Days For Laparoscopic Cholecystectomy Research Articles

BN SO21 - Factors influencing subtotal cholecystectomy

Abstract Background Laparoscopic Cholecystectomy (LC) is the main treatment for symptomatic gallstone disease. Sub-total cholecystectomy (SC) has become increasingly utilised as a safe alternative to conversion to open when unable to visualise the critical view of safety. This avoids the morbidity of an open operation whilst minimising the risk of iatrogenic injury to the common bile duct. Male sex, increasing age, previous acute cholecystitis and ERCP have previously been identified as independent risk factors for SC. We aim to identify factors that increased the likelihood of SC within our cohort and the effect of SC on post-operative morbidity. Method All patients who had LC as either an elective or emergency procedure between 1st July 2020 and 30th June 2022 were identified and included in this study. Patient and operative details were retrieved from their electronic record and a Charlson co-morbidity index was calculated. Any post-operative complication was noted and graded according to the Clavien-Dindo classification. Statistical analysis was performed using SPSS with ANOVA analysis being performed for continuous data. Odds ratios were calculated with a 95% confidence interval. Statistical significance was taken as a p value < 0.05. Results 974 patients underwent LC with 4.8% having SC. Factors associated with increased risk of SC included: previous acute cholecystitis (OR 9.37 (4.69-18.70), increased age (mean = 58.7 vs 50.9), higher Charlson co-morbidity index (mean = 2.60 vs 1.43) male sex (OR 2.49 (1.38-4.48), emergency operation (OR 2.30 (1.23-4.30), Diabetes Mellitus (OR 2.58 (1.23-5.36); and previous ERCP (OR 2.62 (1.13-6.11). 30-day morbidity was higher for SC (25.5% vs 8.1%) with major complication (Clavien-Dindo > 2) being significantly more frequent (OR 6.64(2.53-17.4). Median post-operative length of stay was 2 days for SC and 0 days for LC. Conclusion Although regarded as a safe option in difficult cholecystectomy, our study shows that there is significant morbidity associated with subtotal cholecystectomy. However, the majority of patients only require a short hospital stay post-operatively. Multiple risk factors were identified for SC with previous acute cholecystitis being the most strongly associated with SC. Diabetes was identified as an independent risk factor alongside higher Charlson co-morbidity index as a generic marker of co-morbidity. Interestingly, CBD diameter > 8mm on pre-operative imaging was not shown to increase risk of SC.

The Roth Net at 40 years: celebrating the spirit of innovation

The Roth Net at 40 years: celebrating the spirit of innovation

English

BACKGROUND Mini-cholecystectomy (MC), with its varied incision length, has long been considered feasible with comparable results to laparoscopic cholecystectomy (LC) 1-6,7 We undertook this study, driven by resource-constraints, by well-experienced surgeons, using 3 - 5 cm incision length, in our patients with low BMI. The aim of this study is to compare the results and outcomes between MC and LC. METHODS In this retrospective study of a prospectively maintained database, first 50 patients each were selected for MC and LC respectively. Operative time, pain-score, SSI (Surgical Site Infection), hospital stay, return to normal activity and complications were compared. RESULTS Both groups were matched for age, sex, BMI (Body Mass Index) and American Society of Anesthesiologists (ASA) grading. The mean operating time for MC was 43 minutes and for LC, 64 minutes. Hospital stay for MC was 1.9 days and for LC was 1.8 days, which was statistically not significant. Return to normal activity was 8 days for MC and 6.6 days for LC. In a subset analysis of eight lean and thin patients using 3 - 3.5 cm length incision with rectus muscle splitting, the return to normal activity was 6.9 days which is comparable to LC patients. CONCLUSIONS Mini-cholecystectomy and laparoscopic cholecystectomy produce comparable patient outcomes. In lean and thin patient, MC may be slightly more advantageous than LC in terms of less operating time. KEYWORDS Mini-Cholecystectomy, Laparoscopic Cholecystectomy, Outcome, Lean and Thin Patient

Mini-cholecystectomy versus laparoscopic cholecystectomy: a retrospective multicentric study among patients operated in some Eastern Libyan hospitals.

