symptomatic gallstones and only nine presented complicated disease. None of the patients with asymptomatic disease at the time of surgery progressed to symptomatic or complicated disease. Patients who developed symptomatic disease were not significantly different, although there was a trend toward longer obesity evolution, lower insulin levels, and lower hepatic enzymes level. A multivariate regression analysis revealed that patients with gastric sleeve were more likely to develop symptomatic gallstones. Although further studies are required, the management of gallstones in morbidly obese patients should not be different from normal-weight patients. Therefore, performing a laparoscopic cholecystectomy only in symptomatic patients is an effective approach and asymptomatic gallstones should not be treated at the time of bariatric surgery.

Treatment and Management of Late Complications in Hereditary Hemolytic Anemia

Hereditary hemolytic anemia is a very heterogeneous disorder in which abnormalities of red blood cell structural protein, globin protein, or enzyme defect lead to shortened life span. There has been much progress in revealing its pathophysiology and genetic backgrounds, but the lifelong plans for caring these patients are not well established yet. All patients with hereditary hemolytic anemic have three common problems: transfusion dependency, iron overload and iron chelation therapy. Patients with hereditary spherocytosis (HS) usually manifest severe anemia in neonatal period and infancy, but transfusion requirements may decrease in adulthood. But patients with thalassemia or sickle cell disease usually transfusion-dependent throughout life. Maintaining the optimal hemoglobin (Hb) levels in these patients is crucial because correction of anemia and dilution of abnormal Hb helps prevent certain complications that frequently occur in these patients. Frequent transfusion leads to transfusion-mediated infection and hemochromatosis. Iron chelation therapy should be started early to prevent permanent organ damage. Folate therapy can be helpful in patients with hereditary spherocytosis. Regular evaluations for cholestasis should be started at age 5, and splenectomy with concurrent cholecystectomy can be considered if the patient has cholecystitis. Hydroxyurea can be used to reduce transfusion requirements and prevent complications in patients with -thalassemia and sickle cell disease. Consensus on long-term management of patients with hereditary hemolytic anemia is lacking, especially for adult patients. But further efforts to build guidelines for long-term follow-up and management of the patients with hereditary hemolytic anemia in the context of Korean society are needed. pISSN 2233-5250 / eISSN 2233-4580 http://dx.doi.org/10.15264/cpho.2016.23.1.1 Clin Pediatr Hematol Oncol 2016;23:1∼7

Fast track bariatric surgery: safety of discharge on the first postoperative day after bariatric surgery

BackgroundFast track recovery pathways have resulted in a multidisciplinary approach to enhance postoperative recovery. ObjectivesTo assess feasibility and outcome of early discharge after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). SettingThe American College of Surgeons National Surgical Quality Improvement Program database was analyzed to identify patients with body mass index≥35 kg/m2 who underwent LSG or LRYGB in 2012 and 2013. MethodsPatients were allocated to early discharge (ED) when discharged on postoperative (POD) 1 and late discharge (LD) when discharged on POD 2 or 3. Baseline characteristics and 30-day outcomes were compared between the 2 groups. ResultsRecords of 15,468 LSG and 16,483 LRYGB patients were analyzed; 5220 patients with LSG (33.7%) and 2960 patients with LRYGB (18%) were discharged on POD 1. The early discharge group had significantly fewer co-morbidities and lower rate of complications and readmission. Thirty-day readmission rate in LSG was 2.8% in ED versus 3.6% in LD (P = .008), and in LRGYB, it was 4.3% in ED versus 5.8% in LD (P = .001). Based on multivariate analysis, early discharge was not an independent risk factor for a higher readmission rate after LSG or LRYGB. Predictors of late discharge were age>50 years, body mass index>50 kg/m2, Hispanic or non-Hispanic black race/ethnicity, impaired functional status, diabetes on insulin, chronic steroid/immunosuppressant use, bleeding disorder, being on dialysis, chronic obstructive pulmonary disease, albumin<3.5 mg/dL, longer operative time, and concurrent cholecystectomy. ConclusionDischarge on POD 1 after LSG and LRYGB is feasible in a considerable proportion of patients. In this subgroup, early discharge is well tolerated and may be associated with lower complication and readmission rates.