This study was conducted to analyze the difference between Mini-Cholecystectomy (MC) and Laparoscopic Cholecystectomy (LC) in terms of feasibility and postoperative outcomes to determine if MC could be accepted as a good alternative procedure to LC. A retrospective comparative study of 206 consecutively operated patients of chronic cholecystitis (138 LC and 68 MC), in Al-Jalaa, Ajdabiya and Almrg Teaching hospitals between January 2014 and December 2015 was performed. All cases within the two groups were balanced for age, sex, co-morbidities, ultrasound and intraoperative findings. Exclusion criteria were acute cholecystitis, preoperative jaundice, liver cirrhosis, suspicion of malignancy, previous upper abdominal surgery and pregnancy. Mean age of the patients in the study was around 37 years. Female patients represented 88.84%. Intraoperative complications occurred in about 2% of the patients with bleeding in three cases (one in MC, two in LC) and injury to the bile ducts occurred in one case who underwent LC. Operative duration was longer in LC (mean values 64 minutes for LC and 45 minutes for MC). Rate of conversion to classical cholecystectomy in LC was 5% while it was 0% in MC. Only one case of wound infection was registered in the LC group. Postoperative hospital stay was insignificantly longer for LC versus MC (1.97 days for MC and 2.63 days for LC). Mini-cholecystectomy is a feasible technique, which can be considered as a good alternative method for gallbladder removal for surgeons who have no experience with laparoscopic techniques and in peripheral hospitals where LC is not available.

A study of clinical presentations and management of cholelithiasis

Background: Cholelithiasis or gallstones, is one of the most common and costly of all the gastrointestinal diseases. Gallstones are associated with high-calorie diets, type 2 diabetes mellitus, dyslipidemia, hyperinsulinism, obesity, and metabolic syndrome. The aim of the study was to analysis the incidence, clinical presentations, and management of cholelithiasis in tertiary care Hospital at Karimnagar, Telangana, India.Methods: This study was a prospective study; total 50 patients were enrolled in this study. The study was conducted at Department of Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar from September 2016 to September 2017. The data were analyzed and evaluated for clinical profile, management options of cholelithiasis.Results: The present study shows gallstones diseases are a common problem in female population. The female to male ratio is 3:2. Age, gender and incidence statistically there was no significant in this study.Conclusions: Gallstones analysis showed mixed stone in 90% of the cases and cholesterol stones in 8% of the cases as the most common variety. The period of post-operative stay in our study was 7 days for open cholecystectomy and 3 days for laparoscopic cholecystectomy in majority of the cases.

Xanthogranulomatous cholecystitis: A 14‐year experience

AimXanthogranulomatous cholecystitis (XGC) is a rare disease. The present study was conducted to evaluate the results of both open cholecystectomy (OC) and laparoscopic cholecystectomy (LC), in patients with XGC.Patients and MethodsA retrospective study was performed including 4228 patients who underwent an OC or LC between January 2003 and November 2017. Sixty‐three patients with XGC were identified, and their clinical and operative details were analysed.ResultsThe incidence of XGC was 1.49 per cent. The mean age of the patients was 65.8 years, and 57 per cent were male. The most common clinical presentation was acute cholecystitis (44.4 per cent). Forty‐five patients (71.4 per cent) underwent an LC, with a conversion rate of 40 per cent. The mean operative times were 127.2 min for OC, 82.2 min for LC and 141.6 min for LC to OC conversion (LOC). The mean operative time was significantly longer for OC compared with LC (P = 0.02). Fifteen patients (23.8 per cent) had some postoperative complications, of which the most frequent was incisional surgical site infection (6.34 per cent). Two patients died (3.2 per cent). The mean postoperative stay was 5.07 days for LC and 11.77 days for OC (P = 0.005).ConclusionsXGC is a rare disease associated with prolonged surgical times, high morbidity and a high LOC rate.

Simultaneous transabdominal preperitoneal hernia repair and laparoscopic cholecystectomy: A report of 17 cases.

Inguinal hernia repair and cholecystectomy are frequently performed in the field of gastrointestinal surgery. However, reports describing surgical procedures that involve simultaneous transabdominal preperitoneal hernia repair (TAPP) and laparoscopic cholecystectomy (LC), as well as the safety and usefulness of this combination, are limited. Herein, we report a surgical procedure involving simultaneous TAPP and LC (TAPP + LC) and present the outcomes of patients who have undergone this combined surgical procedure, with a particular focus on its safety and usefulness. We simultaneously performed TAPP + LC in 17 patients (mean age, 66.5 ± 8.1 years) with concomitant inguinal hernia and gallbladder stones. We assessed surgical outcomes. The mean operative time was 157 ± 39 min, and mean postoperative hospital stay was 3.2 ± 0.6 days. The median cost was $7673 for TAPP + LC. The mean postoperative length of hospital stay was 1.1 ± 0.6 day for TAPP alone and 3.4 ± 1.4 days for LC alone. The median costs of TAPP alone and LC alone were $4932 and $5453, respectively. Regarding intraoperative complications, the inferior epigastric vessels were damaged in two patients, and seroma was detected as a postoperative complication in one; these complications were spontaneously resolved. No mesh- or infection-related complications were noted. Simultaneous TAPP + LC is safe and can be regarded as a standard surgical procedure for patients with concomitant inguinal hernia and gallbladder stones. The TAPP + LC combination appears to help prevent the need for two hospitalizations and, thereby, reduces hospital stay and economic burden.

Effect of gabapentin in postoperative pain, nausea, and vomiting in patients undergoing laparoscopic cholecystectomy

Background: Postoperative pain, nausea, and vomiting are frequent and unpleasant adverse events associated with surgery. The reported incidence of postoperative nausea and vomiting after laparoscopic cholecystectomy (LC) is quite high. Recently, studies have been undertaken to determine the role of gabapentin for the prevention of postoperative pain, nausea, and vomiting. Objective: To evaluate the effects of oral gabapentin on early postoperative pain, nausea, and vomiting in patients undergoing LC. Materials and Methods: A total of 40 patients scheduled to undergo LC were enrolled for this double-blind placebo-controlled study. Patients were divided into two groups of 20 patients each. Group A received two doses of 600 mg (300 mg ± 2 tablets) gabapentin: first dose 2 h before surgery and second dose 6 h after surgery. Group B received matching placebo (tablets) of same size and shape as gabapentin tablets. All patients were observed for postoperative pain, nausea, and vomiting on first and second postoperative days. In addition, pulse rate and systolic and diastolic blood pressures were analyzed pre- and postoperatively. Injections ondansetron and diclofenac were used as the antiemetic and analgesic medications, respectively, on as-and-when required basis. Results: Intergroup comparison with respect to pulse rate and systolic and diastolic blood pressures between the two groups was insignificant (p > 0.05). On the first and second postoperative days of LC, average numbers of analgesics used in gabapentin group were 1.2 ± 0.13 and 0.65 ± 0.15 and in placebo group were 2.6 ± 0.10 and 2.2 ± 0.16, respectively. Intergroup comparison was highly significant (p < 0.001). The average number of antiemetics received on first and second postoperative days in gabapentin group was 0.35 ± 0.1 and 0.05 ± 0.04 and in placebo group were 1.31 ± 0.16 and 0.60 ± 0.15, respectively. Intergroup comparison was highly significant (p < 0.001). Pain score in gabapentin group on first and second postoperative days was 2.6 ± 0.17 and 2.2 ± 0.15 and in placebo group 3.80 ± 0.81 and 3.2 ± 0.17, respectively. Intergroup comparison was highly significant (p < 0.001). Conclusion: Administration of gabapentin 2 h before and 6 h after the surgery significantly decreased the incidence of postoperative pain, nausea, and vomiting.