Your Bile Ducts Are What You Eat: A Rare Etiology of Cholangitis Presidential Poster

Introduction: Acute bacterial cholangitis is a dreaded complication of obstructed bile ducts, most commonly by gall stones (1). We report a rare cause of cholangitis, with an obstructed bile duct by food chyme from a choledocho-gastric fistula. Case Report: A 61 year old woman with cholecystectomy for chronic cholecystitis one month ago presented with right upper quadrant abdominal pain, darkened urine, and acutely elevated cholestatic liver tests with direct bilirubin level of 5.4 mg/dL. MRCP showed new intrahepatic and extrahepatic bile duct dilation with multiple intraductal hypointense structures and pneumobilia. During admission, patient developed worsening abdominal pain with sepsis. An urgent ERCP was performed for biliary decompression for presumed ascending cholangitis. Endoscopy revealed a pre-pyloric choledocho-gastric fistula. Cholangiogram via the fistula showed dilated common bile duct (1.5cm) with multiple filling defects. A biliary sphincterotomy was performed with drainage of pus, followed by balloon-sweep extraction of food chyme and placement of a 10mm x 6cm biliary metal stent. Patient had significant clinical improvement with resolution of her sepsis, abdominal pain, and elevated liver tests. 2 weeks later, patient had repeat ERCP for stent removal and biliary clearance. The persistent choledocho-gastric fistula was closed with an over-the-scope clip system (Bear-Claw). Discussion: Bilio-enteral fistulae are rare complications of cholecystitis with reported intra-op incidence of 0.15%-4.8% (2). The most common types of fistulae are cholecysto-duodenal, cholecysto-colonic, and choledocho-duodenal fistula (3). Choledocho-gastric fistula is a rare type of bilio-enteral fistulae, described only anecdotally. Definitive diagnosis often requires ERCP (4). For treatment, laparoscopic fistula closure using an endo-stapling device had been described during concurrent cholecystectomy (5). However, most often, endoscopic approach is taken that involves placement of a biliary stent to lower intra-ductal pressure and reduce flow through the fistula (6). The fistula typically resolves spontaneously within a few weeks, however sometimes requires endoscopic closure. Newer endoscopic techniques, utilizing overstitch endoscopic suturing system or over-the-scope clip system (our case), have been reported successful in closing the persistent fistula (7).Figure 1Figure 2

Concurrent cholecystectomy at the time of laparoscopic gastric bypass does not increase short-term morbidity, mortality, or length of stay

Concurrent cholecystectomy at the time of laparoscopic gastric bypass does not increase short-term morbidity, mortality, or length of stay

Safety of laparoscopic adjustable gastric banding with concurrent cholecystectomy for symptomatic cholelithiasis.

The prevalence of cholelithiasis correlates with obesity. Patients often present for bariatric surgery with symptomatic cholelithiasis. There is a concern of cross-contamination when performing laparoscopic adjustable gastric banding (LAGB) with concurrent cholecystectomy. The primary goal of this study is to address the safety and feasibility of this practice. A retrospective cohort study was designed from a prospectively collected database. All LAGB patients from July 2005 to April 2013 were included. Patients undergoing LAGB with concurrent cholecystectomy comprised the study group (LAGB/chole). The control group (LAGB) consisted of patients undergoing LAGB alone, and was selected using a 3:1 (control:study) case-match based on demographic and comorbidity data. The primary outcome was overall complication rate, with secondary outcomes including operating room (OR) time, length of stay (LOS), 30-day readmission/reoperation, erosion, infection, and band/port revisional surgery. There were 4,982 patients who met criteria. Of these, 28 patients had a LAGB with concurrent cholecystectomy, comprising the LAGB/chole (study) group. The remaining 4,954 patients were eligible controls, of which 84 were selected for the LAGB (control) group. Demographic and comorbidity data, along with mean follow-up time, were similar between the two groups. OR time was longer in the LAGB/chole group, but LOS was the same. The overall complication rate in the LAGB/chole group was 21 (n = 6) versus 20% (n = 17) in the LAGB group (p = 0.893). Thirty-day readmission and reoperation were similar. There was also no difference in port site, wound, and intra-abdominal infections. There were no band erosions in either group. Performing a concurrent cholecystectomy at the time of LAGB does not result in increased immediate or delayed morbidity. Although longer to perform, this safe operation would avoid a second surgery for a patient already diagnosed with symptomatic cholelithiasis.

Mesohepatectomy for the treatment of patients with centrally located hepatocellular carcinoma.