Low ninety-day re-admission rates after emergency and elective laparoscopic cholecystectomy in a district general hospital

Re-admission rate following laparoscopic cholecystectomy is currently defined as within 30 days of the initial operation. This may underestimate the true incidence and financial cost of postoperative morbidity. This study aimed to analyse re-admissions within 90 days of elective and emergency laparoscopic cholecystectomy at a district general hospital, and to compare outcomes to larger teaching centres. We undertook a retrospective analysis of all patients re-admitted within 90 days of laparoscopic cholecystectomy during an 18-month period (June 2006 to December 2007). Patient characteristics, details of the primary operation, and reasons for re-admission were identified, and a comparison of re-admissions following elective versus emergency procedures was performed. A total of 326 laparoscopic cholecystectomies were performed during the 18-month period (246 elective, 80 emergency). No operations required conversion to an open procedure. Twenty-five patients were re-admitted within 90 days of their operation, of whom only 14 had complications directly related to their surgery (overall re-admission rate 4.3%). There was no statistical difference in re-admission rate or cause of re-admission between elective and emergency procedures. However, the mean time to re-admission following elective procedures was significantly longer (36 days; P = 0.0003). Re-admission rates at our district general hospital are comparable to those reported by larger teaching centres. Current 30-day re-admission data may significantly underestimate morbidity rates and socio-economic cost following elective laparoscopic cholecystectomy.

Long-term outcome of biliary reconstruction for bile duct injuries from laparoscopic cholecystectomies

Major bile duct injuries remain a potentially devastating complication after laparoscopic cholecystectomy. A retrospective review was conducted of patients who underwent a biliary-enteric reconstruction of a biliary injury to assess their long-term outcome. Retrospective review of bile duct injury database from January 1990 to December 2005. A total of 144 patients were treated for bile duct injury, and 84 (58%) required a biliary-enteric reconstruction. Stratification by Bismuth-Strasberg injury level revealed E1 or E2 in 23, E3 in 33, E4 in 17, E5 in 1, and B+C in 10. Forty-four (52%) were operated within 7 days of laparoscopic cholecystectomy, the remainder operated at a median of 79 days after referral. Early or late mortality occurred in 3 (4%). At a mean follow-up of 67 months, 9 patients (11%) developed a biliary stricture presented at a median of 13 months after bile duct repair. Level of injury was very important in predicting a postoperative biliary stricture: E4 (35%) versus E3 (9%; P = .023), and E4 versus E1, E2 B+C (0%; P = .001). More strictures occurred in patients operated within 7 days of laparoscopic cholecystectomy (19%) versus delayed repair (8%; P = .053). Overall, 90% of patients are alive and nonstented; 5 patients have chronic liver disease (1 on the waiting list for liver transplant). Nonbiliary complications occurred in 15 patients; the total morbidity was 40%. Bile duct injuries that require a biliary-enteric repair are commonly associated with long-term complications. Level of injury and likely timing of repair predict risk of postoperative stricture.

Relaparoscopy for the detection and treatment of complications of laparoscopic cholecystectomy

Background: Laparotomy remains the commonest intervention in patients with abdominal complications of laparoscopic surgery. Our own policy is to employ relaparoscopy to avoid diagnostic delay and unnecessary laparotomy. The results of using this policy in patients with suspected intra-abdominal complications following laparoscopic cholecystectomy are reviewed. Methods: Data were collected from laparoscopic cholecystectomies carried out by five consultant surgeons in one center. Details of relaparoscopy for complications were analyzed. Results: Thirteen patients underwent relaparoscopy within 7 days of laparoscopic cholecystectomy for intra-abdominal bleeding (2 patients) or abdominal pain (11 patients). The causes of pain were subhepatic haematoma (1), acute pancreatitis (1), small bowel injury (1), and minor bile leakage (6). In 2 patients no cause was identified. Twelve patients were managed laparoscopically and 1 patient required laparotomy. Median stay after relaparoscopy was 7 days (range 2 to 19). Conclusions: Exploratory laparotomy can be avoided by prompt relaparoscopy in the majority of patients with abdominal complications of laparoscopic cholecystectomy.

Editorial (CON) Re Minimally Invasive Port-Access Mitral Valve Surgery

Editorial (CON) Re Minimally Invasive Port-Access Mitral Valve Surgery

Complications of endoscopic biliary sphincterotomy.

Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes. We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994. Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure). The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01). The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.

Sequential endoscopic/laparoscopic management of sickle hemoglobinopathy-associated cholelithiasis and suspected choledocholithiasis.

We reviewed the medical records of 17 patients with sickle hemoglobinopathy-associated cholelithiasis who were candidates for laparoscopic cholecystectomy (LC) between 1991 and 1994. Eight patients with suspected choledocholithiasis (CDL) were identified, all of whom had preoperative endoscopic retrograde cholangiopancreatography (ERCP), which revealed CDL in 3 patients (18%), all of whom had endoscopic ductal clearance. Choledocholithiasis was suspected because of hyperbilirubinemia or serum liver enzyme abnormalities. Incremental hyperbilirubinemia exceeding "baseline" values by > 5 mg/dL was the best predictor of CDL. Subsequent LC was successful with discharge within 2 days of LC in all but one patient, who was converted to open cholecystectomy. This small series suggests that in sickle hemoglobinopathy patients with cholelithiasis (1) CDL is relatively common among patients with an increase above baseline hyperbilirubinemia, (2) bile duct dilatation, alkaline phosphatase, and serum aminotransferase levels are poor predictors of CDL, and (3) sequential endoscopic/laparoscopic management of cholelithiasis and suspected CDL is successful.

Symptomatic gallbladder stones. Cost-effectiveness of treatment with extracorporeal shock-wave lithotripsy, conventional and laparoscopic cholecystectomy.

In order to strike the most favorable balance between health benefits and costs, three treatment modalities for symptomatic cholelithiasis were compared in a cost-effectiveness study: extracorporeal shock-wave lithotripsy (ESWL), conventional cholecystectomy (CC), and laparoscopic cholecystectomy (LC). Data were analyzed from 55 patients who were treated by ESWL, 45 patients who had CC, and 47 patients who had LC. The study was performed by analysis of patients charts and a written questionnaire. After ESWL 35% of the patients were free of stones, 23% had fragments < or = 5 mm, and 42% had fragments > 5 mm at 1-year follow-up. Persistent complaints were reported by 59% after ESWL, 11% after CC, and 14% after LC (P < 0.001). New complaints arose in 12% after ESWL, 11% after CC, and in 5% after LC (P = NS). Patient appreciation score was highest for LC and lowest for ESWL. Mean hospital stay was 2.4 days for ESWL, 10 days for CC, and 3.5 days for LC. Overall costs of treatment were: $5,066 for ESWL; $5,893 for CC; and $3,117 for LC. This study reveals that laparoscopic cholecystectomy is the most effective treatment of the large majority of patients with symptomatic cholelithiasis. ESWL should only be considered in the case of a solitary, relatively small, completely radiolucent stone.

An evaluation of laparoscopic versus open cholecystectomy

To compare open cholecystectomy (OC) with laparoscopic cholecystectomy (LC) in terms of clinical aspects and a limited review of costs. The Austin Hospital, Melbourne, a university teaching hospital. Prospective LC patients were compared with a retrospective group of OC patients whose surgery had been performed by the same surgeons. Consecutive patients undergoing LC were interviewed, their medical records were analysed and the cost of their hospitalisation was assessed. Similar data, collected previously from patients undergoing OC, were used for comparison. There were 108 patients in each group, 93.5% treated electively. All had gallstones. No deaths or common bile duct injury occurred. The mean operating room time was 131 +/- 3.7 minutes for OC and 164 +/- 4.7 minutes for LC. Operative cholangiography was attempted in 80% in each group, being successful when attempted in all OCs and in 95% of LCs. The conversion rate of LCs to OCs was 4.5%. Minor complications were more frequent with OCs. The mean duration of hospital stay was 6.5 +/- 0.3 days for OCs and 2.0 +/- 0.2 days for LCs. The amount and period of analgesia were significantly less in the LC group. Patients recovered significantly faster after LC (P < 0.01) during the first eight weeks after surgery. There was no difference by 12 weeks. The overall cost for each LC was $838 less than OC for the entire hospital stay. These results support the view that LC is a safe and justified replacement for OC in the elective situation, with benefits to the patient, hospital and general community. The hospital cost for LC was less than for OC.