Mesohepatectomy is considered a feasible option for patients with centrally located hepatocellular carcinoma (HCC). However, mesohepatectomy is a technically demanding and less frequently used procedure. In this study, we summarized the surgical experience and evaluated the clinical outcomes of mesohepatectomy in 24 patients with centrally located HCC. Of these patients, 9 were treated with hepatectomy of Couinaud's segments IV, V and VIII with concurrent cholecystectomy; 8 underwent resection of segments IVb, V and VIII, including 7 patients who also received a cholecystectomy; 4 underwent hepatectomy of segments IVa, V and VIII; and 3 patients were treated with hepatectomy of segments I, IV, V and VIII, with concurrent cholecystectomy. The Pringle maneuver was used on 17 patients during hepatectomy. Total hepatic vascular exclusion (HVE) was performed on 3 patients and HVE was not used on 4 patients. The average mesohepatectomy operative time was 238 min and the average intraoperative blood loss was 480 ml (200-2,200 ml). There was no intraoperative mortality and the postoperative morbidity rate was 25% (6/24). The 1- and 3-year overall survival rates were 76 and 46%, respectively. Therefore, mesohepatectomy is a safe and effective surgical procedure for the treatment of centrally located HCC and HVE during mesohepatectomy for centrally located HCC is crucial to the success of the operation and postoperative patient recovery.

Gallstone ileus: revisiting surgical outcomes using National Surgical Quality Improvement Program data

BackgroundAlthough surgical management remains the mainstay of therapy for gallstone ileus, the optimal approach—enterolithotomy alone or combined with biliary-enteric fistula disruption—is controversial because of the reliance on small single-center series to describe outcomes. Using the American College of Surgeons' National Surgical Quality Improvement Program database, we sought to (1) review the outcomes of patients undergoing surgical management of gallstone ileus and (2) determine if cholecystectomy in addition to enterolithotomy increased morbidity or mortality rate. MethodsWe analyzed the demographics, comorbidities, acuity, operative time, postoperative hospitalization length, and 30-d morbidity and mortality rates of 127 patients from 2005 to 2010 who underwent a procedure for the relief of gallstone ileus. We identified a subset of 14 patients who underwent simultaneous cholecystectomy. We compared the “no cholecystectomy” and “cholecystectomy” groups using standard statistical methods. ResultsThe overall 30-d postoperative morbidity and mortality rate was 35.4% and 5.5%, respectively. Superficial surgical site infection and urinary tract infection were the most common complications. There was no significant difference in mortality rate between the no cholecystectomy and the cholecystectomy groups (5.3% versus 7.1%, respectively; P = 0.78), but the latter group did experience more minor complications, longer operations, and longer postoperative hospitalization. ConclusionsOther recent studies on this topic have collected data or reviewed literature across several decades, making this study in particular one of the largest truly modern series. Perhaps reflecting changes in perioperative management, surgical treatment of gallstone ileus is less morbid than previously described, but there is still insufficient evidence to favor concurrent cholecystectomy.

Cost-effectiveness analysis of cholecystectomy during Roux-en-Y gastric bypass for morbid obesity

Controversy exists regarding the use of concurrent cholecystectomy during Roux-en-Y gastric bypass performed for morbid obesity. A decision model was developed to evaluate the cost-effectiveness of current strategies: routine concurrent cholecystectomy, Roux-en-Y gastric bypass alone with or without postoperative ursodiol therapy, and selective cholecystectomy based on preoperative findings on ultrasonography. Probabilities were obtained from a comprehensive literature review. Costs and hospital days were obtained from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. One-way sensitivity analyses were performed. The least expensive strategy was to perform RYGB alone without preoperative ultrasonography, with an average cost (over RYGB costs) of $537 per patient. RYGB with concurrent cholecystectomy had a cost of $631. Selective cholecystectomy based on preoperative ultrasonography was dominated by the other 2 strategies. Our model was most sensitive to the probability of developing gallbladder-related symptoms after RYGB alone. When the incidence of gallbladder-related symptoms was <4.6%, the dominant strategy was to perform a RYGB alone without preoperative ultrasonography. For values >6.9%, performing concurrent cholecystectomy at the time of the RYGB was superior to other strategies. When ursodiol was used, the least expensive strategy was to perform a concurrent cholecystectomy during RYGB. The main factor determining the most cost-effective strategy is the incidence of gallbladder-related symptoms after RYGB. The use of ursodiol was associated with an increase in cost that does not justify its use after RYGB. Finally, selective cholecystectomy based on preoperative ultrasonography was dominated by the other strategies in the scenarios evaluated.